Leading Change and Transitions

Original Editor - User Name Top Contributors - Mandy Roscher, Kim Jackson, Rachael Lowe, Tony Lowe and Jess Bell

Introduction[edit | edit source]

Change is inevitable. Personal change; organisational change; implementing new treatment protocols or guidelines, changing to electronic medical record keeping etc. All of these changes and transitions affect healthcare workers. Coping with change and transitions and knowing how to lead others through the process can be a helpful skill.[1]

Change Definition[edit | edit source]

William Bridges- “Change is situational; it is the external event that is taking place, a new strategy, a change in leadership, a merger or a new product. The organization focuses on the outcome that the change will produce, which is generally in response to external events. It can happen very quickly.”[2]

Transition Definition[edit | edit source]

William Bridges- “Transition is the inner psychological process that people go through as they internalize and come to terms with the new situation that the change brings about. The starting point for dealing with transition is not the outcome but the endings that people have in leaving the old situation behind. Getting people through transition is essential if the change is actually to work as planned.” [2]

Examples of Change vs Transition[edit | edit source]

“While change is an event (a death, birth, merger, reorganization, new job, or downsizing), the human response to change, transition, is a process.” [3] For change to be successful peoples’ emotional and psychological needs must be met.

Consider a practitioner that is moving premises. The change is relatively easy. He needs to hire a moving company, print new business cards, transfer the phone line, inform patients of the move etc. With good planning, a change can happen relatively easily. The transition is often more difficult. Learning to work at new premises, working in a building with new people, adapting to a new environment and dealing with your patients’ responses to the move can be much more challenging. Change is the actual process whereas transition is how someone deals with the change

Models of Change and Transition[edit | edit source]

To implement effective change with smooth transitions, change models can be used to help understand and facilitate the process.

There are different models of change and transition and most overlap in their ideas and processes. It has been suggested that combining and adapting multiple change models can facilitate the best process, depending on the change needing to be implemented [4].

Kotter’s 8 Steps for Change[edit | edit source]

John Kotter developed his 8 step model for change in 1995.  His model looks at the entire change process from before the change right the way to after the change is implemented and innovation can continue.

Steps 1, 2 and 3 are focused on “creating a climate for change”. Steps 4, 5 and 6 focus more on “engaging and enabling the change”. Lastly, steps 7 and 8 are aimed at “implementing and sustaining the change.”

Kotter's 8-steps[5][6][edit | edit source]

  1. Establishing a sense of urgency
  2. Creating the Guiding Coalition
  3. Developing a Vision and Strategy
  4. Communicating the Change Vision
  5. Empowering Broad-Based Action
  6. Generate Short-Term /Quick Wins
  7. Consolidation Gains and Producing More Change
  8. Anchoring New Approaches in the Culture (Make it Stick)

Kotter’s 8 step model is considered a good starting point for implementing change as it manages to address both change and transition. [4][7]

In the initial development of this model, there was minimal evidence to prove its effectiveness. It was, however, widely adopted in spite of this.[7] The change process is a difficult construct to research and measure. As such, there is still limited evidence validating the eight-step process as a whole.[4] There has been some promising research applying the model in a healthcare environment.[1]

There are limitations in his approach. Such as, It can be quite rigid.[8] Kotter suggests the steps should always be followed sequentially with limited overlap. This may not fit with the various cultures and the transitions people need to make in the process [4]. Certain steps may also not be applicable in various situations. For example, in a change that involves confidentiality, steps 1 and 4 may not be as relevant [4].

An example of using Kotter's 8 step process in implementing the ICF into an Occupational Therapists’ clinical practice:

Appleby H, Tempest S. Using change management theory to implement the International Classification of Functioning, Disability and Health (ICF) in clinical practice. British Journal of Occupational Therapy. 2006 Oct;69(10):477-80.

Bridges Transition Model[edit | edit source]

Bridges model of transition is based on Williams Bridges’ idea that “it isn’t the changes that you do, it is the transitions” [7]. His model isn’t based on the change as such, but rather people’s reactions to the change. Bridges proposes that if people can feel guided through a change process the change will be more successful.

It is made up of 3 stages.

Transition model.jpg
  1. The Ending Phase
  2. Neutral Zone
  3. New Beginnings

The ending phase is a “letting go” phase. People have to come to terms that change is occurring and this may potentially be threatening to them.[9] The ending phase marks the start of a change but more importantly the end of what was previously in place. The ending phase may evoke negative emotions and resistance.[10]

The Neutral Zone occurs once people start making the change but are pulled between the old and the new. [9]. This can often be a time of insecurity and confusion but also one of positivity and optimism.[3] People can be unsure of themselves in the neutral zone and potentially require a lot of support to progress to the next phase of moving forward into new beginnings.

The New Beginnings phase can only be met once someone is ready to move forward. They need to “give up” the old and embrace the change. The transition from the neutral zone to new beginnings can be very difficult for some people. New beginnings come with acceptance, there can be renewed energy and acceptance of the change.[10]

The idea of this model is that people involved in the change process need to move through the 3 transitional stages. People respond differently to change, some being more open and willing to change and others more resistant. At the start of the change process in an organisation, the number of people in the ending phase is far greater than those in the neutral zone or new beginnings. In the middle of the change, most people fall into the neutral zone, pulled between the past and future. By the end of the process, most fall into new beginnings.[9] It is important to note, in Bridges' model, that some people start out the process in new beginnings. Those are the people that are normally enthusiastic and open to change. And similarly, at the end of the change, there may be some that are still stuck in the ending phase and may never truly accept the change.

An example of effective ways to manage transitions.

Bridges W, Mitchell S. Leading transition: A new model for change. Leader to leader. 2000;16(3):30-6.

ADKAR[edit | edit source]

The ADKAR model was developed in 2003 by Jeff Hiaat. It was designed as a goal-oriented process to help guide individuals through change. ADKAR stands for Awareness, Desire, Knowledge, Ability and Reinforce.


A- Awareness of the need for change

D- Desire to support and participate in the change

K- Knowledge of how to change

A- Ability to implement required skills and behaviours

R- Reinforcement to sustain the change

Each area can be assessed using key questions. For example, in the awareness phase, key questions could be “Why is this change necessary” or “What will happen if we don’t change?”[11]. When using the ADKAR model each area is assessed using a score out of 5, the first area where one scores 3 or less would be the persons “barrier” point and this would be the area to focus on to facilitate effective change.[10]

Kubler Ross Change Curve Model[edit | edit source]

Elizabeth Kubler Ross developed the 5 stages of grieving and accepting. It addresses the emotions and reactions that people move through during change and transitions. Her model is based on circumstances where there is meaningful loss eg a diagnosis of a terminal illness. This has subsequently been adapted into a change management model. It can be applied to any change that involves strong emotions around old processes or systems that are being replaced with new ones.

The five stages are:[12]

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

People need to move through each of these stages to progress to full acceptance and they may need to be supported through this process.

Video explaining Kubler Ross

An example of the application of Kubhler Ross’s model to a doctor needing to embrace the change to an electronic recordkeeping system:

Shoolin JS. Change management–Recommendations for successful electronic medical records implementation. Applied clinical informatics. 2010;1(03):286-92.

Leading Change and Transitions[edit | edit source]

The above models are just a few examples of change models. Healthcare is changing rapidly. Whether you work on your own in a small private practice or in a large hospital environment, change occurs on a daily basis. It is helpful to understand the different models and apply the various principles to smaller changes that are occurring.

With larger changes, for example, implementing a new electronic record keeping system, it may be more helpful to systematically follow one or more of the change models to ensure smooth transitions take place.

Additional Resources[edit | edit source]

Detailed Video on Kotters 8-Step Model

References[edit | edit source]

  1. 1.0 1.1 Kumar A, Kent F, Wallace EM, McLelland G, Bentley D, Koutsoukos A, Nestel D. Interprofessional education and practice guide No. 9: Sustaining interprofessional simulation using change management principles. Journal of interprofessional care. 2018 Nov 2;32(6):771-8.
  2. 2.0 2.1 William Bridges. What is Transition. Available from: https://wmbridges.com/what-is-transition/(accessed 13/07/2019)
  3. 3.0 3.1 Lawrence E, Ruppel CP, Tworoger LC. The emotions and cognitions during organizational change: The importance of the emotional work for leaders. Journal of Organizational Culture, Communications and Conflict. 2014;18(1):257.
  4. 4.0 4.1 4.2 4.3 4.4 Appelbaum SH, Habashy S, Malo JL, Shafiq H. Back to the future: revisiting Kotter's 1996 change model. Journal of Management Development. 2012 Aug 10;31(8):764-82.
  5. 5.0 5.1 Galli BJ. Change management models: A comparative analysis and concerns. IEEE Engineering Management Review. 2018 Oct 9;46(3):124-32.
  6. Haas MRC, Munzer BW, Santen SA, Hopson LR, Haas NL, Overbeek D. #DidacticsRevolution: Applying Kotter's 8-Step Change Management Model to Residency Didactics. West J Emerg Med. 2019;21(1):65-70.
  7. 7.0 7.1 7.2 Brisson-Banks CV. Managing change and transitions: a comparison of different models and their commonalities. Library Management. 2010 May 18;31(4/5):241-52.
  8. Chappell S, Pescud M, Waterworth P, Shilton T, Roche D, Ledger M, Slevin T, Rosenberg M. Exploring the process of implementing healthy workplace initiatives: mapping to Kotter's leading change model. Journal of occupational and environmental medicine. 2016 Oct 1;58(10):e341-8.
  9. 9.0 9.1 9.2 Bridges W, Mitchell S. Leading transition: A new model for change. Leader to leader. 2000;16(3):30-6.
  10. 10.0 10.1 10.2 Jason Giesbrecht. Leading Change and Transitions. Physioplus 2019
  11. Hiatt J. ADKAR: a model for change in business, government, and our community. Prosci; 2006.
  12. Malone, Erin. The Kubler-Ross change curve and the flipped classroom: Moving students past the pit of despair. Education in the Health Professions. 2018;1(2):36.