Leading change has become one of the essential core competencies of health professionals today. Since 2001, the authors have been the key designers and facilitators of the Dorothy Wylie Nursing Leadership Institute (DMW-NLI). The background, key characteristics and benefits of the DMW-NLI have been described in detail elsewhere (Simpson et al. 2002). One of the Institute's key features is that participants bring a change initiative that they wish to pursue and - during their time on site - we assist them in developing that project to the point where it has a strong chance of success. When we incorporated this aspect into the DMW-NLI program, we believed that opportunity to apply the learning of the Institute to a desired initiative in the home setting would add significant value, not only to the participants, but also to their sponsoring organizations. Further, it was our hope that we could develop a methodology to advance the change initiative, which would be a valuable tool that participants could use in future change projects.

As we looked to the literature, we found no shortage of articles on change theory, as well as numerous tools and techniques for project management. However, we did not find one single approach or methodology that we felt was comprehensive yet concise enough to serve as a practical guide for those who wish to advance a change initiative in their practice settings today. Therefore, we developed an integrated conceptual framework and methodology for leading change initiatives, building on selected current and classic theories of change that are relevant today. Both the framework and methodology have proven very hardy, and will, we believe, be of interest to nurse leaders and other health professionals in leadership roles.

This paper will provide a brief overview of relevant background literature on leading change initiatives, introduce the DMW-NLI Change Leadership conceptual framework, describe a number of activities that support the framework, and conclude with a summary of its impact to date and implications for leaders and managers.

Leading Change Initiatives: Selected Literature and Background

One of the first to study change theoretically was Kurt Lewin, who in the 1950s led a core group of social psychologists who studied organizational change by immersing themselves in the culture in partnership with managers inside organizations (Kleiner 1996). Lewin and his colleagues describe change as involving an unfreezing process, a learning or changing process and a refreezing process. Practitioners who follow Lewin's approach to change attempt to conduct a force-field analysis to gather information regarding the problem or desired change, and to gain information about the driving and restraining forces for change.

In The Change Masters (1983), Rosabeth Moss Kanter describes a model of change designed to guide executives in promoting innovation and entrepreneurship within their organizations. In her model, Kanter identifies three sequential "waves of activity" that characterize innovation leading to change: problem definition, coalition building and mobilization. She argues that leaders who wish to promote innovation should do so using a collaborative and participative approach. However desirable a change, it always has an impact and requires some change in behaviour from those involved.

In the 1980s and 1990s, William Bridges (1980, 1991; Bridges and Mitchell 2002) advanced our understanding of change leadership by describing knowledge he had gained during 15 years of work with people in the midst of personal and career change, and a subsequent decade of observing organizational change. Bridges differentiates between organizational change and transition. Change, he says, is about what will be altered; transition is about how the change will feel for those required to make it. Change can be planned and managed using a more or less rational model.

Since then, many authors have described the steps involved in planning and managing change. Kotter (1996) describes eight steps to transforming an organization, including establishing a sense of urgency; forming a powerful guiding coalition; creating a vision; communicating the vision; empowering others to act on the vision; planning for and creating short-term wins; consolidating improvements and producing still more change; and institutionalizing new approaches. Ackerman-Anderson and Anderson (2001) describe a "conscious change leadership" process that is continuous and non-linear and incorporates an evaluation component. Their steps include preparing to lead the change; creating vision, commitment and capacity; assessing the situation and determining design requirements; designing the desired state; analyzing the impact; planning and organizing for implementation; implementing the change; celebrating and integrating the new state; and learning and course-correcting.

Golden (2006) developed a four-stage change framework to transform healthcare organizations, building on the work of earlier authors and incorporating his work on organizational redesign, ensuring the organization is sufficiently aligned to support the change.

Finally, our work has been informed by our experience as management consultants. We have noticed a tendency by those leading change not to spend enough time or energy in strategically planning for it, including identifying and engaging stakeholders who may be affected. We sought to develop an integrated conceptual framework and approach that would link the relevant theory to a series of concrete and practical steps.

Integrated Conceptual Framework for Change Leadership

In our discussions with change leaders (e.g., Janet Brown, Ontario Ministry of Health Priority Project, personal communication 2003) and in our observation of clients involved in change projects, we found three typical approaches to leading change within an organization. They include a strategic approach, an organizational development or people-driven approach and a project management approach. We also noted that many leaders tended to emphasize one approach over another. Leaders who prefer strategy-driven approaches focus on the need for change and the desired outcome; they tend to provide minimal specifications or rules, and work towards defining a shared purpose or outcome. Leaders who prefer organizational development or people-driven approaches tend to focus on stakeholder engagement, facilitation and capacity building. People who prefer more project management-type approaches tend to emphasize the definition of the tasks, deliverables and accountabilities required to implement the new or changed processes.

During development of our methodology, we each individually recalled situations in which a change faltered because the person with a terrific vision failed to provide people with the necessary direction or support to make the change happen. We could also think of cases where persons or groups were so relationship- driven that everyone felt good about the process, yet nothing concrete was accomplished. Finally, we recalled projects in which managers locked themselves in their office, divided everything into small tasks and workgroups, and produced impressive work plans, but failed to garner any excitement or commitment for the initiative or to realize the subtle connections between tasks and relationships.

Accordingly, we set about to develop a model that incorporates all these approaches, as we believe all are essential in order to introduce and manage change successfully. Our model for change, therefore, includes three major elements of change leadership: Being Strategic, Engaging People and Managing the Project (Figure 1).

As the framework indicates, the first requirement for successful change leadership is Being Strategic - in the choice of a project and the timing of it; generating enthusiasm by the development of a compelling vision and values to guide the change; and being clear about the need for change and the desired outcomes.

The second requirement for success is Engaging People, which includes identifying, analyzing and enlisting the support of stakeholders. In order to succeed in implementing any change, project leaders must enlist others, including stakeholders who may not see the change initiative project as their highest priority. The second aspect of Engaging People is to create and launch a project team - identifying, in a deliberate way, the skills and experiences needed, the strengths and skills that different team members can bring and how the team can be enabled both to participate and to succeed.

The third and last requirement for success is Managing the Project. Many projects do not achieve a full measure of success because leaders fail to ensure that their vision is translated into concrete steps, with deliverables, key activities, accountabilities, timelines and communication.

Note that the framework is not static and that the elements overlap. For purposes of clarity, however, we will discuss each element separately.

To be successful in implementing any change, strong leadership skills, as well as insight into one's own personal motivations, are required. Two domains of the DMW-NLI framework are key underpinnings to our Leading Change work. They include

• Kouzes and Posner's (2002) Five Leadership Practices (Modelling the Way, Inspiring Shared Vision, Challenging the Process, Enabling Others to Act and Encouraging the Heart) and
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• the Use of Self: Personal Integrity, Emotional Intelligence (Goleman et al. 2002) and Life-long Learning.

Activities to Assist Change Leaders in Applying the Framework

Through our experience at the DMW-NLI and the recently initiated Health Leaders Institute (HLI), which is geared to all health professionals, not just nurses, we have developed and refined a number of activities that assist participants to take home-based projects from the idea stage through to the development of a robust plan. We believe that these activities, if replicated by those undertaking any change initiative, will enhance the chances of success.

Getting started

Prior to launching into a change initiative, we recommend that the individuals who will have ownership of the change process engage in focused reflection, consider the following questions that touch on the three aspects of the framework and identify whether they have sufficient passion for the project to carry it through.

1. Is the project strategic?

• What challenges/problems is this project going to address?
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• How will your organization's functioning be improved once the project is completed?
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• To what extent is your proposed project consistent with organizational, nursing or programmatic strategic plans or priorities?
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• Is the timing good to embark on this project?

2. Will you be able to engage the necessary people?

• Who are the key stakeholders (persons, groups) who are likely to be affected by or influential in the success of your project?
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• Is there support from at least one key stakeholder?
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• Are there any highly placed opponents?
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• Can you create the necessary project team to bring the project to fruition?

3. Will you be able to manage the project successfully?

• Is the project a manageable size and doable?
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• Do you have adequate resources to manage this project? (Consider both human and fiscal resources.)

4. How do you feel about the project?

• What excites you about the project? (Considering that you will be spending a lot of time and energy on this project over time, it is important to consider why you care about it.)
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• What concerns or frightens you about this project? What are you worried about?

Next, we suggest that the project leaders discuss their proposed project with a number of key stakeholders within their organization - individuals who can be counted on to provide honest and helpful input regarding the project's strategic, human and logistical challenges and chances of success. In pursuing these discussions, it is also advisable to secure a formal sponsor for the project - someone at a higher level in the organization who is supportive, can smooth the way and help to access needed resources and who is willing to provide advice and assistance along the way.

Having given preliminary thought to all three aspects of the framework, and having secured appropriate support, the project leaders are then ready to undertake the more specific activities required to flesh out their plans.

Being strategic

Kanter (2000) states that the most important things a leader can bring to a changing organization are passion, conviction and confidence in others. She comments that too often executives announce a plan, launch a task force and then simply hope that people find the answers - instead of offering a dream, stretching their horizons and encouraging people to do the same. Our experience as consultants confirms this perception. For that reason, we start our project work with "Being Strategic." In this stage, project leaders, in a series of exercises, define the goals and values of their project and then draft a compelling vision of the preferred future.

To describe the goals for the project, leaders need to consider

• the challenges/problems their project will address,
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• how their organization's functioning will be improved once the project is completed and
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• the extent to which the proposed project is consistent with strategic priorities.

We suggest writing two to four goals for the project - statements that succinctly describe the challenge the project is going to address and the main benefits that will be realized.

It is also crucial to articulate the values that are most important to the successful completion of the project. Values are the underlying principles behind the need for change. Clarification of values is a significant part of Being Strategic, as values speak to the themes or principles the project leaders want stakeholders to understand and hold as priorities.

Once the goals and values are clear, it should be possible to craft a vision statement for the preferred future. If project leaders want to get people excited about the change initiative, they require a vision statement that is compelling - that describes a unique and ideal image of what the future will look like when the project is successful (Kouzes and Posner 2002) and how everyone will benefit from it. In crafting a vision statement, it is sometimes helpful to consider the following questions:

• What ideal or passion inspires you and your organization to undertake this project?
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• What future do you envision for your constituents and for the greater organization or community as a result of this project?
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• What is unique about your dream for this project?
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• How will the project serve the common good of all stakeholders?

When project leaders have created a draft vision statement for their project we suggest they identify a trusted friend or colleague whom they can approach to test-run the vision, or public and private situations that may arise during the following weeks in which they could share the vision with others and get a reaction.

Kouzes and Posner (2002) emphasize that the most powerful visions use metaphor or visual analogy to change abstract notions into tangible and memorable images. Accordingly, the final activity in Being Strategic recommends that project leaders select a metaphor for their project - a picture that will capture the essence of the vision in a way that is clear and engaging.

Engaging people

This element of the framework consists of two distinct aspects: engaging key stakeholders and developing a project team.

Kanter (2000) comments that change is created constantly and at many levels in an organization. She notes that while there is the occasional earth-shaking event, there are also the everyday actions of people engaged in their work, and that change leaders need the involvement of people who have the resources, knowledge and political clout to make things happen. In our Engaging People work, we therefore recommend that project leaders undertake a deliberate process in which they identify stakeholders; determine whether they are likely to be influential, supportive, neutral or resistant to the proposed change; and craft deliberate strategies to build coalitions of supporters. The findings of Laschinger et al. (2000) regarding empowerment are relevant here: individuals require access to informal and formal power structures, information, opportunity, support and resources, in order to be empowered. It is often helpful to document the stakeholder analysis using a tabular format (stakeholder, type of support or resistance, strategy, communication plan). The strategies that project leaders can employ to work with key stakeholders will vary according to their kind and level of support and influence (RNAO 2002).

Influential and supportive stakeholders have the potential to promote and direct the adoption and dissemination of the project. They are the project leaders' best allies, and can do a great deal to ensure the project's success. They will need attention and information in order to maintain their commitment and endorsement. The approach will be to leverage their support. Strategies for leveraging support include the following:

• Review the project with stakeholders and ask for suggestions and feedback on how to engage others, on the clarity of the vision, and so on.
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• Analyze how and where they'd like to be involved and invite them to participate.
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• Provide them with information on the status of the project - and keep it top of mind.
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• Use them as a test run - to clarify the vision and to provide input into the approach and strategy.
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• Obtain approval and support for key project activities where necessary.
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• Provide opportunities where stakeholders can be publicly supportive.

Some stakeholders will be neutral about the project, not caring much either way whether it succeeds or not. There are likely also some stakeholders about whose support the project leaders are uncertain. The approach to these individuals will be to build commitment. Some strategies for building the commitment of neutral stakeholders include:

• Recognize their needs. Try to identify how they might benefit from success in your project, and link their needs to the benefits.
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• Help them to see how the status quo is shortchanging them in some way, and demonstrate how supporting the project will help them achieve their particular agenda.
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• Build relationships. Cultivate stakeholders (and not just in relation to your project).
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• Use external stakeholders, consultants or both to give impartial credibility to the project.
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• Involve stakeholders at some level - at a minimum, by keeping them informed.

Finally, there will be stakeholders who will be resistant. These stakeholders have the potential to impede the project's adoption and dissemination. There is a tendency to generalize or downplay resistance and, as a result, not factor in a thorough analysis of sources and kinds of resistance (Kotter 1996).

Many authors have presented strategies to address resistance. In 1979, Kotter and Schlesinger identified six approaches to dealing with resistance that are still very useful today. They ranged from education and communication, to participation and involvement, to facilitation and support, to negotiation, and even to manipulation or coercion. The last two are rarely the best choices and should be used only as a final resort. The particular strategy chosen will need to be customized to address the reason for resistance, giving consideration to the amount and type of resistance anticipated (withdrawal vs. sabotage); balance of power and trust issues between initiator and resistor; energy for implementing the change (both the project leaders and the stakeholders); and the stakes involved and consequences of failure to change (again, for both the project leaders and the stakeholders).

Gantz (2005) links strategies to deal with resistance to the underlying causes, which we further developed in Table 1.

[Table 1]

Many excellent initiatives fail because of ineffective or insufficient communication. In the same way that stakeholder strategies need to be customized, so too do stakeholder communications. As the project leaders are identifying their key stakeholders and strategies, we suggest that they identify how they will communicate with each of these individuals. In formalizing the communication plan, it is helpful to think about how the project could benefit each stakeholder, or how each might be negatively affected if the project does not go ahead. Then determine who would be the best person to lead communication with each stakeholder, how best to frame the message and the best media and timing for doing so.

The second activity in Engaging People is to enlist others for the implementation by engaging a project team. When the project leaders are ready to create a team, there are a number of questions they will want to consider:

• What size do we want this team to be? (Smaller is generally easier logistically, but larger offers the opportunity to get more perspectives and stakeholder commitment.)
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• What skills and experiences do we need for success?
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• Who needs to be involved? Who has high influence with the target audience?
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• What unique perspective could each person bring to our team?
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• Which of this person's strengths and skills can our team use?
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• What would motivate him or her to want to participate?
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• What enabling actions do we need to take to help this person make the maximum contribution to the team? (Consider opportunity, information, support and resources - e.g., training, making connections, time release, background information.)

We recommend that project leaders be purposeful in establishing their project team, and suggest that they document their deliberations using a "team launch" table with the following headings: team member; major contribution; and enabling actions (what the project leaders need to do to prepare the team member to make his or her optimal contribution).

Managing the project

This element of the framework is designed to assist project leaders to develop a clear idea of how they are going to manage their project. It includes, at a minimum, a project plan and an evaluation strategy.

Change can get derailed if details are overlooked. The project plan maps out the pacing and timing of change and those who will be responsible for project elements and key deliverables. The first step in the project plan is to identify key milestones and target dates. In doing so, it is helpful to keep in mind

• the major steps that need to be undertaken,
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• small wins you hope to achieve and
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• points at which you should pause to monitor your progress (and possibly re-adjust your plan).

Next, project leaders will want to identify the major activities required to achieve each milestone, and attach an accountable team member's name to each milestone or activity. It is best to keep descriptions brief and not make a project out of the project plan.

While details are important, we strongly encourage project leaders to avoid becoming obsessed with planning every detail. Rather than trying to control the entire change process, letting those involved run with various elements of the change can spark and develop unexpectedly positive results (Auster et al. 2005).

As the plan is being prepared, we suggest that the project leaders discuss how they will obtain any necessary approvals. For this they will need to consider its cost implications and identify the following:

• required resources, including human resources, supplies, capital and so on;
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• potential funding sources (e.g., donations, grants); and
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• potential savings (direct or cost avoidance - e.g., if you reduce turnover you may be able to avoid some advertising and orientation costs).

It is also helpful to build opportunities for staff learning into the project plan. In our rapidly changing environment, one can increase the likelihood of success and adaptation by building staff capabilities for continuous learning and evolution.

In today's climate of fiscal constraints in healthcare, there is an increased requirement to ensure that accountability is woven into the work we do. The final consideration in Managing the Project is the development of an evaluation plan in order to provide accountability and indicators of the project's success. Kanter (2000) states that one of the mistakes leaders make is to launch projects and then leave them. We recommend that project leaders think about how they will support and measure success from both a process and an outcome perspective. We encourage them to be specific as to what it is that they are going to measure, who will be accountable for the evaluation components and the timing. Evaluation steps and measures can then be written into the project plan wherever they are needed.

Use of a tabular format for documenting the project plan and evaluation strategy is helpful; headings might include: milestones, target dates, activities, accountabilities and evaluation measures.

Finally, if the project has significant financial costs or implications, project leaders may also have to develop a business case to secure commitment from key decision- makers in the organization. Typical components of a business case include the following:

• problem statement
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• mission or vision
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• specific objectives
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• preferred approach
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• expected benefits
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• plan of work, timeline and key milestones
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• performance and progress measures
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• risks and ways to avoid or address them
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• project management and staffing
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• cost estimates and funding sources (if any)
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• alternatives considered
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• opposing arguments and responses.

Sharing the good news

Finally, while communication with stakeholders is a deliberate and thoughtful part of the Engaging People strategy, there will be many occasions when project leaders will be presented with the opportunity to promote their project to interested parties. We therefore recommend that they take the time to develop a one- to two-minute "pitch" for their project - the kind of description that can be shared with key people they may just happen to encounter on the elevator, in the corridor or in the lineup in the cafeteria. Tips for making these brief presentations successful include the following:

• Identify the features and benefits of the project. Features are characteristics that answer the questions who, what, where, when and how. Benefits are the ways in which the project will meet stakeholder needs; they start with action verbs such as improve, enhance, manage, control, respond and so forth.
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• Include no more than three to four important features and three to four important benefits in your business case. Be sure to consider features and benefits from the perspective of the stakeholders, emphasizing the "WIIFM" (What's in it for me?) factor.
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• Practise communicating the key features and benefits to a group of constructively critical colleagues.

Conclusions and Implications

By December 2006, participants in the DMW-NLI and Health Leaders Institutes had launched over 500 change initiatives in their organizations. These projects were loosely grouped into the following categories, and descriptions of them are listed on the Institute websites at www.dwnli.ca and www.healthleaders.ca.

Practice:

• Care Delivery Models
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• Care Pathways and Best Practices
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• Client-Centred Care
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• Clinical Practice Changes
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• Developing New Programs or Processes
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• Scope of Practice

Leadership:

• Leadership Development/Optimizing Nursing Leadership
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• Policy Development
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• Professional Practice
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• Retention/Recruitment
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• Workload Measurement/Management

Knowledge:

• Healthy Workplaces/Quality of Work Life
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• Knowledge Development and Transfer
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• Orientation
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• Relationship Building
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• Role and Standard Development
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• Resource Management and Development
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• Values and Culture

Admittedly, some of the change initiatives have faltered, and others have not achieved all that their sponsors hoped. But many have been spectacularly successful. Several initiatives have been published, and many project teams have made presentations at professional conferences, workshops and similar gatherings.

Most importantly, those who have had the opportunity to develop their projects through the described integrated methodology have acquired skills and tools that they can use in future change initiatives, and have gained confidence in their ability to effect change. Furthermore, their organizations have benefited and will continue to benefit from the application of this process. The authors regularly receive communications about project successes, project presentations and requests to use the framework for other purposes.

In conclusion, the comprehensive methodology described in this paper provides an integrated and thorough approach to guide the implementation of change, an approach that has proven valuable and, when applied to future change initiatives, can ensure a thorough project launch with a good likelihood for success.

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