Lewin’s change model
Paper details:
Review the following nursing scenario from the Agency for Healthcare Research and Quality:
A 60-year-old female is admitted to the ward with a 2-day history of severe left lower abdominal pain and leukocytosis. Her white count is 13,000, and she has WBCs in her urinalysis. Two hours after admission, she begins to experience an acute exacerbation of her abdominal pain and is believed to have a diverticular perforation and acute abdomen. At this point, her physician decides to send her to the OR. The unit clerk is aware of the plan, but the patient’s nurse is not. The patient is transported to the OR. Moments later, the OR calls to report that the patient has no permits signed, nor have any other pre-op protocols been completed.
1- Create a plan using Lewin’s change model, documenting strategies needed to support followership and empowerment
2- Used the following Reference:
Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS® Instructor Guide: Specialty ScenariosMed-Surg [Webpage]. Retrieved from http://www.ahrq.gov/teamsteppstools/instructor/scenarios/medsurg.htm
CIN: Computers, Informatics, Nursing
• March/April 2003
1
CIN: Computers, Informatics, Nursing • Vol. 21, No. 2, 80-85 • © 2003 Lippincott Williams & Wilkins, Inc.
C O N T I N U I N G
CE
E D U C A T I O N
Using Lewin’s Force
Field Analysis in
Implementing a
Nursing Information
System
Change is a regular occurrence in the healthcare
environment. The computerization of nursing systems is one aspect of the changes taking place in
the information revolution. As a result, nurses
have widely varying attitudes toward computers
and change in the workplace. To transition the
nursing team effectively from one system to another, the nurse informaticist must be aware of
the factors that encourage and those that impede
the change. Strategies must be developed to assist nurses in moving forward with the transition.
This article presents a theoretical discussion of
how Lewin’s Force Field Analysis Model could be
applied in the practice setting to implement a
nursing information system successfully.
MARILYNN G. BOZAK, RN, MS, OCN
From bar code technology for medication administration to wireless bedside documentation systems to clinical decision support systems, technology is an integral
part of the daily workflow for nurses. Rapidly developing technologies are changing the way nurses manage
information and deliver care. In acute care settings,
there is an increasing focus on managing both high-risk
patients and those with chronic diseases. Integrated delivery networks are moving to the forefront, and the Internet is becoming a source of health and medical information for clinicians and patients alike.1
Many nurses are skeptical of information technology
and may resist learning or using a new system.1 Recognizing this resistance and planning strategies to work
through these barriers may be the key to implementing
a successful nursing information system in a complex
healthcare organization. As change becomes an increasingly common occurrence in the healthcare environment, change theory offers one way of understanding
the dynamic interaction between individuals and social
systems.
As opposed to unplanned or accidental change,
planned change is the direct result of a conscious effort
between the individual who works to bring about the
change and those on whom the change has a direct impact.2 By understanding the principles of change theory,
the nurse informaticist can strategically plan and successfully implement the transition from one nursing system to another.
This article focuses on using Kurt Lewin’s model of
change to implement a nursing information system.
80
KEY WORDS
Field theory • Change • Information system •
Nursing • Attitudes
Lewin’s model can provide the guidance needed to analyze the process of change and assist in identifying
forces that either propel the change forward or create
barriers that stagnate the change.
LEWIN’S THEORETICAL FRAMEWORK
Regarded as the father of change theory, Kurt Lewin
concerned himself with offering a deeper explanation of
human behavior while uncovering ways to improve
human behavior.3 His theory of change provides the
structure for understanding nurses’ behavior during
times of change and ways to improve the behavior
when introducing change into the workplace.
Lewin4 stated that all change is the result of certain
forces in a field or particular environment. Although
field theory was developed originally in the physical sciences as a method of analyzing phenomena, Lewin expanded the concept to the area of psychology.3 He in-
From the University of South Florida, Tampa, Florida.
Corresponding author: Marilynn Bozak, RN, MS, OCN, 10714
Carrollwood Drive, Tampa, FL 33618 (e-mail: mgbozak@msn.com).
CIN: Computers, Informatics, Nursing
• March/April 2003
cluded all psychological activity that confronts an individual and applied concepts of psychological movement
toward a particular goal. Simply stated, field theory is a
method of identifying and analyzing causal relations
and applying scientific constructs to those relations.
Lewin’s operational framework for change is his
Force Field Analysis Model.3 This model provides an
understanding of individual and group behavior as determined by motivation and intention. Lewin4 identified
two dynamic, yet opposing, forces that have an impact
on the change process in an environment. Driving
forces move toward a positive region and encourage the
change to occur. Static forces that attempt to maintain
the status quo are identified as restraining forces.
A driving force might be the result of external forces
compelling the change. It may also result from internal
problems with a current system or simply the desire to
improve a situation. Restraining forces can prevent a
change from occurring by creating barriers. For example, concerns that a project will fail, a past negative
experience with unsuccessful change, or the fear of losing the current state of contentment are typical restraining forces.2 For change to transpire successfully,
the driving forces must be strengthened in favor of the
change while the restraining forces are weakened or
eliminated.4
Lewin considered three steps when describing the
process of change: unfreezing the current level, changing or moving to the new level, and freezing at the new
level.4 Current literature identifies the third step as “refreezing.”2,5 However, Lewin used the term “freezing”3,4 in his theoretical works. Both terms are interchangeable and used to identify the state of permanency
achieved at the new level. To avoid confusion with current literature, the term “refreezing” will be used rather
than “freezing.”
The first step of Lewin’s process, unfreezing, involves
the identification of the current need or problem. At
this stage, there may be feelings of discomfort, apprehension, and upset among the participants. The nurse
informaticist facilitates activities that distinguish the
driving forces and restraining forces in this step. Strategies are developed to strengthen the driving forces and
weaken or reduce the restraining forces. It is during this
phase that people in the organization begin to realize
that the change is necessary and valuable to the success
of the organization.2
The second step of the process involves changing or
moving to a new level. It is here that the actual change
occurs and the driving forces have equalized or overcome the restraining forces. The nurse informaticist has
gathered the necessary information to move forward
with the proposed change. A detailed plan is constructed for implementing the change, and the change is
executed within the organization.2
In the final step of Lewin’s process, refreezing, the
change is stabilized at the new level within the organization. The nurse informaticist assists with maintenance and
evaluation as functions stabilize and the change is incorporated into the system.2 Although Lewin included the
idea of permanency at the new level, he did not imply that
the organization was now immune to future change.4
NURSES’ ATTITUDES TOWARD CHANGE
AND COMPUTERS
Change in the workplace can evoke varied responses in
individuals, and rarely is the response one of indifference. Some nurses may feel that the change is challenging and exciting, presenting an opportunity for growth.
Others may have an opposite reaction to change, viewing the situation as threatening and disrupting.5 Nurses
often resist technological change because of concerns
about intrusions into the normal and routine way of
performing activities. Barriers may be self-imposed to
protect and preserve convention rather than face a new
and uncertain situation.2
Individual reactions to change occur for many different reasons. Previous involvement in similar situations
that were unsuccessful may cause nurses to react negatively to the proposed change. Individual life skills,
knowledge, and abilities have an impact on how nurses
view change and whether they feel capable of handling
the change. Levels of involvement in the organization
and relationships with other individuals all have an effect on the process of change.2
Ely’s6 qualitative study of pediatric nurses’ perceived
barriers to change identified organizational factors that
inhibit change. The nurses questioned the certainty and
security of their jobs during organizational change as well
as feelings of powerlessness when faced with transformation in the workplace. Of major concern to the nurses
was the rampant, widespread, and accelerated process of
change in the healthcare environment as a whole.
Change in the workplace may be perceived as the loss
or death of the status quo. Research blending change
theory with the grieving process was one attempt to explain nurses’ perceptions in the midst of organizational
change. Schoolfield and Orduna7 examined the beliefs,
behaviors, emotions, and actions of oncology nurses involved with change in the workplace. Phases of the
grieving process included disbelief or denial of the current situation, anger or resentment toward the proposed
change, turmoil and confusion, and eventual acceptance
and readiness for the change. These factors can have an
impact and inhibit successful change, and the nurse informaticist must support nurses through this process.
Other researchers have identified feelings of loss,
anger, and despair as common responses to organiza-
CIN: Computers, Informatics, Nursing
• March/April 2003
81
tional change.8 Decreased morale among nurses and an
increased mistrust of management also have been identified as frequent reactions to change in the workplace.
Some nurses have reported physical and emotional
symptoms such as exhaustion, irritability, and crying
during their attempt to cope with the disruption of routine and feelings of uncertainty related to emerging roles
and responsibilities.
Studies examining nurses’ attitudes toward computers have shown conflicting results. For example, early
studies indicated a correlation between positive attitudes toward computers and increased years of nursing
experience.9 However, in later studies, nurses with more
years of experience have exhibited negative attitudes toward computers.10
Stronge and Brodt’s9 study of nurses’ attitudes toward computerization found that years of nursing experience and the education level of the nurse correlated
with positive attitudes about computers. Nurses with
more than 21 years of experience in healthcare had a
more positive attitude toward computers than nurses
who had worked in the field fewer than 10 years. They
also found significant differences in attitudes among
nurses in various nursing units. For example, nurses
who worked in rehabilitation pediatrics and nursing administration exhibited more agreeable attitudes toward
computers than nurses in the medical-surgical unit. The
researchers did not find any significant difference
among various age groups (older nurses compared with
younger nurses) and their attitudes toward computers.
Sultana11 agreed with Stronge and Brodt,9 and found
no significant difference in attitudes among nurses of
various ages. However, this study concluded that there
were no significant differences in attitudes toward computers among nursing units, and that years of nursing
experience were not a factor in determining negative or
positive attitudes toward computers.
An Australian study compared the relation of age, education, and years of nursing experience to nurses’ attitudes in the implementation of an information system.12
The study looked at factors related to user satisfaction,
beliefs, and motivation. Results indicated that nurses with
more years of clinical experience exhibited increased resistance to the implementation of an information system.
Nurses with less clinical experience tended to be more accepting and motivated toward the change. The researchers did not find any significant correlation between
age or education and nurses’ attitudes toward computers.
A study of 208 staff nurses in a British hospital also
examined the attitudes of nurses toward computers.10 A
significant association was identified among age, years
of clinical experience, and clinical units in which nurses
worked with positive or negative attitudes toward computers. The study found that nurses 29 years of age or
younger were most likely to exhibit positive attitudes
82
toward computers. Nurses 30 years of age or older and
nurses with more years of nursing experience were most
likely to exhibit negative attitudes toward computers.
Clinical areas in which nurses worked also affected attitudes toward computers. Nurses in rehabilitation, medical, and elderly care units were most likely to display
negative attitudes toward computers.
McBride and Nagle 13 looked at attitudes toward
computers among baccalaureate nursing students and
registered nurses currently employed in a large hospital
setting. They found that both groups had positive attitudes toward computers despite years in nursing or clinical experience. Although the student group had more
computer experience, it was not a significant factor differentiating the two samples.
Research indicates that nurses have differing and
often conflicting attitudes toward change and computers. Nurses may feel powerless in the midst of change or
challenged by an exciting opportunity. They may grieve
over the loss of a system with which they are familiar
and will need to process and integrate their feelings to
accept the change. Older nurses in a particular practice
setting may actively resist computerization, whereas
younger nurses in another area may embrace it. The differences in the study findings suggest the influence of
other characteristics unique to the samples studied, and
the ability to make generalizations from these studies is
limited. This may contribute to the complexity of understanding nurses’ attitudes toward change and computers, but the use of Lewin’s Force Field Analysis
Model will assist the nurse informaticist in identifying
and addressing these concerns.
APPLICATION OF FORCE FIELD
ANALYSIS
In analyzing a situation, Lewin4 stated that one must
characterize the situation in the entire context and not
just isolated elements. The psychological atmosphere is of
fundamental importance and must be determined when
one is identifying driving and restraining forces. The nurse
informaticist must have an understanding of how each
unit is governed and how project decisions are made.
Each unit will have distinct psychological characteristics
and rules for facilitating change. It is important to be
aware of these decision-making factors when navigating
the processes of unfreezing, moving, and refreezing.
Step 1: Unfreezing
In step 1, the problem is identified. In this example, the
current nursing system needs to be replaced with a new
nursing information system. The nurse informaticist must
CIN: Computers, Informatics, Nursing
• March/April 2003
Table 1
Examples of Driving Forces and Restraining Forces
Driving Forces
Restraining Forces
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Viewed favorably by management
Viewed positively by staff
Prior computer experience
Personal needs addressed/supported
Aware of improvement needed in current practices
Positive past experience with change
Desire to learn a new system
Management approval and acceptance
High level of autonomy in organization
Educational/training needs provided for
Adequate financial resources
Constructive, positive social culture
High level of commitment by management, staff, and individuals
identify the people who will be affected by this change
and include all users of the system: nursing management,
administration, and information support services.
Open communication with nursing management and
staff is essential. The nurse informaticist must create a
sense of security and trust in all those involved with the
proposed change.2 Active listening affirms to the nurses
that what they are saying is being heard and understood. The nurse informaticist must show others they
are valued and important by being on time and prepared for meetings.
During this phase, driving forces and restraining
forces are identified. Table 1 suggests examples of
forces that may be considered driving forces and restraining forces. This information can be gathered by
conducting brainstorming sessions with nursing management and staff. Using a flip chart or chalkboard is
an easy way to keep track of the driving forces and the
restraining forces. With the group, the nurse informaticist clarifies and strengthens the driving forces, reinforcing the concept that these forces will assist in moving
the project forward toward a successful outcome. The
group members are encouraged to identify obstacles
they perceive may inhibit or prevent the goal from being
reached. Once the driving forces and restraining forces
have been identified, the nurse informaticist leads the
group in selecting common themes and prioritizing each
of the forces.
Lewin14 used various and sometimes complex geometric frameworks for measuring the strength, direction, and valence of the driving and restraining forces. A
computerized tool is not necessary for the analysis.
However, a software application called Pathmaker from
SkyMark Corporation, Pittsburgh, Pa, is available.15
White2 suggested creating a diagram of driving forces
and restraining forces and assigning a score to designate
the size or strength of the force. For example, if using
numeric values between 1 and 5, the number 1 would
Viewed unfavorably by management
Viewed negatively by staff
Lack of prior computer experience
Personal needs not addressed/supported
Negative past experience with change
Aversion to learning a new system
Management critical/nonaccepting
Authoritarian organizational culture
Lack of accommodation for education/training
Lack of financial resources
Destructive, negative social culture
Low level of commitment by management, staff, and individuals
indicate a weak force, whereas the number 5 would indicate a strong force.
Figure 1 presents a simple example of an analysis diagram. The state of equilibrium has been disrupted as a
result of the driving forces propelling the change. The
goal of the driving forces is to overcome or substantially
weaken the restraining forces so that the desired outcome can be accomplished. Lewin4 cautioned that the
aim is to achieve a state of equilibrium again, but
strengthening a driving force may have the opposite effect of strengthening a restraining force rather than
weakening it.
Once the forces have been clarified and scores assigned designating the relative strength of each force,
the nurse informaticist must devise strategies to
strengthen and enhance the driving forces and to
weaken or reduce the restraining forces. Strategies the
nurse informaticist may use for this include involving
nurses in all phases of implementation from selecting a
vendor to testing the new system. Nursing staff must be
informed of all events relative to the progression of the
project and what new roles or responsibilities may result from the project. It is important to communicate to
nurses the administration’s commitment to the project.
The nurse informaticist also must organize regular
meetings with nursing staff to facilitate open communication and encourage the support of the new system.2,16
Step 2: Moving
Once the change has been recognized and accepted by
the nursing management and staff, the process of planning and implementing the new information system can
move forward. During this phase, the nurse informaticist continues to encourage open communication and
group discussion. Nurses should be encouraged to assist
with decisions related to screen design and layout. They
CIN: Computers, Informatics, Nursing
• March/April 2003
83
FIGURE 1. Example of a force field analysis diagram.
can participate in the development of contingency procedures in the event of system down time. Once the
staff feels actively involved and personally committed to
the project, they will be more likely to support a successful implementation.
The nurse informaticist must be aware of possible
underlying or residual resistance to the project and
deal with it to keep the project moving. For example,
although initial resistance to the proposal is no longer
present, resistance may occur as the result of challenges associated with workflow once the system is implemented. The activities discussed during the process
of unfreezing may need to be used again during this
phase to facilitate forward movement of the project.
Once the change from the current system to the new
nursing information system has been implemented, the
nurse informaticist must offer ongoing evaluation and
support.
Step 3: Refreezing
The final step in Lewin’s model is the refreezing stage.
The nurse informaticist has strategically planned and
implemented the nursing information system, and what
now follows is a period of stability and evaluation. The
84
change is maintained by providing continued assistance
and support to people using the information system.
Once the process is completed and deemed stable, the
nurse informaticist begins withdrawing from the project. Individuals within the organization now are entrusted with providing ongoing support of the new information system to nursing management and staff.
CONCLUSION
When implementing change in a healthcare organization, the nurse informaticist must ensure that the proposed change is viewed as a challenge rather than a
threat. Adjusting to change may be difficult and demanding. Therefore, a well-formulated strategy will encourage adaptation to change rather than resistance.
Setting of project goals, careful planning, good communication skills, involvement of those affected by the
change, and support of nursing management and staff
are essential components in the implementation of a
successful nursing information system. Integration of
Lewin’s Force Field Analysis Model can provide the
necessary framework for planning, implementing, and
evaluating the acceptance and success of a nursing information system.
CIN: Computers, Informatics, Nursing
• March/April 2003
REFERENCES
9.
1. Ball MJ, Lillis JC. Health information systems: challenges for the
21st century: managing clinical and economic outcomes. Adv
Pract Acute Crit Care. 2000;11(3):386-395.
2. White KM. Planned change. In: Ricchiccioli JT, Tilbury MS, eds.
Clinical Leadership in Nursing. Philadelphia: WB Saunders;
1998:179-195.
3. Marrow AJ. The Practical Theorist: The Life and Work of Kurt
Lewin. New York: Teachers College Press, Columbia University;
1977.
4. Lewin K. Field Theory in Social Science: Selected Theoretical Papers. Westport, CT: Greenwood Press; 1975.
5. Lancaster J. Nursing Issues in Leading and Managing Change. St.
Louis, MO: Mosby; 1999.
6. Ely B. Pediatric nurses’ pain management practice: barriers to
change. Pediatr Nurs. 2001;27(5):473-480.
7. Schoolfield M, Orduna A. Understanding staff nurse responses to
change: utilization of a grief-change framework to facilitate innovation. Clin Nurse Spec. 1994;8(1):57-62.
8. Ingersoll GL, Fisher M, Ross B, Soja M, Kidd N. Employee re-
10.
11.
12.
13.
14.
15.
16.
sponse to major organizational redesign. Appl Nurs Res.
2001;14(1):18-28.
Brodt A, Stronge JH. Nurses’ attitudes toward computerization in a
midwestern community hospital. Comput Nurs. 1986;4(2):18-28.
Simpson G, Kenrick M. Nurses’ attitudes toward computerization
in clinical practice in a British general hospital. Comput Nurs.
1997;15(1):37-42.
Sultana N. Nurses’ attitudes toward computers in clinical practice. J Adv Nurs. 1990;15(6):696-702.
Marasovic C. Attitudes of Australian nurses toward the implementation of a clinical information system. Comput Nurs.
1997;15(2):91-98.
McBride SH, Nagle LM. Attitudes toward computerization: a test
of construct validity. Comp Nurs. 1996;14(3):164-170.
Lewin K. The Conceptual Representation and the Measurement
of Psychological Forces. New York: Johnson Reprint Corporation; 1968.
SkyMark Corporation Website. Available at: http://www.skymark.com/resources/tools/force_field_diagram.asp. Accessed May
28, 2002.
Glancy TS, Brooks GM, Vaughn VS. Hospital information systems: nursing’s integral role. Comput Nurs. 1990;8(2):55-59.
CIN: Computers, Informatics, Nursing
