change force field analysis

Management of change through force field analysis

JEAN SANDRA BAULCOMB B S c , S R N , P G D i p O n c o l . , D P S N , F E T C , C L M

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

Introduction

Managing change is seen as being skilled at creating,

acquiring and transferring knowledge thereby modify-

ing its behaviour to reflect 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

reflect upon potential benefits 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

defining core concepts difficult, therefore several mod-

els/theories were considered for guidance when plan-

ning a proposal for a change of shift system within a

haematology/oncology day unit to promote better util-

ization of nursing skills and management experience.

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 08.00–17.00 hours. The ward operates a

12 hours shift pattern, predominately working three

full shifts per week from 07.00–19.30 hours.

Background

One major recommendation of the Department of

Health (1995) Calman-Hine report on cancer services,

signified 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 confines of the haematology ward, to provide day

unit facilities for all patients receiving chemotherapy for

haemato-oncology malignancies. Further to this, con-

tinued pressures on bed management within the Trust,

Correspondence

Jean Sandra Baulcomb

Eastbourne District General Hospital

Kings Drive

Eastbourne

East Sussex

UK

E-mail:

[email protected]

B A U L C O M B J . S . (2003) Journal of Nursing Management 11, 275–280


Today’s NHS is rapidly changing, placing more emphasis on the managerialresponsibilities of ward managers. Managing change is seen as being skilled at

creating, acquiring and transferring knowledge to reflect new knowledge and

insights. Defining core concepts is often difficult and requires the drawing onmodels/theories of change for guidance. Guidance from Lewin’s (1951) force field

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 benefits 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 withoutadditional 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 field, management

Accepted for publication: 19 March 2003

Journal of Nursing Management, 2003, 11, 275–280

ª 2003 Blackwell Publishing Ltd 275

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 staffing the unit had to be achieved

through the current staffing 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 significantly 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 can-

cer centre for treatment, are now opting to have their

treatment locally. Funding to increase the staffing

establishment was again sought but was not forthcom-

ing and the standard ad-hoc daily staffing allocation

was proving inappropriate for the level of service pro-

vision 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 es-

tablishment. 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 Trust’s 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.

Major force of change

• Increased demand for quality and high level of cus-

tomer service and satisfaction.

• Greater flexibility in the daily nursing management

and work organization within the unit.

• Changing nature and composition of the workforce.

No hidden costs were involved, as the change was a

result of a reorganization and more appropriate man-

agement of shift patterns through making better use of

the current resources (staff).

Aim of proposed change

• To establish independent rostered staffing allocation

of the day unit separate from the inpatient area.

Objectives

• To initiate change in staffing 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) signifies:

• 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.

J. S. Baulcomb

276 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275–280

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 Lewin’s model the

ideal choice for guidance. The management significance

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.

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 manage-

ment 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 man-

ager 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 Blanchard’s (1988)

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 weekstoassessprogressandcompletioninMarch2002.

Following the initial meeting a 90/10 split was gen-

erated in favour of the proposal.

The main objections stemmed predominately from:

• fear of being unable to cope if unit exceptionally busy;

• inability to perform specific procedures if venous

access proved difficult;

• 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 difficult 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.

Lewin’s (1951) force field 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 staffing allocation ad-hoc and lacking

continuity.

Optimal: more controlled staffing allocation promo-

ting continuity.

Problem: lack of staffing 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 equi-

librium was achieved through the ward manager redu-

cing the resisting forces allowing movement towards the


ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275–280 277

Figure 2Weights within force field analysis.

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

J. S. Baulcomb


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 benefits if successfully imple-

mented.

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 influence the rest of the team;

• therefore group behaviour tends to change.

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 benefits/problems they had per-

ceived from making the change.

Benefits 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 Monday–Friday;

• 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 first discussed has

now resolved,

now look forward to day unit allocation.

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.

Benefits of change for patients

• Knew whom they were going to meet on next ap-

pointment 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 at-

tending for treatment.

• Reduced waiting time for treatment.

Benefits of change for the organization

• Enhanced provision of service delivery.

• No complaints received from patients.

• Increased flexibility in use of day unit function.

• Effectively meeting Calman-Hine recommendations.

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 un-

foreseen benefits for both the patients and the organ-

ization.

Conclusion

Planned change represents an intentional attempt to

improve operational and managerial effectiveness.

Using Lewin’s three-step model, this change was

undertaken by:


ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 275–280 279

• 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 (partici-

pative 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 dis-

cussion, brought about by the inconsistency of staffing

continuity within the day unit. Force field 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 definite

conclusion could not be reached until the proposal was

tried and tested. Following evaluation staff were more

confident 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 attendance’s and treatments. No complaints

were received from the patients attending for treatment.

Recommendations

• No day unit allocation for staff unable to administer

chemotherapy.

Staff will need to be qualified for 12–18 months prior

to undertaking theoretical training and practice assess-

ment in the administration of cytotoxic therapy. Appro-

ximate 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 organ-

ization and management, and allow enough time to

benefit from this more autonomous role. Plan to com-

mence with the next allocation roster.

• 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 attendance’s to further in-

crease, and to provide peer support for the trained staff

allocated to the unit.

• To continue reviewing the current staffing establish-

ment 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 staffing on the new

haematology/oncology unit once completed.

Managing change forms a part of every ward man-

ager’s 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 benefits

of change in order to decrease the negative aspects. The

use of Lewin’s (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

benefits 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 Calman-

Hine Report). Department of Health, London.

Garvin D. A. (1993) Building a learning organisation. Harvard

Business Review 71 (4), 78–91.

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 influ-

ence. In Behavioural Concepts in Management (D. Hampton

ed.), Dickinson Press, Belmont, CA.

J. S. Baulcomb


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