NURS 6053 Week 9 Change Model Fit Thread Example

Week 9 Discussion: Initial Post

Five Departments, Five Clocks: Why Kotter Fits the Late-Discharge Problem Better Than Lewin Alone

Before choosing a change model, I want to characterize the change itself, because the fit depends on it. My organizational stressor is late-day discharges: patients ready to leave in the morning leave in the late afternoon, which keeps emergency admissions boarding for hours. The cause is not one broken step. Nursing completes discharge teaching when the assignment allows; hospitalists round on the sickest patients first and write discharge orders late in the morning; pharmacy reconciles discharge medications in a queue; case management arranges services by phone; transport runs on its own dispatch schedule. Each of five departments runs on a separate clock, under a separate reporting line, and any fix has to change how those clocks align. This is a cross-departmental change with no single owner, and it will meet resistance from groups whose own workflows seem reasonable to them.

Lewin's three-stage model deserves a fair hearing. Unfreezing would mean helping each group see that the current pattern is a problem, for example by showing hospitalists the boarding times in the emergency department. Moving would introduce a new practice, such as a morning discharge huddle. Refreezing would stabilize the new practice through routines and reinforcement so it does not slide back (Lewin, 1947). The model is simple and clear, and refreezing is an idea this problem badly needs, since past discharge initiatives in many hospitals fade. But Lewin's model says little about how to build a coalition across departments that do not report to the same leader, and that is the hard part of this change.

Kotter's eight stages fit better because two of them address exactly what this change requires. Creating a sense of urgency comes first: each department must see the cost of late discharges in its own terms, whether emergency boarding, hospitalist workload the next morning, or transport overtime. Forming a powerful guiding coalition comes second: a group with members from all five departments and enough authority to change their own departments' routines (Kotter, 2012). Without that coalition, a nursing-led initiative would change nursing's clock and leave the other four unchanged. Hospitals that have moved discharges earlier have typically done so through exactly this kind of interdisciplinary effort, with daily rounds and shared goals across services (Wertheimer et al., 2014).

The usual criticism of Kotter is that the model is linear and leader-driven, assuming change moves through stages in order under direction from the top, when real organizational change is messier and depends on frontline engagement (Appelbaum et al., 2012). I think that criticism is fair, and my answer is to combine the models at different levels. Kotter's stages would guide the hospital-level coalition and timeline, while Lewin's refreezing logic would guide each unit: once a unit adopts the morning huddle, its routines, documentation, and feedback would be adjusted so the new practice becomes the default. Using both lets each model do what it does best.

Reply to Laura

Laura, your stressor, medication errors on one unit's night shift, is contained within one department and one reporting line. I think that reverses the match: Lewin's model may fit your change better than Kotter's, because you do not need a cross-departmental coalition, and a clear unfreeze-move-refreeze sequence with strong refreezing through audit and feedback could be enough. Would a guiding coalition add anything on a single unit?

Reply to James

James, you chose Kotter for reducing hospital-acquired pressure injuries across the organization, and I agree with the match. One question: who creates urgency for the wound care and nutrition departments, whose own measures may not include pressure injuries at all? The urgency stage may need a different message for each department, as I found with discharges.

References

Appelbaum, S. H., Habashy, S., Malo, J.-L., & Shafiq, H. (2012). Back to the future: Revisiting Kotter's 1996 change model. Journal of Management Development, 31(8), 764-782. https://doi.org/10.1108/02621711211253231

Kotter, J. P. (2012). Leading change. Harvard Business Review Press.

Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154