Change Management Theories in Healthcare: Trends and Research

With constant technological advances and cultural shifts brought about by the Covid-19 pandemic and other factors, change is a massive part of the ability to make profits in the healthcare sector. 

But as the manager of a healthcare department or an entire hospital, how can you manage these changes? What obstacles are there to implementing change? And what models exist to ensure change is correctly integrated within daily tasks and your healthcare organization maintains a new norm?

To answer these questions and many others, we must look at ways of leading and managing change, reasons for resistance to change, and which change management plan is best for your healthcare organization. But before we get into all that, let’s look at what a change management model is in healthcare.

What Are Change Management Models and Theories In Healthcare?

Change models make change happen via an overall structured process, and much like any industry, leaders need to implement change in healthcare systems. But achieving shifts in healthcare is more complex than in any other industry. One of these reasons is that despite private healthcare funding much of the care, US healthcare organizations such as hospitals and clinics are considered part of the public sector.

Within the total number of healthcare organizations in the US, over half are non-profit, and profit organizations run about one quarter. As a result, healthcare change management models must resolve more complex issues.

Given this complex matrix of factors, achieving change in healthcare can feel like a daunting, almost impossible task. However, our guide to change management theories in healthcare will equip you with a clear vision and the tools needed to achieve change with the support of all your staff to benefit patient care and customer satisfaction.

Why are change management models needed in healthcare?

The reasons for transformation in healthcare are vast, and the scope is broader than in conventional office environments. The two main reasons for any change in healthcare are research and technology. Technology is needed not just to stay competitive with other healthcare organizations but to save lives most effectively and to diagnose illnesses as early as possible. Just as in any other industry, technology is constantly evolving.

The difference in healthcare is that equipment involves higher-cost one-off expenses, and investing in research is a higher-cost ongoing process than research in other fields. A financial company may commission software developers to make a customer banking app and update it monthly. However, healthcare research requires more significant investment over a more extended period as new information is being harvested by researchers, requiring specialized staff.

New care practices are the research outcomes and must be implemented by change leaders immediately, mainly where cultural shifts brought on by Covid-19 are concerned. But these practices are constantly changing as research discovers new findings. The relentlessly dynamic impact of research on care makes it challenging for healthcare staff to keep up, creating negative feelings toward change and increasing the need for change management models.

What Are The Reasons For Resistance To Change in Healthcare?

Employees in healthcare are a unique group. Unlike other industries, healthcare practice enflames staff opinions and values, leading to value-based care practice. This dynamic is very different from rules in other industries because, in healthcare, people look after vulnerable people who depend on them. When it comes to vulnerable people, there are a lot of very fixed opinions on specific care practices, cultural attitudes, and differing standards. This reason is why the change process is challenging due to limiting beliefs.

Individual change leads to organizational change. Within a different healthcare organization, there are smaller sub-cultures in departments and wards within an overarching organizational culture. Change managers need to identify the different cultures in other areas and be aware of why staff resists change to facilitate change effectively.

Top Reasons For Resistance To Change: 

• Safety concerns with new practices.
• Staff holding embedded patient care norms.
• Change affecting the psychological safety of staff.
• Staffing issues and other resource concerns.
• Change is not relevant to a specific department.
• Perceived gaps between the theory and practice.
• Fear of lack of autonomy to give personalized care.
• Staff could see a change model as top-down and patronizing.
• The media promotes negative feelings toward change for the team and the public.

Such issues often stem from group dynamics, resulting in negative feelings about change. These common issues must be known by change leaders and identified in specific individuals and groups to help staff understand and support the change. The change leader can tackle this issue by engaging in shared decision-making as a part of successful change processes to overcome resistance and sustain change.

What Role Does Digital Adoption Play In Healthcare Change Management?

The ever-pressing progress of technology is unavoidable in any industry, especially the healthcare industry. One example is that hospitals and clinics have adopted electronic medical records (EMR) in the United States. Moving to digital medical records has required many healthcare organizations to rework their entire medical records systems, but it also equips them for the future, increasing productivity and efficiency.

Technology adoption and change management in healthcare are fraught with similar challenges to technology adoption in any other industry. But in many ways, healthcare staff face more complex challenges to successful digital adoption than other industries.

Reasons for healthcare staff struggling with digital adoption:

• The complexity of healthcare organizations requires massive coordination on multiple levels. Employees must learn new technology, software, and workflows.
• Staff must cope with the potential threat of automation.
• Organization leaders must attempt to manage change on top of already overwhelming schedules.

According to IBM data from a United States Department of Health and Human Services (HSS) study, security breaches cost healthcare organizations over nine million dollars annually. Healthcare staff needs to understand the drawbacks as well as the benefits of any technology adoption. Suppose the team is given training before and during technology adoption. In that case, staff can help reduce losses, and when staff feels more confident with technology, they will be more open to embracing future technology adoption.

Staff is often motivated by opportunities or threats. One way to reduce resistance is to promote the opportunities of technology rather than its potential threats. In healthcare settings, there are several ways to communicate these benefits.

EMRs are more easily shared, and patient history is more straightforward for clerical and medical staff to move from one healthcare setting to the next. Additionally, convenience and efficiency are improved, leading to improved quality of care. We have now looked at how digital adoption affects staff’s ability to change. Let’s take a closer view of why change management models are essential to supporting staff to change.

Which Change Management Models Are Best For Health Care?

Although managing change is more complex and challenging in health care than in other industries, the process is made more accessible and effective by choosing the most suitable change management methods. In healthcare, leading change successfully is frequently achieved via change management methods, including:-

• The Lewin Model.
• Bridges Transition Model.
• Kotter’s 8-Step Change Model.
• ADKAR change management model.

According to research in 2021 conducted by Harrison et al. cited above, the Lewin model and Kotter’s eight-step model are the most commonly used change management models in healthcare. The other two models have been included for balance against more soft, person-centered approaches, as this is a large part of healthcare practice. Part of their value to healthcare is that some of these included models, such as the ADKAR model, focus less on tasks and do not make staff implement changes before they can understand them.

The ADKAR model focuses more on human psychology, helping staff to understand the need for change to support healthcare change management, making it more suitable and effective in healthcare organizations. First, let’s look at more task-oriented change models such as the Lewin Model for contrast, as these can also be helpful in some healthcare organizations.

Lewin’s Three-Stage Model Of Change

Lewin’s Three-Stage Model Of Change uses three steps to achieve change. It helps manage change within short-term, intensive change initiatives due to the aggressive top-down approach to achieving change through three stages.

1. Unfreeze

The preparation stage. Look at how things operate to see the resources needed for the desired results. Communication is essential in this phase, as healthcare staff must be aware of what changes need to happen to prepare them for the subsequent steps.

2. Change

The implementation stage. Project leaders set changes into motion, and communication is again of very high significance as change is a complex process to handle for team members. Support must be available via communication channels at this critical phase. Implement required skills of staff needed for change to take place.

3. Refreeze

The refreeze stage is part of an ongoing process to achieve success. This stage involves developing a strategy to ensure change sticks. Analyze the effect of the new changes and measure how close you are to achieving goals set at the unfreeze phase.

Healthcare managers and change leadership should use this theory alongside a softer model for longer-term change management strategies. But for short-term wins, Lewin’s model can be perfect for achieving change quickly as the desired outcome. Leaders must bear in mind that without a softer model monitoring employee experience to some level alongside the Lewin Model, adverse effects on employee retention and performance may occur due to burnout.

Kotter’s Eight-Step Model

In a study by the National Library Of Medicine linked above, nineteen healthcare organizations used Kotter’s Eight-Step Model, more than twice that of any other change model. This model supports change leaders with implementing change initiatives in healthcare organizations as it is task-oriented, and healthcare organizations are often driven by completing tasks to a schedule. The model includes eight steps:

1. Motivate the team by creating an environment filled with a sense of urgency.

2. Build a guiding coalition, including all the right staff to plan, coordinate and carry out the change.

3. Establish a clear vision and each accompanying change initiative.

4. Enlist a workforce of volunteers driven toward the same goal.

5. Identify any challenges or obstacles.

6. Break goals into bite-size chunks and communicate successes little and often.

7. Maintain momentum, and push harder after every successful implementation.

8. Continue the new culture to ensure changes don’t dissolve over time.

Kotter’s eight-step model is an intensive way of implementing change. The sense of urgency for short-term wins could lead to high rates of staff burnout. Something healthcare staff are already at risk of before the change leader implements a change plan. Therefore, Kotter’s change management theory model is best for significant, drastic change within a change management strategy, where an organization needs a massive shift quickly.

Over a few months, short-period change management strategies in health care work well with this model. One example could be a move to paperless patient onboarding in an ER unit, which is a high-pressure, task-oriented environment. Although burnout due to this change could potentially be high, staff may be more pragmatic and see improvements quickly, reducing staff stress and increasing patient care quality over the time taken to implement the change.

Paperless onboarding would primarily involve getting used to new technology and simple employee training, and the sense of urgency, the first step of the model, is innate in ER staff due to the nature of the work. Implementing this change would work well with change models such as Kotter’s eight-step model as it is task-oriented and involves staff support. Next, let’s look at a softer model, ADKAR Analysis.

ADKAR Analysis

ADKAR (Awareness, Desire, Knowledge, Ability, Reinforcement) analysis is vastly different from the first two models as it focuses on understanding the emotions and thoughts of the people affected by the change. In healthcare, many stakeholders are affected by changes with different ways of gaining or losing.

ADKAR has the potential to collect feedback that change leaders can use to see how different stakeholders are affected and the flexibility to adjust changes to everyone’s advantage. There are five steps to achieving an ADKAR analysis; the first is creating awareness for healthcare staff.

Step 1: Awareness

Show healthcare staff what changes are necessary and why. Detail is needed when explaining changes, and change leaders should define training schedules. Face-to-face announcements and training are preferred so staff can ask questions to enable them to participate early in the process.

Step 2: Desire

Create a desire to be supportive of the change to create an environment in which employee engagement increases so much that attitudes toward change become positive organically. At this stage, dialogues could occur between stakeholders and adjustments made to each stakeholder group’s satisfaction.

Step 3: Knowledge

Ensure adequate support is available for employees. Training, coaching, and checklists provided by the business are some types of support.

Step 4: Ability

Ensure employees, relatives, and patients can give feedback about their change journey. Leaders of change, such as project leaders or healthcare managers, record and action this to provide the best opportunity for learning and development. At this point, the change leader can make further adjustments to the plan based on the feedback.

Step 5: Reinforcement

Use rewards and cash or holiday incentives to employees and other means such as championing staff who embody shared values. Also, HR could implement an internal advertising campaign to remind everyone that the change leader adjusted the plan based on their feedback. These actions ensure the new status quo is maintained for ongoing performance improvement.

Of all the change management tools in this list, the ADKAR model is the model most focused on human experience and supporting staff to engage with new ways of fulfilling their role naturally. For this reason, the ADKAR model can be effective for long-term change strategies within large or small teams. It can be beneficial in healthcare environments due to the many stakeholders of different professions with competing goals.

The ADKAR model is great for many healthcare contexts but particularly for departments caring for high vulnerability patients needing sensitive communication with patients and relatives, like an intensive care unit. Staff in such care environments can hold more specialized skills than in other departments. The ADKAR change management model can support the change with constant feedback and communication to ensure that changes do not negatively impact care.

Bridges Transition Model

Developed by William Bridges over thirty years ago, the Bridges transition model focuses on the human experience of processing and acting on change. This model is softer, more philosophical, and more human-oriented than some of the other models and is formed of three basic principles:-

Endings

Although it sounds somewhat philosophical, every ending is also a beginning. This point forms the first phase of the Bridges transition model. This phase represents the human act of accepting and managing loss. Within this stage, staff lose some things to a change management strategy and keep others.

It’s essential for those coordinating a change strategy to remember that it can be uncomfortable, even painful, for staff to leave behind the old way of doing things. Managers strengthen professional relationships and increase communication by outwardly acknowledging this.

Neutral zone

Once the loss is accepted comes the next phase: the neutral zone. This zone is when the strategy has ensured the old culture is out, but the new culture is not in force.

This stage is the most critical stage of the transition period when staff is changing their deeply embedded beliefs and routines for completing tasks and what values they hold.

Significant concepts such as identity and sense of reality are confronted in this stage and re-aligned. New processes are created in each team member’s mind as the status quo is left behind or re-imagined.

New beginnings

New ways of understanding things, new values, and new attitudes all contribute to forming a sense of the new status quo, cementing changes as part of a transformation strategy. When change is well managed, staff members feel liberated and empowered as they begin to understand and act on their new role within a new system.

For some companies, change models such as the bridges transition model will help them to understand the employee experience of processing change. Understanding the employee experience of change is powerful in healthcare to reduce resistance to change because there are many different levels of staff with different specialisms who are empowered to complete tasks a certain way.

Engaging with this hierarchy of specialisms is easier with the Bridges transition model as it encourages understanding staff mentalities. However, using the Bridges transition model with a more task-oriented model can help establish leadership in health care environments and the need to reach specific change goals.

What is a Change Leader?

A change leader is a senior staff member, often a healthcare manager, who becomes a change agent. A change agent is a staff member who begins the change process and often goes on to coordinate changes as a change leader. The essential attributes of a change leader are that they have a deep understanding of their current healthcare organization culture and communicate with staff effectively to implement change using the appropriate change model.

The leadership style of the change leader is an essential means of ensuring the best communication is possible and that the communication style fits with the change management model. Now let’s look at the main leadership style types and how they might fit different change management models.

How Do Leadership Styles Affect Change In Healthcare?

The five leadership styles can be used for various reasons by a change leader in healthcare in many other applications. The five leadership styles are below.

Authoritarian Leadership

I give a task; you do it. This premise is behind the authoritarian leadership style, with no dialogue between the change leader and the team. In this style, change leaders take on the role of a visible authority figure. This style is excellent when the change leader has superior knowledge on a topic compared to the rest of the team, and there are strict time constraints for change projects.

Advantages

• Consistent results. 
• Fewer errors when carrying out plans.
• The chain of command is clear to the team.
• The leader uses less time for decision-making.

Disadvantages

• This style reduces creativity and innovation. 
• It kills collaboration.
• Team input is discouraged.
• May lead to team resistance.

The authoritarian style’s task-oriented nature and top-down approach make it ideal for use with Lewin’s model of change. This combination can lead to impressive results when an organization needs change to occur over a short period.

Participative Leadership

In contrast to the authoritarian style, the participative leadership style involves much more collaboration and dialogue. Participative leadership is far more democratic and makes a more engaging experience for team members, motivating them to contribute ideas and solutions. On the other hand, the discussion takes time and can lead to unclear answers, making this leadership style inappropriate in a time-constrained environment.

Advantages

• Better team motivation and job satisfaction.
• Creativity promotion.
• Strong team cohesion.
• Higher productivity is likely.

Disadvantages

• Democratic decision-making can waste time.
• Leadership bias toward employees in decision outcomes.
• Weaknesses in communication can occur.
• Compromises in security due to transparent data sharing.

The participative leadership style fits well with the ADKAR change management model due to the promotion of understanding and dialogue between change leaders and team members. However, within the context of change, the change leader would benefit from experience in change management to coordinate team members toward the best outcome in a democratic but focused manner.

Delegating Leadership

The delegating leadership style involves assigning initiatives to other staff within a team. This style works best when the unit is experienced and proficient in the task, naturally taking responsibility and enjoying working alone. Change leaders using this style must be aware of conflict when the team cannot reach an agreement, resulting in team divisions and lowering morale and motivation.

Advantages

• This style welcomes Creative and innovative ideas.
• Delegating leadership promotes a positive workplace setting.

Disadvantages

• It can become unclear who is in charge.
• This style can lead to challenges when adopting change.

Transactional Leadership

Everything is evident in the transactional leadership style; the leader, goals, and what will happen if the team achieves or fail objectives. Transactional leadership is oriented toward the structure to complete tasks rather than organizational change. Change leaders give rewards or punishments in response to goals being hit or missed.

Advantages

• Goals are clear and straightforward to achieve.
• Team motivation and productivity increase.
• No confusion about who the leader is.
• The system is easy to put into practice and easy to follow.

Disadvantages

• This style reduces creative and innovative ideas.
• Lack of understanding of individual team members’ needs.
• Discourages future leadership skills in staff.

Kotter’s eight stages change management model fits perfectly with transactional leadership, emphasizing short-term wins and a sense of urgency. This type of environment can lead to healthcare staff seeing their colleagues benefit or be disadvantaged by hitting or missing goals, creating motivation to succeed in allocated tasks to promote change.

Transformational Leadership

Using the Bridges transition model with a more task-oriented model can be helpful for organizational change management within larger healthcare organizations. A transformational change leader uses a strategic vision speech to inspire their team to set off as empowered and motivated individuals to achieve their goals. The transformational change leader is also the role model for the shared values of an organizational change.

Advantages

• Employee retention rate is improved (especially crucial in healthcare).
• The organizational vision is emphasized by the change leader, standardizing service delivery.
• Staff morale usually increases.
• Transformational leadership prizes relationships as the focus of shared values.

Disadvantages

• Leaders can make unfulfilled promises.
• Constant feedback and motivation drain resources.
• Team consent is needed to carry out tasks.
• Staff sometimes break protocols and regulations.

Transformational leadership can create a more exciting environment for healthcare staff. But the question is, is it safe and appropriate for hospital teams to be excited by inspirational speeches instead of being motivated by the delivery of safe, consistent care practice? The answer comes in the form of balance. If implemented correctly, a change leader can give a speech to promote change safely and consistently in an inspirational manner.

The other advantage of transformational leadership in healthcare change management is that it fits well with change. This point makes it ideal for use with any change management models mentioned above. Still, it may be most useful alongside either Kotter’s model of eight stages or in combination with Lewin’s change model as short-term goals fit so well with the inspiration of staff because inspiration often occurs in short bursts at a time.

How Does Complexity Science Help Change Leaders In The Healthcare Industry?

Leadership styles and change management models can support change leaders to achieve institutional change management in healthcare. But what about the theory of change management in the healthcare industry? Many theories help make sense of the reasons for resistance to change in healthcare and support understanding why these reasons occur to influence human behavior toward accepting change.

Okay, it’s time for a science lesson. One theory that can help change leaders understand the fundamentals of change is the complexity science theory. Prigogine developed complexity science as we know it today and apply it to leadership and organizational theory, and at its core is the concept of complex adaptive systems (CAS).

Breakdown of complex adaptive systems

Complex – A system has lots of diversity, and the differences are significant in number. The system includes a variety of parts working bother together and separately.

Adaptive – The system can learn from past experiences and change as a result.

Systems – The system is a network or made up of networks.

Complexity theory, with CAS at its core, can be used to consider specific individuals or groups within health care organizations when leading change. Change leaders can examine the behaviors of these individuals to understand how their behaviors influence the CAS’s ability to function. Once the change leader accomplishes this, the appropriate leadership style and change management models can be applied to help support the individual or group to embrace change and allow the CAS to function correctly.

If this sounds a bit cold and clinical, that’s because it is. CAS theory is separate from the practical side of implementing a change management model, and some change leaders are not theory-minded. That said, taking a step back can be useful and considering a different perspective on change management. Theories such as complexity theory allow change leaders to do this.

However, a 2021 BMJ study found that despite healthcare organizations frequently using CAS, they often misuse it due to misunderstandings about its methodology and potential. For this reason, change leaders should read about the topic in depth before applying it in practical scenarios to avoid adding to the confusion and complexity of change management. Now that we have focused on specific areas of change management let’s take a broader view.

What Is The Best Approach To Change In Your Healthcare Organization?

Healthcare organizations have many exclusive reasons for resistance to change. Examples of these factors are a complex matrix of competing internal and external stakeholders, embedded hospital culture, and a fear of technology taking away the human aspect of care. The change leader of a healthcare environment must be aware of the complexity of these factors when selecting and using a change management model.Balance is key to success in using a change management model to implement change in healthcare. Inspirational speeches by a transformational change leader are helpful, as long as the emphasis is on safe care. The ADKAR change management model can be beneficial if staff complete tasks in the daily clinical routine. When a change leader in healthcare keeps balance in mind, any chaotic and unpredictable healthcare organization can be changed positively for the future, increasing profits, patient safety, and optimal customer experience.

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