essay on change management in nursing

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Trust and Nursing

Delivering effective change management and driving a culture of innovation.

Wymer, Joshua A. MSN, RN, CNOR, CSSM, RN-BC, NEA-BC, CHCIO, CDH-E, FACHE; Stucky, Christopher H. PhD, RN, CNOR, CSSM, CNAMB, RN-BC, NEA-BC

San Diego Market, Defense Health Agency, San Diego, California, and Naval Medical Center San Diego, San Diego, California (Mr Wymer); and Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl, Germany (Dr Stucky).

Correspondence: Joshua A. Wymer, MSN, RN, CNOR, CSSM, RN-BC, NEA-BC, CHCIO, CDH-E, FACHE, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134 ( [email protected] ).

The authors wish to recognize the late Patricia “Trish” Seifert, MSN, RN, CNOR, CRNFA(E), FAORN, FAAN, for her belief in nurse-led innovation and the power of nurse leaders to shape their organizations and the health care of tomorrow.

The views expressed are solely those of the authors and do not reflect the official policy or position of the US Army, US Navy, the Department of Defense, or the US Government.

Copyright: “I am a military service member or federal/contracted employee of the United States government. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that ‘copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties.”

The author declares no conflict of interest.

Trust is foundational for all interpersonal communication and activities in an increasingly networked and interdependent world. Trust is also essential to the effective delivery of health care and for building collegial environments rich in innovation and readily adaptable to change. As the world's most trusted profession and vested peer collaborators across interprofessional health care teams, nurses are uniquely qualified to shepherd change and foster an innovation mindset across organizations and systems. Innovation requires creative teams that are appropriately resourced and supported, and team-based innovation requires time, space, and safety for groups to realize their full potential and maximize contributions. Appropriate staffing, resourcing, internal engagement, and external partnerships are essential to successfully conceive, launch, sustain, and deliver change initiatives that successfully challenge the status quo. Diverse teams are vital to enhancing the performance, effectiveness, and delivery of change and innovation. Effective change management and innovation practices require courage and imagination, skills that nurses have long possessed. Nurses are uniquely equipped to champion human-centered design through all phases of innovation while bringing knowledge of patients and communities to bear in ways that deliver innovation, are respectful of challenges, and mindful of opportunities to strengthen individuals and communities.

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Approaches to leadership and managing change in the NHS

Affiliation.

• 1 Freelance Tissue Viability Nurse and Health Visitor, Bedford.
• PMID: 29791219
• DOI: 10.12968/bjon.2018.27.10.554

The NHS is continually changing as research evidence leads to new practices and technology transforms the workplace. Resistance to some changes may occur because of staff fears about adapting to and coping with new methods. This is where change models and leadership are important. This article discusses changes taking place in the NHS, and some theoretical models of change. Leadership styles are also discussed, including those most useful for the nurse to use when leading a team and implementing change.

Keywords: Change agents; Change models; Leadership; Leadership styles; Managing change.

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4.3 Implementing Change

Change is constant in the health care environment. Change is defined as the process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures. [1] The outcomes of change must be consistent with an organization’s mission, vision, and values. Although change is a dynamic process that requires alterations in behavior and can cause conflict and resistance, change can also stimulate positive behaviors and attitudes and improve organizational outcomes and employee performance. Change can result from identified problems or from the incorporation of new knowledge, technology, management, or leadership. Problems may be identified from many sources, such as quality improvement initiatives, employee performance evaluations, or accreditation survey results. [2]

Nurse managers must deal with the fears and concerns triggered by change. They should recognize that change may not be easy and may be met with enthusiasm by some and resistance by others. Leaders should identify individuals who will be enthusiastic about the change (referred to as “early adopters”), as well as those who will be resisters (referred to as “laggers”). Early adopters should be involved to build momentum, and the concerns of resisters should be considered to identify barriers. Data should be collected, analyzed, and communicated so the need for change (and its projected consequences) can be clearly articulated. Managers should articulate the reasons for change, the way(s) the change will affect employees, the way(s) the change will benefit the organization, and the desired outcomes of the change process. [3] See Figure 4.5 [4] for an illustration of communicating upcoming change.

Change Theories

There are several change theories that nurse leaders may adopt when implementing change. Two traditional change theories are known as Lewin’s Unfreeze-Change-Refreeze Model and Lippitt’s Seven-Step Change Theory. [5]

Lewin’s Change Model

Kurt Lewin, the father of social psychology, introduced the classic three-step model of change known as Unfreeze-Change-Refreeze Model that requires prior learning to be rejected and replaced. Lewin’s model has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction and cause change to occur. They facilitate change because they push the person in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the person in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces. [6] , [7]

• Step 1: Unfreeze the status quo. Unfreezing is the process of altering behavior to agitate the equilibrium of the current state. This step is necessary if resistance is to be overcome and conformity achieved. Unfreezing can be achieved by increasing the driving forces that direct behavior away from the existing situation or status quo while decreasing the restraining forces that negatively affect the movement from the existing equilibrium. Nurse leaders can initiate activities that can assist in the unfreezing step, such as motivating participants by preparing them for change, building trust and recognition for the need to change, and encouraging active participation in recognizing problems and brainstorming solutions within a group. [8]
• Step 2: Change. Change is the process of moving to a new equilibrium. Nurse leaders can implement actions that assist in movement to a new equilibrium by persuading employees to agree that the status quo is not beneficial to them; encouraging them to view the problem from a fresh perspective; working together to search for new, relevant information; and connecting the views of the group to well-respected, powerful leaders who also support the change. [9]
• Step 3: Refreeze. Refreezing refers to attaining equilibrium with the newly desired behaviors. This step must take place after the change has been implemented for it to be sustained over time. If this step does not occur, it is very likely the change will be short-lived and employees will revert to the old equilibrium. Refreezing integrates new values into community values and traditions. Nursing leaders can reinforce new patterns of behavior and institutionalize them by adopting new policies and procedures. [10]

Example Using Lewin’s Change Theory

A new nurse working in a rural medical-surgical unit identifies that bedside handoff reports are not currently being used during shift reports.

Step 1: Unfreeze: The new nurse recognizes a change is needed for improved client safety and discusses the concern with the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for client safety. [11] The nurse manager initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports.

Step 2: Change: The nurse manager gains support from the director of nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed.

Step 3: Refreeze: The nurse manager adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness.

Lippitt’s Seven-Step Change Theory

Lippitt’s Seven-Step Change Theory expands on Lewin’s change theory by focusing on the role of the change agent. A change agent is anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort. Change agents can be internal, such as nurse managers or employees appointed to oversee the change process, or external, such as an outside consulting firm. External change agents are not bound by organizational culture, politics, or traditions, so they bring a different perspective to the situation and challenge the status quo. However, this can also be a disadvantage because external change agents lack an understanding of the agency’s history, operating procedures, and personnel. [12] The seven-step model includes the following steps [13] :

• Step 1: Diagnose the problem. Examine possible consequences, determine who will be affected by the change, identify essential management personnel who will be responsible for fixing the problem, collect data from those who will be affected by the change, and ensure those affected by the change will be committed to its success.
• Step 2: Evaluate motivation and capability for change. Identify financial and human resources capacity and organizational structure.
• Step 3: Assess the change agent’s motivation and resources, experience, stamina, and dedication.
• Step 4: Select progressive change objectives. Define the change process and develop action plans and accompanying strategies.
• Step 5: Explain the role of the change agent to all employees and ensure the expectations are clear. 
• Step 6: Maintain change. Facilitate feedback, enhance communication, and coordinate the effects of change.
• Step 7: Gradually terminate the helping relationship of the change agent.

Example Using Lippitt’s Seven-Step Change Theory

Refer to the previous example of using Lewin’s change theory on a medical-surgical unit to implement bedside handoff reporting. The nurse manager expands on the Unfreeze-Change-Refreeze Model by implementing additional steps based on Lippitt’s Seven-Step Change Theory:

• The nurse manager collects data from team members affected by the changes and ensures their commitment to success.
• Early adopters are identified as change agents on the unit who are committed to improving client safety by implementing evidence-based practices such as bedside handoff reporting.
• Action plans (including staff education and mentoring), timelines, and expectations are clearly communicated to team members as progressive change objectives. Early adopters are trained as “super-users” to provide staff education and mentor other nurses in using bedside handoff checklists across all shifts.
• The nurse manager facilitates feedback and encourages two-way communication about challenges as change is implemented on the unit. Positive reinforcement is provided as team members effectively incorporate change.
• Bedside handoff reporting is implemented as a unit policy, and all team members are held accountable for performing accurate bedside handoff reporting.

Read more about additional change theories in the Current Theories of Change Management pdf .

Change Management

Change management is the process of making changes in a deliberate, planned, and systematic manner. [14] It is important for nurse leaders and nurse managers to remember a few key points about change management [15] :

• Employees will react differently to change, no matter how important or advantageous the change is purported to be. Recognizing this variability is crucial for effectively managing the transition process.
• Basic needs will influence reaction to change, such as the need to be part of the change process, the need to be able to express oneself openly and honestly, and the need to feel that one has some control over the impact of change. Ensuring these needs are met can significantly reduce resistance.
• Change often results in a feeling of loss due to changes in established routines. Employees may react with shock, anger, and resistance, but ideally will eventually accept and adopt change. Acknowledging these feelings and providing support can facilitate smoother transitions.
• Change must be managed realistically, without false hopes and expectations, yet with enthusiasm for the future. Employees should be provided information honestly and allowed to ask questions and express concerns. This transparency builds trust and helps in aligning everyone towards common goals.

Strategies for Effective Change Management

• Engage Stakeholders Early: Involve key stakeholders in the planning stages of the change process. Their input can provide valuable insights and help in identifying potential challenges early on.
• Communicate Clearly and Frequently: Clear and frequent communication is essential. Use multiple channels to disseminate information and ensure that the message is consistent and comprehensible to all staff members.
• Provide Training and Resources: Equip employees with the necessary skills and resources to adapt to the change. This might include training sessions, informational materials, or access to support personnel.
• Build a Supportive Culture: Create an environment where change is viewed positively. Encourage collaboration and create opportunities for employees to share their experiences and strategies for adapting to change.
• Monitor and Adjust: Continuously monitor the progress of the change initiative and be prepared to make adjustments as needed. Solicit feedback from employees and be responsive to their concerns.

There are multiple strategies that can employed to overcome resistance to change. First, it is important to understand the underlying reasons for resistance. Resistance is commonly aligned to feelings of fear, lack of trust in leadership, or logistical concerns regarding workload, seniority, etc. To implement change effectively, a leader should empower staff by making sure they feel that their voice is respected and valued. When individuals feel valued and hear, they are more likely to support change, even if they do not personally agree with all elements associated with the change. Leaders also must understand that change is stressful for individuals. Depending on the significance of change, a leader may take actions to ensure that employee assistance programs, support groups, or additional counseling services or resources are available. These additional resources can be beneficial for individuals as they work through the emotions associated with the proposed change. Additionally, the benefits for any change should be clearly described. It is important to highlight how the proposed change will help improve work processes and client care quality. It is also helpful to acknowledge and demonstrate appreciation for early adopters of the change. This can provide motivation and encouragement for others to follow suit and fosters a positive attitude toward future changes.

• Ana, B. H., & Hendricks-Jackson, L. (2017). Nursing professional development review and resource manual (4th ed.). American Nurses Association, Nursing Knowledge Center. https://www.nursingworld.org/~49379b/globalassets/catalog/sample-chapters/npdsamplechapter.pdf ↵
• “ Change-1080x675.jpg ” by Amman Wahab Nizamani is licensed under CC BY-SA 4.0 ↵
• Nursing Theory. (n.d.). Lewin’s change theory. https://nursing-theory.org/theories-and-models/lewin-change-theory.php ↵
• Kritsonis, A. (2005). Comparison of change theories. International Journal of Scholarly Academic Intellectual Diversity, 8 (1). https://globalioc.com/wp-content/uploads/2018/09/Kritsonis-Alicia-Comparison-of-Change-Theories.pdf ↵
• AHRQ. (n.d.). Bedside shift report checklist. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.pdf ↵
• Lunenburg, F. C. (2010). Managing change: The role of the change agent. International Journal of Management, Business, and Administration, 1 3(1). https://naaee.org/sites/default/files/lunenburg_fred_c._managing_change_the_role_of_change_agent_ijmba_v13_n1_2010.pdf ↵

The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.

Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.

Process of making changes in a deliberate, planned, and systematic manner.

Nursing Management and Professional Concepts 2e Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Understanding Change Management in Nursing Leaders Nursing Essay

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Change Management for Nursing Students Essay

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Change management monitors and manipulates the occurrence of all changes and puts much effort into implementing new changes with minimum disruption to an organization’s internal processes. Successful changes require a transparent approach, integrity, and a shared vision that facilitates fruitful decision-making. Integrating skills check-off for nursing students starts by identifying the necessary skills, imposing them on the students, cooperating with the clinics, and controlling their success simultaneously.

Inspiring change is a challenge that all organizations face because it requires a determined approach. Initially, the leaders use tools such as outlines, flow charts, and process maps to plan their changes openly to the employers (Unal & Teskereci, 2022). It eliminates the belief among nursing students that change causes workload because such visualization through the tools improves their understanding of strategic goals. When all parties realize the urgency and have a shared vision, they eliminate the status quo and employee resistance.

Nowadays, healthcare services should quickly and safely adapt to the unprecedented changes in disease patterns, treatment modalities, and human resource challenges. For instance, creating scenarios for skills check-off for nursing students help them to meet patient care requirements efficiently and with high quality. If the students want to be professional nurses, then they should have developed empathy, flexibility, and communication skills. By conducting several tests and monitoring patient and nurse communication, professionals assess students according to the criteria. Eventually, students receive comprehensive feedback on their skills. This check-off helps nursing students understand the job requirements and eliminate future challenges.

To conclude, change management experiences should be planned using the available tools and the organization’s vision. As nursing students adapt to changing behaviors, they become autonomous and critical thinkers. Checking off their skills provides them with a valuable assessment of their professional qualities and feedback to improve some weaknesses. University and hospital cooperation are essential to deduce the nurses’ resistance to change.

Unal, A., & Teskereci, G. (2022). Change management experiences of nursing students in clinical practice: A phenomenological study. Nurse Education Today , 109 .

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Reasons for resistance to change in nursing: an integrative review

Rozita cheraghi.

1 Ph.D. Candidate in Nursing. Student Research Committee, Tabriz University of medical sciences, Tabriz, Iran

Hossein Ebrahimi

2 Department of Psychology Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Nasrin Kheibar

Mohammad hasan sahebihagh.

3 Community Health Nursing Department, School of Nursing and Midwifery, Tabriz University of medical sciences, Tabriz, Iran

Associated Data

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. All requests relating to data should be addressed to [email protected].

Change is a very complex and multifaceted phenomenon that is intertwined with the understanding of nursing practice, so, resistance to change in nursing can be considered as an important challenge. Knowing the reasons for this resistance can help in solving it in nursing. Therefore, the present study was conducted with the aim of investigating the reasons for resistance to change in nursing as an integrated review.

This integrative review was conducted using the Whittemore & Knafl method in 5 stages, including problem identification, searching the literature, evaluating primary sources, analyzing data, and presenting the results. Databases like SID, Irandoc, Magiran, Google Scholar, Web of Science, PubMed, CINAHL, and Scopus were searched using the keywords; “Resistance”, “Change”, “Nursing”, “Resistance to Change” and their Persian equivalents in the time range of 2000 to January 2023. After applying inclusion criteria and assessing the articles using Bowling’s Quality Assessment Tool, finally, 15 papers were included from 2964.

After reviewing and critically appraisal of the qualified articles, the findings were placed in three main categories including; (1) individual factors, (2) interpersonal factors, and (3) organizational factors and six subcategories.

Undoubtedly, change is an integral component in nursing care, and resistance to it is the result of a set of individual, interpersonal and organizational factors that change managers should pay special attention to in order to make changes due to the reasons of this resistance, and the development process of developing changes in the clinical field is easily possible.

Introduction

Change is a very complex and multifaceted phenomenon that is intertwined with the understanding of nursing practice [ 1 , 2 ], and it’s happening fast in health care, so, all nurses, as a part of the change process, must be knowledgeable and skilled [ 3 ]. In the dynamic environment of healthcare, the organization’s agility to change is the key to its survival [ 4 ]. However, not all employees in an organization react equally to ongoing changes in their workplace organization, some employees respond to these changes with enthusiasm and as opportunities for learning and growth, while others resist such changes and show increasing feelings of frustration, alienation, and sadness [ 5 ]. It would be said; a key barrier to implementing change is employee resistance to change [ 6 ]. So that, resistance to change (RtC) is widely recognized as the main reason for failure when it comes to change initiatives. Despite the importance of this issue; still relatively limited knowledge exist about the factors that cause resistance to change in the organization [ 7 ].

Generally defining the concept of “resistance to change” is not easy [ 8 ], but based on the literature; resistance is defined as the informal and covert behavior of an individual in response to a perceived or actual threat to maintain the status quo [ 9 , 10 ]. In other words, resistance is defined as failure to do anything that is asked by managers from employees [ 11 ]. Also, behavioral resistance is known as a prevent or stop change [ 9 ], which can ultimately be the main cause of change failure [ 12 ]. However, sometimes the nature of resistance can finally be a valuable resource for achieving change [ 8 , 13 ].

Organizational resistance can be caused by power and conflict, or be the result of differences in functional orientation, structure, and organizational culture [ 14 ]. Some of the reasons for the organizational changes according to the studies are restructuring in the workplace, advances in technology, a greater need for efficiency, and the growth of new services [ 3 ]. Some others at the group level include resistance to change caused by group norms, group cohesion, group thinking, and intensifying commitment [ 15 ], and at the individual level include uncertainty and Lack of job security, selective perception and retention, and getting used to the current work [ 16 ].

Implementing change in the healthcare system is difficult, challenging, and often has short-term results [ 17 ], especially when the context of change includes changes in care organization, modification of common clinical practices, increased collaboration between different disciplines, and changes in patient behavior [ 18 ]. This happens because the healthcare services are delivered in an environment where groups of people act in different and unpredictable ways, where tensions arise through opposing, competing, or collaborative forces, and where decisions are influenced by priorities, and records of healthcare professionals are adopted [ 19 ].

Studies show that; Nurses are inherently resistant to clinical change [ 1 ], and there are several reasons for this. RtC in nursing is likely based on fear, uncertainty, doubt, frustration, distrust, confusion, and anger [ 20 ]. Although accepting change is challenging for nurses, resistance is usually an ordinary and predictable reaction to change [ 21 ].

Resistance has historically been viewed with negative consequences due to its potential impact on organizational success [ 9 ]. However, resistance is a normal response to a threat to the status quo because change requires people to abandon their current processes [ 22 ]. Individual’s resistance can be an obstacle to implementing change [ 23 ], and plays an important role in successful adaptation to change [ 22 ]. Improvements in the changes in the provision of organizational healthcare are often positive and carried out to improve the quality, safety, and efficiency of healthcare, thus increasing the experiences for patients and employees. However, despite these positive results, nurses often face resistance to change and are considered a natural consequence [ 9 ].

Accepting change in the core of nursing and health care is considered a challenge, and some of these challenges are related to the movement of information and knowledge from research to the implementation of evidence-based best practices [ 24 ]. It is because employees and organizations simply do not like change [ 25 ], and the organizational culture (context and environment of the organization) that is conservative and may strengthen the resistance that can prevent the implementation of new changes [ 26 ]. This kind of resistance is the result of the cognitive and behavioral reactions of the recipients of the change towards the change [ 27 ], which is often in conflict with the organizational identity and causes an unpleasant image of individual, and threats the organizational identity [ 28 ]. Although the effect of resistance to change is not static: instead, it can have a negative, festering effect on relationships with perceived organizational effectiveness and commitment to the organization over time [ 5 ].

What is obvious is that resistance to change in nursing care can be an important challenge, although various studies have addressed the concept of change, however, very few and scattered studies have focused on the reasons for resistance in nursing. Therefore, this study was conducted with the aim of an integrated overview of the reasons for resistance to change in nurses. An integrative review is a specialized review method that summarizes empirical or theoretical studies that have already been conducted to provide a more comprehensive understanding of a specific phenomenon or healthcare problem [ 29 ]. In fact, integrated reviews have the potential to expand the body of knowledge and create nursing science, knowledge of research, practice, and policies, at the same time, this category of studies shows the current state of knowledge in each field, helps to develop theory and has a direct application in practice and health policies [ 30 ]. Therefore, the results of this study can help to clarify the reasons for resistance to change in nursing and, as a result, to solve it.

Study design

This study is an integrated review based on articles related to the reasons for resistance to change in nursing which was conducted to collect data from various studies. This integrative review was conducted using the Whittemore & Knafl method in 5 stages of review, including (a) problem identification, (b) searching the literature, (c) evaluating data from primary sources, (d) analyzing data, and (e) presenting the results, using of this method also increases the rigor of this study [ 30 – 32 ].

Search strategy

Based on the Whittemore & Knafl method, 1) in the first stage, the following question was set to answer the study’s aim: What are “the reasons for resistance to change in nursing”?

2) In the second stage, searching for articles was conducted by two researchers in the time range from 2000 to January 2023. We searched databases such as; Persian database(Magiran, SID, Irandoc), Google Scholar, Web of Science, PubMed, CINAHL, and Scopus by using the keywords; “Resistance”, “Change”, “Nursing”, and “Resistance to Change” in English and Persian separately or combined by using the Boolean operators(AND and OR). In this stage; the results of the comprehensive search included 2964 articles after reviewing them based on the inclusion criteria such as: accessing the full text of the article, including the keywords in the title and abstract of the article, and writing in Persian and English language, finally 2949 were removed, and the 15 articles were included.

Eligibility criteria

3) In this stage, two researchers evaluated the data and the content of selected studies for their quality by using “Bowling’s Quality Assessment Tool“(consists of items for checking the structure of the methodology and presenting the results of the studies: high, moderate, and low-quality) [ 33 ], which caused the removal of 5 of these articles by that. Then we compared the results, and finally 15 articles were included in this study (Fig.  1 following the renewed PRISMA guideline 2020) [ 34 ].

PRISMA flow diagram

Data extraction

The data extraction was based on the main data from the 15 articles included: the publication’s year, the language of the study, the main keywords and the methodology of the study, and also the results.

Data synthesis

4) In the fourth stage, data were evaluated independently by two researchers and updated in a continuous process, after that, the data were analyzed and interpreted. This process was verified by three authors including; documenting the required data through five methodological stages, and analyzing separately by researchers.

All of the extracted data were read by researchers and determined significant items and similar and different data were assessed and examined throughout the data analysis process.

Eventually, confirmation and verification were performed by all authors to ensure that all 15 reviews were thoroughly evaluated in all of the methodological stages and the results were matched by the research questions of the study.

Quality appraisal

Whittemore and Knafl (2005) state that assessing the quality of the included evidence is not essential in a supplementary review [ 31 ]. All studies meeting the inclusion criteria, regardless of their methodological quality, were retained in the review to examine all evidence of the factors that influenced the nursing role implementation in practice settings. Also, Bowling’s quality checklist was used to appraise the articles, which allowed us to evaluate and compare study objectives, design, methods, analysis, results, discussion, and clinical implications [ 33 ].

For our review, studies were deemed to be of relatively high quality, and studies that were in the moderate or low-quality range were omitted.

5) In the last step, the results were obtained according to the framework of 15 articles that were selected. It is necessary to mention that was found no paper in Persian, and all articles included in this study were in English (Table  1 ).

Selective qualified articles

After reviewing and evaluating the qualified articles, the findings were classified into three main categories as follows: (1) individual factors, (2) interpersonal factors, and (3) organizational factors and six subcategories (Table  2 ).

Main categories and sub-categories extract from the review of selected articles

The present study was conducted to investigate the reasons for resistance to change in nursing as an integrated review of various studies. In this review; three main categories (individual factors, interpersonal factors, and organizational factors), six sub-categories, and thirty-seven codes were identified.

What is clear to us is that change in improving patient outcomes is common and important in the current healthcare systems [ 40 ]. The process of change is an inevitable issue in healthcare, so understanding the benefits of change for patients is most likely to be successful when caregivers have the opportunity to influence change. Making changes can be challenging because they conflict with basic human needs for a sustainable environment [ 41 ]. Although changes in clinical environments are inevitable, resistance to them for various reasons; can be created.

Based on the findings of the present study, individual factors ; It is one of the factors that can be based on the individual attitude and understanding and personality characteristics of nurses. Attitudes toward an impending change may be positive, negative, or neutral. Resistance to change in nursing is probably based on negative and defensive feelings toward change such as fear, uncertainty, doubt, disappointment, mistrust, confusion, and anger [ 42 ]. The findings of Amarantou’s study (2018) also confirm that resistance to change is indirectly influenced by individual’s emotions and personality characteristics [ 7 ]. Tendency to pessimism in employees is one of the personality characteristics that causes negative attitudes and perceptions toward change. The use of this defense mechanism is adopted unintentionally when danger occurs in order to reduce stress. The tendency to pessimism is directly related to a person’s personality and reflects a negative perception of human behavior and is characterized by pessimistic behavior and the inability to establish appropriate interpersonal relationships [ 43 ]. In the current study, individual personality characteristics indicate how pessimistic employees are toward change. Persons who have high levels of the above personality traits are more likely to experience negative emotional reactions, deny changes, show a judgmental and negative attitude towards change, and believe that the effect of implemented changes will be unfavorable [ 7 ].

All personnel in an organization does not react equally to ongoing changes in their organization [ 37 ]. A feeling of insecurity, doubt, and on the other hand, low motivation in implementing change [ 36 ], with a lack of trust and negative belief in change [ 26 , 27 ], and a lack of readiness to accept change [ 35 ] seeks resistance to change. Individuals with conservative personality traits and low flexibility to change can also make this process more difficult [ 26 ]. Changes in the structure or design of organizations as a result of the introduction of new technologies are likely to lead to changes in work roles and increased feelings of uncertainty and insecurity among personnel. Job insecurity may cause personals to resist proposed changes [ 44 ]. When personnel are satisfied with their current position in the organization, they may become increasingly anxious about future changes because they fear that intrinsic rewards and well-being will be negatively affected. Consequently, when individuals feel that their well-being is threatened, they try to protect it and resist possible changes [ 45 ].

Among other effective factors that can cause RtC in nursing is interpersonal factors of employees. Studies show that communication barriers in the organization ultimately affect the implementation, quality, and sustainability of change [ 9 ]. Employees’ job perception includes rewards and inner satisfaction that they receive from their jobs and interactions with their colleagues [ 46 ], and the positive Colleagues’ opinion are indirectly effective in the resistance behavior of personnel and reducing resistance to change [ 47 ]. The quality of communication between employees is related both to the information before the implementation of the change and to the quality of the information during the implementation of the change [ 48 ]. This factor also refers to the overall quality of communication within the organization, and studies also indicate that poor communication is related to uncertainty in change and often magnifies the negative aspects of change and creates resistance to it. Also, inadequate cross-functional and vertical communication during the stage of change implementation, makes personnel more reluctant to the proposed changes, since they are less informed. So, communication quality will be negatively associated with attitude towards change, disposition towards change and anticipated impact of change [ 7 , 49 ].

The third factor of resistance to change in nursing, is the organizational factors which are in three sub-categories; management factors, organizational values, and structural factors are placed. As mentioned, accepting change at the core of nursing and health care is a challenge because nurses are not only inflexible but also adept at strengthening the existing [ 24 ]. Therefore, changes in healthcare environments require effective managers who can implement change strategies to improve patient outcomes [ 40 ].

The effect of RtC can strengthen the negative effect on organizational effectiveness and organizational commitment, and the lack of leadership support will amplify with time. In this regard, it seems that managers supporting change in the organization can play an important role in improving resistance [ 5 ]. The results of the studies show that a key obstacle to the implementation of change is the culture reported by managers to change [ 6 ], that lack of proper education and guidance is one of the reasons for this [ 35 ], so it seems that the use of appropriate communication; education; feedback, and self-evaluation can be considered a suitable solution to overcome the resistance [ 6 , 50 ]. In general, if the information provided about the change is timely, valid, informative, and sufficient, a more positive evaluation of the change will emerge in the individual [ 51 ]. The tendency to amplify the status quo and the difficulty of change application besides the lack of organizational support can cause resistance to change in nursing [ 35 ]. The lack of participatory management and not being involved in the change process can be considered a factor in the failure of change [ 12 , 27 ]. Employee’s participation in decision-making; Responsibility and ownership of making changes amplify and can be effective in reducing resistance [ 52 ]. Low levels of participation and fear of job loss occur as a result of negative feelings towards change [ 53 ]. It is important to understand cultural change as involving strategic change, which consists of changing an individual’s mind and behavior. How the culture change for each individual is evoked also has an important impact on the result and the consequences for each person [ 54 ]. All noteworthy organizational changes require a few level of corporate culture alter. In spite of the fact that culture alter is essential for making and fortifying organizational change, our position is that making fundamental auxiliary changes may serve as the introductory intercession for changing culture [ 55 ].

Organizational culture is characterized as a set of anticipated behaviors that are for the most part supported inside the group [ 56 ], can play a significant role in RtC. The evidence indicates that to be more successful in the process of change resulting from the implementation of organizational culture, all nurses must be involved in this process from the beginning, otherwise, the employees will feel unappreciated and not involved, and resistance to change will be an unexpected result, and organizational commitment will be reduced [ 36 , 57 , 58 ]. By improving the understanding of the change process, nurses as change agents can meet the challenge of managing change in their clinical environment [ 40 ]. As mentioned; human resources education and amplifying proper communication is among the effective tools to overcome the resistance resulting from the organizational culture [ 6 ]. The nature of the relationship between employees and management, if the pessimism that employees express towards management to change, will mean that they will question the real motivations for implementing the change [ 43 ]. Employees who feel their managers are trustworthy, supportive, inspiring, and can better deal with change; will be more effective in dealing with resistance to change. Therefore, if there is a good relationship between the leadership and the organization’s members, it is expected to see less resistance to change [ 7 ].

Organizational values including organizational culture, negative organizational perception, and conflict with organizational identity also play a fundamental role to cause nurses’ resistance to change. Understanding organizational orientations may hinder the adoption of new evidence-based programs and practices [ 26 ]. Also, changes are frequently in conflict with the organizational identity, which causes an unpleasant impression on individual, and this leads to the distortion of the intended purpose of the change and puts the organizational identity at risk [ 28 ]. Change management starts before any change action is implemented and continues with an understanding of the culture and environmental context in which the change is to be implemented. So, it is important to ensure that change is not just implemented, but that employees and other stakeholders are ready for it [ 24 ].

Structural factors such as organizational characteristics, resources and budget, job characteristics, and environmental changes, along with other organizational factors, are effective factors in creating resistance to change in health care workers. Higgs and Rowland (2010) emphasize factors such as environmental changes, organizational characteristics, resources, and budgets as broad factors affecting the change process [ 36 , 59 ]. Organizational changes are carried out with the aim of changing the way care is provided [ 60 ], one of these changes is related to job characteristics and employees with changes such as moving workplaces, creating new units, merging with existing units, and recruitment of new employee [ 61 ]. Based on this, the key strategies for change management should be focused on the need for sensitivity to organizational culture and characteristics [ 24 ].

Organizational change can be called a stressful factor in the work environment [ 62 ], but although these changes can lead to mental and physical stress among the healthcare team, providing support and positive organizational resources, such as job support and control, may help reduce nurses’ burnout and RtC. Studies also indicate that; when change-related stressors are high, nurses who report high levels of manager’s support; report lower levels of organizational support, and lower levels of cynicism toward workplace change than employees; who report low levels of organizational support [ 63 ]. So, changes in nursing work cause a high workload and increase in administrative stress, which ultimately leads to an increase in pessimism among them regarding the change. Trying to control the job in the organizational structure is necessary to deal with the increase in workload, and reduce pessimism and resistance to change [ 64 ].

Finally, based on the results obtained from selected studies, due to the nature of the nursing profession on the one hand and the occurrence of rapid and large changes in clinical environments and care organizations on other hand, several factors can cause resistance to these changes and affect the care and safety of patients. This resistance is influenced by three important factors, individual, interpersonal, and organizational factors. The effects of these factors, can directly and indirectly, affect the proper care of patients. Therefore, paying attention to these factors to improve them with education, improving communication, efficient and collaborative management, understanding organizational values, and developing organizational structure can reduce resistance to changes in patient care environments.

Changes in the nursing environment are an integral part of nursing practice. The findings of this integrated review confirm the complexity and multifaceted nature of these resistances. A set of individual, interpersonal, and organizational factors in nurses leads to resistance to change and is considered an important challenge in nursing care. Knowing these factors can help reduce resistance and improve the quality of nursing care. So nursing managers and decision makers should pay special attention to this in order to make changes. So that, nurses can provide safe and qualified care for their clients and improve the level of health and satisfaction of patients.

Limitations

The limitations of this study include: not searching for articles in languages other than English and Persian, so our search strategies may have under-represented studies in other languages, such as Spanish and Portuguese.

Acknowledgements

Considering that the present study was an integrated review study and the results of other researchers’ studies have been used, the research team would like to express their gratitude to all whose studies were used in this study.

Author contributions

RCH: study design, data collection, and search, analysis and interpretation, drafting of the manuscript; HE: data collection and search. All authors read and approved the final manuscript. NKH: data collection and search.MS: corresponding author, supervision of the review, and critical revision of the final manuscript.

No funds were used to conduct this study.

Data Availability

Declarations.

The author(s) declared no potential conflicts of interest with respect concerning the research, authorship, and/or publication of this article.

Ethical approval was not required to conduct this review.

Not applicable.

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