Journal of Nursing Management, 2003, 11, 275280

Management of change through force field analysis

JEAN SANDRA BAULCOMB
BSc, SRN, PG Dip Oncol., DPSN, FETC, CLM

Haematology Ward Manager, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex, UK

Correspondence Jean Sandra Baulcomb Eastbourne District General Hospital Kings Drive Eastbourne East Sussex UK E-mail: Jean.Baulcomb@esht.nhs.uk

B A U L C O M B J . S . (2003) Journal of Nursing Management 11, 275280 Management of change through force field analysis

Todays NHS is rapidly changing, placing more emphasis on the managerial responsibilities of ward managers. Managing change is seen as being skilled at creating, acquiring and transferring knowledge to reect new knowledge and insights. Dening core concepts is often difcult and requires the drawing on models/theories of change for guidance. Guidance from Lewins (1951) force eld analysis demonstrates the complexities of the change process and how driving and resisting forces were incorporated within the planning and implementation phases. Findings outline the benets of a small scale change for staff, patients and the organization when successfully used to introduce a change of shift pattern within a progressively busy haematology day unit, in order to meet service demands without additional funding. Conclusions have been drawn in relation to the process and recommendations for practice made to further enhance care delivery within the unit. Keywords: change process, force eld, management
Accepted for publication: 19 March 2003

Introduction
Managing change is seen as being skilled at creating, acquiring and transferring knowledge thereby modifying its behaviour to reect new knowledge and insights (Garvin 1993). Nurses today work in a health service that is rapidly changing. Traditional nursing roles have an ever-increasing management responsibility, and it is important when considering change management to reect upon potential benets not only for the patient but also for staff and the organization as a whole. The theory of change management draws on a number of social science disciplines and tradition. This makes dening core concepts difcult, therefore several models/theories were considered for guidance when planning a proposal for a change of shift system within a haematology/oncology day unit to promote better utilization of nursing skills and management experience.
2003 Blackwell Publishing Ltd

The current unit consists of 17 overnight beds and 11-day unit beds. The day beds are located within the centre of the inpatient area, operating from Monday to Friday 08.0017.00 hours. The ward operates a 12 hours shift pattern, predominately working three full shifts per week from 07.0019.30 hours.

Background
One major recommendation of the Department of Health (1995) Calman-Hine report on cancer services, signied that all chemotherapy should be administered in a designated area. In order to meet this recommendation, 11 inpatient beds were converted into day beds within the connes of the haematology ward, to provide day unit facilities for all patients receiving chemotherapy for haemato-oncology malignancies. Further to this, continued pressures on bed management within the Trust, 275

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led to a revision of the management of treatments that could be completed as day cases, so freeing up overnight beds. This resulted in patients, other than those with haemato-oncology conditions receiving their treatments within this day unit. A major setback however of this reorganization has remained, in that stafng the unit had to be achieved through the current stafng levels as no extra funding was available. This decision, at the time, was considered feasible as the inpatient establishment had decreased by the 11 beds, resulting in a reduction in the need for less trained nurse cover on night duty. Staffs commitment to working the 12 hours shift pattern, of three shifts per week, required a minimum of at least two staff to rotate into the day unit to ensure adequate daily cover throughout the working week. The number of patients attending the day unit has however signicantly increased since its inception in some instances by as much as 75%. Current trends forecast this number to further escalate, as a direct consequence of the Calman-Hine (1995) report. Local patients, who had previously attended the nearest cancer centre for treatment, are now opting to have their treatment locally. Funding to increase the stafng establishment was again sought but was not forthcoming and the standard ad-hoc daily stafng allocation was proving inappropriate for the level of service provision and continuity of care. Therefore, a proposal of the need for change within the unit was discussed in order to attempt to improve the service provision to day unit patients, maintain continuity for inpatient cover, and to remain within the current funded establishment. A development opportunity was also seen to provide for a more autonomous management role for trained staff, through a more appropriate and serviceable roster that allowed a longer period of time within the unit. The change would further provide an opportunity to move the current position forward in preparation for the Trusts proposed plans for a new haematology/ oncology unit. This would be in response to a further recommendation of the Calman-Hine Report (1995) for NHS Trusts to provide a continuing improvement in local services for cancer patients.

No hidden costs were involved, as the change was a result of a reorganization and more appropriate management of shift patterns through making better use of the current resources (staff).

Aim of proposed change

To establish independent rostered stafng allocation of the day unit separate from the inpatient area.

Objectives
To initiate change in stafng allocation within day unit. To improve and further develop the management skills of trained staff within the unit. To improve and further develop the clinical skills of trained staff, furthering their professional development. To promote continuity of care. To make recommendations for improvement in managing the change process. To successfully accommodate the increase in the number of patients requiring treatment.

Literature review
Developmental change (Ackerman 1997) signies: planned or emergent change; enhances to the existing allocation pattern and aspects of the organization. and focuses on the improvement of: staff skills; service delivery process; the existing situation over a period of time. Transitional change, however: seeks to achieve a known desired state different from the existing one; it is planned; its foundation lies in the work of Lewin (1951), who conceptualized change as a three-stage process of: unfreeze; change; refreeze. The Group Dynamics School (Schein 1969): places emphasis on achieving change through teams rather than individuals; rationalizes that people in organizations work better in teams.
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Major force of change

Increased demand for quality and high level of customer service and satisfaction. Greater exibility in the daily nursing management and work organization within the unit. Changing nature and composition of the workforce. 276

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which would be more applicable to managing change within the NHS. Lewin (1951) aspired to the underlying concept of a planned approach, the basis of whose theory lies with the understanding of what is happening by moving the current ad-hoc allocation (the actual) to a rostered allocation (the optimal) thereby eradicating a problem and achieving a goal. Achieving lasting and effective change requires the co-operation and involvement of the whole team not isolated individuals, which made Lewins model the ideal choice for guidance. The management signicance of the change was to: give opportunity and responsibility to staff; provide more autonomy for leading and managing the unit; involve staff in the booking in process; involve staff in carrying out treatments; involve staff in making appropriate treatment follow ups.

participative change cycle and the change kaleidoscope (Ballogan & Hope Hailey 1999). Opportunity was given for staff to discuss the proposal and highlight any immediate positive and negative thoughts and feelings. The trial period was initiated in December 2001 and commenced in January 2002 with a review meeting at 6 weeks to assess progress and completion in March 2002. Following the initial meeting a 90/10 split was generated in favour of the proposal. The main objections stemmed predominately from: fear of being unable to cope if unit exceptionally busy; inability to perform specic procedures if venous access proved difcult; change of shift from 12 hours 3 days per week to 7.30 hours 5 days per week. This resistance was partially overcome through: reassurances that assistance would be available if required; guarantee of evenings and a weekend off-duty. Despite the potential positive outcome, change is often resisted, in this case at individual level. Staff, are naturally wary of any disruption from their normal routine and it is often difcult to pinpoint the exact reasons for the resistance, but they are often the result of not perceiving the need for change. Staff tend to have an established pattern of working and a vested interest in maintaining the status quo (Bernstein 1968). Fear of the unknown causes anxiety, and to help overcome this the use of planned change represents an intentional attempt to improve the operational effectiveness of the unit. Lewins (1951) force eld analysis was used to assess the move from the current (actual) situation to the optimal in this particular area of the ward. Actual: day unit stafng allocation ad-hoc and lacking continuity. Optimal: more controlled stafng allocation promoting continuity. Problem: lack of stafng continuity in day unit. Goal: to ensure staff continuity within unit. This theory places emphasis on the driving and resisting forces associated with any change, and to achieve success the importance lies with ensuring that driving forces outweigh resisting forces. Driving forces tend to initiate change or keep it going whereas restraining forces act to restrain or decrease the driving forces (Fig. 1). The intention to reach a state of equilibrium was achieved through the ward manager reducing the resisting forces allowing movement towards the 277

Method: diagnostic phase of change

Within any major organization, staff are a valuable resource, therefore there is a need to: empower them; provide opportunity to develop skills; support them in developing leadership and management skills. This was achieved by giving each of them the responsibility for the management/organization of the unit, initially on a weekly basis, whilst the ward manager adopted a more supportive role to assist their development. Full use was made of their: strengths; skills; other acquired abilities. in order to deliver high quality effective patient care in a more autonomous role. Staff were given the freedom to: think; organize; and plan for themselves. with leadership intervention only when things were seen not to be progressing smoothly. As this was a small-scale project, simple project planning skills were applied to formalize the proposed change. Participative, rather than consultative change, was achieved through Hersey and Blanchards (1988)
2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275280

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Figure 1 Lewin's (1951) force field analysis.

Figure 2 Weights within force field analysis.

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2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275280

Management of change through force field analysis

desired state without increasing staff tension. To be successful this change sought the support of peers, patients, colleagues, managers, and consultants, all of whom were kept fully informed of the progress and reminded of the potential benets if successfully implemented. Weights were further added to these forces to portray the relative importance of each force. Driving forces needed to outweigh the restraining forces enabling the actual shift toward the optimal. This was accomplished by the manager purposely choosing to increase and/or amplify the driving forces, effectively eradicating and/ or suppressing the restraining forces (Fig. 2). Participative change, although a slow process is intended to last, if staff believe in what they are doing, so creating an intrinsically imposed change. In order to achieve this the four steps of the cycle were utilized. These being: staff were initially provided with the knowledge; intent that they would develop a positive attitude on the proposal; once individuals accept and are willing to try then they will inuence the rest of the team; therefore group behaviour tends to change.

Problems
Some days busier than others therefore additional help required. Anxiety regarding falling behind with daily patient caseload.

Advantages
Able to organize own work. Opportunity to improve clinical skills. Time to develop nurse/patient relationship. Feeling of achievement at end of each shift. Freedom of shift pattern hours. Autonomy of role.

The advantages far outweighed the problems, which were however not seen as insurmountable, and with perseverance could easily be overcome or eliminated altogether.

Benets of change for patients

Knew whom they were going to meet on next appointment as roster was prepared well in advance. Able to negotiate treatment times, e.g. morning or afternoon. Knew which member of staff to ask for when attending for treatment. Reduced waiting time for treatment.

Findings
In order to evaluate effectively there was the need to look at the change in terms of: effect on the individual; effect on the patients; effect on the organization. The ward manager saw staff and patients, and asked their views about the benets/problems they had perceived from making the change.

Benets of change for the organization

Enhanced provision of service delivery. No complaints received from patients. Increased exibility in use of day unit function. Effectively meeting Calman-Hine recommendations.

Benets of change for staff

liked to focus on job; liked to know that unit is mine and I can manage it for the week; no problem working MondayFriday; enjoy the challenge of: (a) organization; (b) further development of practical skills; (c) further development of management skills; nice to have a later start and evening free; increased anxiety when change rst discussed has now resolved, now look forward to day unit allocation.
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In using this model and introducing the change, the ward manager had anticipated more resistance from the team than actually occurred. No major problems were encountered from this evaluation, and it was agreed that the ward manager had introduced a change that was not only advantageous to the staff, but held unforeseen benets for both the patients and the organization.

Conclusion
Planned change represents an intentional attempt to improve operational and managerial effectiveness. Using Lewins three-step model, this change was undertaken by: 279

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Unfreezing: removing the ad-hoc allocation. Moving: impressing upon staff the positive aspects of the change. (a) Increased skills cannulation phlebotomy. (b) Increased managerial development. (c) Increased understanding of day unit role. Refreezing: stabilising new independent rostered allocation. (a) supporting staff on busy periods/days. Staff responded better to a directed controlled style of management with management participation (participative style) led by the ward manager as change agent. With this style, once a change is accepted it tends to be long lasting. Overall the change process worked successfully with little resistance after the initial staff meeting, and discussion, brought about by the inconsistency of stafng continuity within the day unit. Force eld analysis theory was used to explain the driving and resisting forces associated with change, and the use of participative change moved the initial knowledge to group behaviour. The old patterns of behaviour were unfrozen, the change was successfully introduced and evaluated and refreezing of the new behaviour established. All the ward team was involved throughout the whole process with managers and consultants being continually updated. Although constraints were recognized and voiced, the general concensus of agreement was that a denite conclusion could not be reached until the proposal was tried and tested. Following evaluation staff were more condent in their roles and were unanimous in their decision that they did not want to return to the old ad-hoc daily allocation. The unit was more organized and successfully coping with the increased number of patient attendances and treatments. No complaints were received from the patients attending for treatment.

To increase rotation numbers from one to two trained nurses. Aim to commence within the next 6 months, in light of the forecast for patient attendances to further increase, and to provide peer support for the trained staff allocated to the unit. To continue reviewing the current stafng establishment and pursue further funding. Unlike areas such as intensive care unit/coronary care unit (ITU/CCU) very little literature is available on workforce analysis in relation to nurse/patient ratios in a day unit cancer setting. These recommendations, are achievable and will be seen to further enhance and support rostered day unit allocation for staff and pre-empt the stafng on the new haematology/oncology unit once completed. Managing change forms a part of every ward managers role, from minor everyday changes to more involved change over a longer time-span. To achieve success it is important to place emphasis on the benets of change in order to decrease the negative aspects. The use of Lewins (1951) model as guidance in managing change helped, not only the ward manager to gain a clearer picture of where there was resistance, but also the remainder of the team involved. Managing does not have to be an autonomous role. Involving staff in every step of the way helps them to gain insight into the benets that can lead to a successful conclusion, bringing about effective and lasting change.

References
Ackerman L. (1997) Development, transition or transformation: the question of change in organisations. In Organisational Change (V. Iles & K. Sutherland eds), National Co-ordinating Centre for NHS Service Delivery and Organisations R & D, London. Ballogan J. & Hope Hailey V. (1999) Exploring Strategic Change. Prentice Hall, London. Bernstein L. (1968) Management Development, Business Books, London. Department of Health and the Welsh Office (1995) A Policy Framework for Commissioning Cancer Services (The CalmanHine Report). Department of Health, London. Garvin D. A. (1993) Building a learning organisation. Harvard Business Review 71 (4), 7891. Hersey P. & Blanchard K. (1988) Management of Organisational Behaviour, 5th edn. Prentice Hall, Englewood Cliffs, NJ. Lewin K. (1951) Field Theory in Social Science, Harper Row, London. Schein E. (1969) Management development as a process of influence. In Behavioural Concepts in Management (D. Hampton ed.), Dickinson Press, Belmont, CA.
2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275280

Recommendations
No day unit allocation for staff unable to administer chemotherapy. Staff will need to be qualied for 1218 months prior to undertaking theoretical training and practice assessment in the administration of cytotoxic therapy. Approximate time-scale from qualifying 18 months to 2 years. To increase day unit allocation from 1 to 2 weeks. In order to further increase staff expertise in organization and management, and allow enough time to benet from this more autonomous role. Plan to commence with the next allocation roster. 280