This past week in school we focused on change theory in organizations. Riveting stuff, I thought to myself, getting into the assigned scholarly journal articles on the subject. But then I started thinking about it more, especially in the context of my work. Change is a part of life, as everyone knows. It’s the constant, in a sea of variables. Everything changes. To be alive is to embody change, whether one realizes it or not. So what makes people so reluctant to do something new? Even if it’s the best practice or will actually benefit them in the end? What are ways organizations screw it up? And if nearly two-thirds of new programs fail, how can they do better?

Reasons People Resist Change

It is interesting to observe change in healthcare. It is non-stop. It is the neverending story that you wish would just finish for the love of Pete. Just when you think you’ve got things down, there is something new, or something you’re reminded of that wasn’t being done. Or someone, somewhere much higher up than you makes a decision that changes your day-to-day work in a heartbeat. And-shocker-the staff isn’t always thrilled about it. The worst changes are those in which a workflow is changed and then, within a few months, is changed right back. Thinking back to COVID brings back a lot of memories (not so good ones, at that) of changes in processes. Hospital administrators and managers were working with the most up-to-date knowledge they had. But even with masking, there was a lot of variation and changes- first, re-wear your mask. Then, don’t re-wear your mask. Next, masks from home are okay. Then, masks from home are definitely not okay. It was hard to keep up.

Change often elicits frustration, anger, and refusal. In McGonigle and Mastrian’s Nursing Informatics and the Foundation of Knowledge (2021), the authors discuss these as common reactions. The authors also mention that the end-user needs to be involved in all workflow redesigns. Otherwise, the new process could very well be resisted. Fear along with anxiety are two other common responses to change. Fear and anxiety make me think of AI in healthcare, and the typical gut reaction that I see in staff. There is this idea that “AI is going to take my job” going around. I don’t think that’s true (not in healthcare at least). There simply won’t be enough healthcare workers for all of the aging population without AI. AI is going to be a necessary part of the healthcare experience. AI is already being used more and more often. In fact, when I called up my doctor’s office not too long ago, I was greeted by some type of AI which helped to screen the call and determined that, yes, I did indeed need to talk to an actual human. But I have been hearing a lot of negative comments about its use in healthcare.

In this Psychology Today article, the author discusses these responses (fear and anxiety) among others, including a concept called the “moral force.” This is the idea that the way something’s always been done is the best way. Another way of looking at it is status quo is best.

This concept reminds me of the ham story, which ties into the status quo theory of resistance to change or- “But I’ve always done it this way!” You may have heard this one, or something like it. A woman baking a ham cuts the ends off before baking it. Her husband asks her why, and she says she’s not sure, that’s how her mom taught her to do it. So she calls up her mom and asks her, “Mom, why do you always cut off the ends of the ham when you bake it?” Mom says, “I don’t know, grandma taught me to do that.” So they call up grandma and ask her why she always cuts the ends off the ham before baking it. And she says, “that’s the only way it would fit in my pan!” The moral of the story? Cut the ends off your ham. Just kidding! (I mean do that if you need to make it fit.) The moral of the story is that there was no good reason for subsequent generations to keep cutting the ends off the ham. They just did it because it had always been done that way. There was literally no other reason why, and “because I’ve always done it this way” doesn’t cut it in healthcare.

The same Psychology Today article mentioned apathy and lack of faith in those instigating the change. Apathy makes sense. Sometimes people just don’t care. Or they care, but not enough to change, and they don’t think it would matter that much if they do. A lack of faith is something I’ve witnessed too- if the employees are far removed from those in the upper echelons of management, never even seeing those people or hearing from them, they might not care a whole lot when a new change is rolled out. Or management tries to put a positive spin on the change but it’s hard to see it that way because of glaring reasons why the change doesn’t sound good.

I’d argue though, that one of the biggest reasons for resisting change in healthcare is change fatigue. I say this after working in healthcare for the past seven years, in a hospital, throughout the pandemic. Change in healthcare is constant and the rate of it is increasing. But people, especially nurses, are tired. Change fatigue can lead to burnout, and contributes to higher turnover rates. Oftentimes, a change initially sounds like more work, and then- guess what- it actually is more work. More tasks to be added into an already busy day. And it’s not like the old tasks are going anywhere. You’re going to have to do those too! So nurses can be suspicious of new changes that are rolled out.

But nurses have to adapt. We have to keep implementing the new ideas, and the best practices. New changes need to be rolled out thoughtfully. Even when they are, a change in practice (based in evidence) takes an inconceivable seventeen years to fully go into effect. Seventeen years! We (as nurses) have to do better than that. That’s where implementation science will hopefully come into play more and shrink that gap between evidence and practice. It needs to.

Theories

There are many theories of change which include the Phases of Change Theory, Lewin’s Theory of Planned Change, Kotter’s Model of Change, and Rogers Diffusion of Innovation Theory. In Part II, I’ll get into the actual theories and talk about facilitators of change.

Have you witnessed resistance to change at work? Was there something that made it better? I’d love to hear from you!