Journal of Nursing Management, 2000, 8, 265±272

The development of a model to manage change: re¯ection on a critical incident in a focus group setting. An innovative approach
M. CARNEY

RGN, RM, RNT, FFNRCSI, MBA (HONS)

Lecturer, School of Nursing and Midwifery, University College Dublin, Ireland

Correspondence Marie Carney School of Nursing and Midwifery University College Dublin National University of Ireland Earlsfort Terrace Dublin 2

CARNEY M . (2000) Journal of Nursing Management 8, 265±272 The management of change: using a model to evaluate the change process. An innovative approach

management of change. The Change Management Model may provide nurse managers or change agents with a structured and measurable model for managing and evaluating the change process. A measurement constructs tools to further assist the evaluation process is also described. Background The author argues that certain key variables can be identi®ed which contribute to the successful implementation of change. These variables include critical success factors for change, communication issues, change dynamics that include resistance or acceptance of change, and the variables related to the management of the implementation and evaluation stages of the change process. Key issues Change is a constant in the health care ®eld. Nurse managers must learn to accept change as a normal process and to develop coping and managing strategies for the successful management of change. This acceptance of change as a dynamic process will create opportunities and challenges for nurses. Conclusion The Change Model was developed through re¯ection on critical incidents related to change by students at a University School of Nursing and Midwifery in the Republic of Ireland, in a focus group setting. The Measurement Construct Tool was developed through a review of the tools currently in use and from ideas generated in a matrix related to change presented by Clarke & Garside (1997). Students who were involved in the initial focus group discussions agreed that the Change Model was highly effective in describing how the change was managed; that the Change Management Measurement Constructs Tool facilitated the evaluation of a change process; and permitted the inherent subjectivity related to the change process to be replaced by an objective measurement tool. Both the model and the Measurement Construct Tool are in the process of being tested for validity and reliability.
Accepted for publication: 17 March 2000

Aim This paper describes the development of a model to manage and evaluate the

Introduction
Theories concerning the nature of change include description of the main components of the change process, and methods of introducing change (Carnell 1995). There has been much debate on the factors that contribute to the f 2000 Blackwell Science Ltd

successful implementation of change, but views differ on how this might be achieved. This paper does not seek to review the full range of literature on the topic of change, rather, the focus will be on particular aspects of change that are viewed as problematic, including those aspects 265

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from the focus group discussions that took place among a group of 18 bacculauret nursing students. The paper will go on to describe how the model was developed, and the models component parts.

Change as a dynamic process
There exists both in the nursing and in the business community's academic press a large and growing body of literature on the management of change. A realization that change is the result of competition between the driving and restraining forces is evident in much of this literature and as Lewin (1951) noted some forces drive change whilst others will resist it. The change agent, who is the person facilitating change needs to identify and analyse these forces and if possible to manage them, and in this way allow driving forces to take effect (Leavitt 1964, Kanter 1995). The dynamics of change include an understanding of the realities surrounding change. Often change is introduced without due regard for the realities of individual areas of practice or of the needs of individual practitioners, and change agents may have complete disregard for the likely consequences of the change on the lives of others, or the understanding that even minor change may have unintended consequences for individuals and organizations (Kotter & Schlesinger 1979). To minimize these consequences effective change should be managed (Limo-Basto 1995). `Few organizational changes tend to be complete failures, but few tend to be entirely successful either' (Kotter & Schlesinger 1979). It is not the change that causes the problem, rather it is the transition from the prechange to the postchange situation. Transition is the psychological process that people go through in order to come to terms with the new process (Bridges 1991, Broome 1990). This view goes some way to characterize the complexity of change, and permits an insight into the dif®culties encountered when managing change. Change is a constant in the health care ®eld, but it is faster and more complex now than it has ever been before (Mannion 1994). We may not always accept change, but must learn to manage it, and indeed the ability to manage change has become an essential skill for all nurse managers (Zukowski 1995, Glynn 1989, Damanpour 1987, Pryjmachuk 1996). Poggenpoel (1992) suggests that change may lead to real innovation, providing abundant opportunities for creating a better way forward. Bradshaw (1995) and Mulholland (1994) highlight the profound changes that have taken place in the British Health Service during the past decade. The Irish Health Service is undergoing a similar change process that is characterized by a period of transition from a relatively
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stable environment to one of some considerable instability where cost control and value for money are paramount. Nurses are concerned with organizational change. Thus, an effective manager needs insight and knowledge into change theories (McPhail 1997, Redstone & Wilson 1993). Nurses manage care, and must utilize management skills in the delivery of care. It is therefore essential that management skills have their bases in understanding the theories and processes of change management (Post 1989). Poggenpoel (1992) suggests that for nurses to view change as a challenge and to manage it pro-actively and creatively, they need to understand change as a phenomenon, identify the key emotional reactions associated with change such as resistance, and know how to manage change in a positive manner. If change is approached with a certain level of excitement and enthusiasm it will create opportunities that will make the lives of patients better (Muller 1992). Resistance to change is caused by many factors including anxiety, uncertainty, and feelings of loss of control in relation to the direction and pace of the change process (McPhail 1997). The most important reasons for resistance to change are self interest, a lack of understanding of the proposed change, and the desire to keep things as they are (Cutcliffe 1997). In this regard the internal question that is most frequently asked is: Why should I change my life to accommodate this proposed change?

Use of a change management model
Models for practice, work or activity have in their make up ideas, beliefs, knowledge and other less tangible building blocks A model provides direction for practice, work or activity and forms the framework through which change may be managed and evaluated. If a model is used to guide change, consistency in approach can be achieved, with the model serving to direct, guide and make sense of the change process (Pearson et al. 1996).

Development of model through re¯ection on practice
There is a lack of clarity in the literature with regard to the de®nition of re¯ection. Differences in interpretation are primarily due to the ways in which re¯ection is described, the terminology used and the linkages of re¯ection to other mental processes such as to examine or scrutinize, and also to the relationship of re¯ection to critical thinking processes (Atkins & Murphy 1993, Kompf & Bond 1995, Scanlan & Chernomas 1997). Schon (1983) makes the distinction between re¯ection that occurs f 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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during practice and re¯ection occurring in `thinking back on practice'. The latter form of re¯ection is appropriate to the development of the change model since it facilitates `re¯ection on how the experience recently encountered may have contributed to an intended or unintended outcome', in this case a discussion on a previous change situation (Schon 1983, 1987). Critical re¯ection on practice serves to enhance learning, and encourages the development of critical thinking skills (Scanlan & Chernomas 1997). The ®rst stage of the process as de®ned by Schon (1983) was used, and included an exploration of thoughts and feelings related to a change situation that had recently taken place, and a desire to explore the change further. The second stage of the process allows students to `critically analyse the change situation bringing to bear existing knowledge' (Atkins & Murphy 1993). The students were assisted by the tutor in this process. As a result of this awareness and critical thinking, student's developed a new perspective on the change situation, with new learning resulting. Re¯ection may be used in nurse education as a means of integrating theory and practice (Osterman 1990, Reed & Procter 1993, Jarvis 1992). This view is not without its critics. For instance Greenwood (1993) accused Argyris and Schon of relying too heavily on verbal accounts of situations after the event. The ability to re¯ect on one's practice promotes the development of expertise in clinical practice. Kottkamp (1990) expressed the need for practical ways in which re¯ection can be used as an educational tool, rather than as a desirable rhetorical concept. Jones (1995) has described `hindsight bias' as in¯uencing peoples' recollection of events once they know the ®nal outcome, and he questions the validity of re¯ection in some circumstances. This view is accepted, and is indeed a reason for testing the models in order to ensure reliability and validity is achieved.

Flanagan, in 1954 in his work with World War 11 pilots and the technique has been used in nursing in many ways since then in the assessment of practice (Norman et al. 1992; Smith & Russell 1991).

Focus group interviews
Focus groups are seen as a means of gathering the views, opinions, and beliefs on a particular subject from a number of participants in a single session, for the purpose of producing the views and opinions of the group members through social interaction, and where the feelings of participants are stimulated through the dynamic processes occurring within the group (Reed & Procter 1993). Kingry et al. (1990) note that the method has become popular in the caring professions, and is seen as a useful strategy for evaluating interventions and processes. Peer group discussion in the form of two focus groups was the conduit for the re¯ective process described in this study, whereby students discussed and analysed a change process they had recently encountered or had been part of in their clinical practice. The use of focus groups promotes the concept of a safe environment as being `essential to learning the skills of self re¯ection' (Riley-Doucet & Wilson 1997). In order to place some structure on the process a `critical incident approach' was used. The participants were postregistered nurses undertaking a degree in management in a College af®liated to a School of Nursing and Midwifery in the Republic of Ireland. The management of change was a core module presented on the programme. Eighteen students took part in the focus group discussions, and the same group subsequently used the change model and measurement construct tool to evaluate the change they had discussed during group discussions. The purpose of the focus group discussions, and the subject area to be discussed was communicated to the students by the author who acted as moderator. Students were advised on their rights to refuse to partake in the focus groups, should they wish to do so. Two groups of nine students each took part in the focus group discussions, which were undertaken simultaneously on the same site. Students were requested to identify a recent `critical incident' related to change, to re¯ect on this and to discuss the process. The moderator encouraged students to express their concerns and in doing so to integrate theoretical perspectives with their practical experiences of change. Some relevant theoretical concepts were introduced by the moderator during guided discussion on the critical incidents under discussion. Without prior knowledge of the incidents being described by group members the moderator had to be capable of dealing with emerging
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Critical incident approach
The focus group approach to critical incident analysis is not widely demonstrated in nursing literature (Burnard 1987). Smith & Russell (1991) advocate group exercises to discuss and solve clinical and procedural problems, and with a facilitator in attendance as in this case. A critical incident analysis has been espoused as a valuable method of promoting re¯ective nursing (Minghella & Benson 1995). Both re¯ection on practice and a critical incident approach were utilized in the development of the change model. Critical incident techniques were ®rst developed by f 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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views, and to think creatively and quickly in an effort to facilitate the process of re¯ection through analysis to new learning (Beattie 1987). Following the focus group interviews which lasted 90 minutes each the tutor identi®ed the central themes emanating from the interviews. These emerging themes when combined with the literature on change formed the basis upon which the change model was developed.

ensures misinterpretation or ambiguity in relation to meaning is avoided. The Measurement Construct Tool was designed to provide an objective measurement of the model's components. Each sentence is scored on a scale from 0 to 4. The scores for each key variable are totalled at the bottom of each column. A score key assists in the evaluation of the model's effectiveness. These components and their constituent key sentences make up the Change Management Model as set out in Fig. 1.

Analysis of data
At the close of each focus group discussion, the principal themes and issues in relation to the management of change were summarized by the moderator in an effort to verify accuracy in interpretation, and to obtain group con®rmation of these. The analysis and interpretation of focus group data is generally similar to other qualitative data analysis, with the `added dimension of the group context' (Carey & Smith 1994). The qualitative data generated were then analysed using the method of analysis proposed by Burnard (1991). Burnard described a process of `thematic content analysis' adopted from Glaser and Strauss's grounded theory approach. This is a 14-stage process commencing with the recording of notes relating to the focus group discussion, and concluding with the writing up of the process. For the purposes of the development of the change model stages 1±4 only of Burnard's method was used. Firstly the interview notes from the two focus group discussions were read over by the moderator. Following a careful reading of the notes general themes emerged. Headings by which to describe all aspects of the data collected were then generated from these themes. Headings were then grouped into major themes and categories which best described the group members thinking. A literature review on change was then undertaken, and following this the Change Management Model was developed. The model building blocks and principal components are presented in Fig. 1.

Component I: critical success factors for change
The success of any change is determined by a number of critical success factors, or key factors that must be managed well to ensure success. By concentrating on these key factors success is more likely to occur. Critical success factors are factors that must be in place or present before success can be guaranteed. The success factors identi®ed as being of critical importance in the management of change are: commitment levels amongst managers and staff involved in the change process; level of motivation present; use of professional judgement in decision making throughout the process; level of understanding of the need for change demonstrated by staff; identi®able communication skills, and the recognition of the need for a high quality outcome to change.

Component II: the communication process
The second component of the model is the communications process. The key variables are the importance of consultation, education, and participation during the process; the needs of staff and patients are recognized through assertiveness; negotiation with no evidence of coercion takes place; an understanding of the change dynamics exists, and democratic decision making to assist in managing the change process occurs.

Elements of the Change Management Model
The model attempts to make sense of the ®ve building blocks or components identi®ed as being critical to the successful management of change. The principal components of the model are: critical success factors for change; the communications process; acceptance or resistance to change; the implementation process, and the evaluation process. Each component is comprised of seven key variables that have been identi®ed by the author as being the necessary ingredients of any change. Each is described by a key sentence, with the keyword(s) in each sentence underlined for easy identi®cation. The use of keywords
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Component III: acceptance or resistance to change
The level of acceptance or resistance to change is the third component of the model. The key variables are: the level of acceptance to the change, involvement and understanding of the need for change; the likely impact of the proposed change on the social and cultural lives of the individuals concerned; as well as a clear understanding of the need for a project team to assist in the change process. Any resistance to change is overt and manageable with the driving and restraining forces having been identi®ed and managed. f 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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Critical success factors

Communication Score 0-4 process

Score 0-4

Acceptance/ resistance to change level

Change Implementation Score 0-4 Process

Evaluation Score 0-4 Process

Score 0-4

Figure 1 Change Management Model

Component IV: the change implementation process
The key variables identi®ed in the change implementation process and regarded as critical to the successful implementation of the proposed change are: the need for prior research, with a project team interacting and working well together; the use of process tools such as strategy development and planning with clear inputs and outputs identi®ed; recognition and management of the transition state, with provision of the required education programmes for staff to facilitate successful implementation.

Component V: the evaluation process
The evaluation element is the ®nal key component in the model, and includes the following key variables: recognition of the need to evaluate the process at various stages, and to take necessary action; the provision of feedback and recognition and acknowledgement of the contribution of staff.

ment elements of the Change Management Model. It is similar in composition to the Change Model comprising ®ve components and seven key variables. Each of the key variables is broken down and the key variables for each element are measured by scoring from 0 to 4. The Measurement Constructs Tool sets evaluation parameters and further enhances the model's effectiveness as an objective and measurable tool for evaluating change. The Measurement Constructs Tool was developed following the development of the Change Model and was tailored to measure the components and key variables of the Change Model. A review of evaluation instruments in current use was undertaken. This measurement tool was adapted from an idea from the model developed by Clarke & Garside (1997) titled The development of a best practice model for change management and is presented in Fig. 2.

Components of the Measurement Constructs Tool
The scores range from 0 to 4 with four indicating that the critical success factors were fully articulated and understood, and that a visible commitment from all concerned exists. A score of zero indicates that there has been no understanding of the critical success factors or their importance in the change process, and that little top level management support or understanding existed for the
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The Measurement Constructs Tool
The Measurement Constructs Tool is designed by assigning to each variable a score on a scale ranging from 0 to 4, and is used in conjunction with the change management model, by seeking to illuminate the measuref 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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Figure 2 Change Management Model Measurement Constructs Tool adapted from Clarke A. & Garside J. (1997) The development of a best practice model for change management.

change. Points in between indicate moderate success in this area. A score of four indicates excellent communications with all concerned understanding the need for change and all agreeing the methods to achieve the desired change. The consequences of the change are fully understood. A score of zero indicates a total lack of communications throughout the change process. Points between zero and four indicate moderate success in this area. A score of four for the acceptance or resistance to change element indicates full acceptance of the change, with those affected being involved from the beginning. The likely impact on staff has been addressed, and teams have been set up and are working well together. A score of zero indicates complete resistance to the change, where only the individual(s) pushing the change through believes the change to be worthwhile. Points in between indicate moderate success. A score of four for the change implementation element indicates that a Change Management Model or change process tool has been used and understood. The use of strategic planning, and objective setting has been undertaken and there exists very clear agreement on the methods to be used. Full training has been provided. A score of zero indicates that there has been no visible model or methods in place, that no understanding of the change process exists, and staff have not received any training for the change. Points in between indicate moderate success in this area.
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A score of four in the evaluation process indicates that there has been full agreement on the evaluation process at all stages, that all concerned believed that progress had occurred, and the importance attached to evaluation of the change process has been recognized. A score of zero indicate that no evaluation took place at any stage. Points in between indicate moderate success.

The score key
A further guide to the Measurement Constructs Tool is the use of the score key. This may be used to evaluate the overall effectiveness of the change process. A score ranging between 120 and 150 indicates that the change was managed excellently throughout, and a score ranging between 0 and 29 indicates a poorly managed change. Scores in between indicate moderate success.

Discussion
The successful implementation of change is for the greater part judged subjectively by the individuals involved, and may be viewed differently by each person. Views will be in¯uenced by the achievement of personal goals, desired outcomes or perceptions of how the change is likely to affect the social, cultural or economic lives of individuals. The use of the Change Management Model should assist in reducing subjectivity associated with any change, but f 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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uniformity across the weighting system may be dif®cult to achieve in practice. However, the components and key variables that make up the model are usually present in any change situation, and if identi®ed and managed well should contribute to the successful implementation of the change. It is acknowledged that some key variables will have greater importance than others and these should be identi®ed and managed with key priority status. The 18 students who used the model to evaluate change situations which they had recently encountered, all found a positive correlation between their individual experiences and the model scoring system as a means of evaluating the change. In each case the student found the Change Management Model score represented their subjective opinions of the change. They also expressed the view that the use of a model to manage change helped to place the change process within a structured organizing framework. These are the views of a small group of students only, and further research into the effectiveness of the model is required. The triad combination of re¯ection on practice, critical incident identi®cation and analysis, and the use of focus group interviews and discussion to generate a model for practice is an innovative approach. Each part of this particular process is open to critical debate, as indeed is the combination of this triad, and the facilitator's role is also. The weaknesses of the group discussion method lie in the fact that the facilitator may have limited control over the discussion and greater dif®culty in managing the debate, but this was not felt to be the case in this instance although an awareness of this possibility was present throughout. There was no evidence of group conformity preventing full expression of attitudes or feelings, or of group compliance with the views of dominant individuals (Holloway & Wheeler 1996, Carey & Smith 1994). The literature search related to re¯ection, critical incident analysis and focus groups identi®ed advantages and disadvantages to each approach, many of which are mentioned in this paper, and which were accepted and considered throughout the entire process. The models require further testing in a variety of clinical situations where change has taken place to allow reliability and validity to be established.

effectively the change was managed. A Change Model and Measurement Constructs Tool should assist in the management of change. The models provides an objective framework in which change can be managed, evaluated and measured. The 18 students who used the model to evaluate change situations which they had recently encountered, all found a positive correlation between their individual experiences and the model scoring system as a means of evaluating the change.

Acknowledgements
My sincere appreciation to the 18 students who participated in the focus group interviews, and to Ms. Clarke and Mr Garside who granted me permission to adapt their model in the development of the Measurement Constructs Tool presented here.

References
Atkins S. & Murphy K. (1993) Re¯ection: a review of the literature. Journal of Advanced Nursing, 18, 1188±1192. Beattie A. (1987) Making a curriculum work. In The Curriculum in Nursing Education (Allen P. & Jolley M., eds). Croom-Helm. London, pp 15±34. Bradshaw P.L. (1995) The recent health reforms in the United Kingdom: some tentative observations on their impact on nurses and nursing in hospitals. Journal of Advanced Nursing, 21, 975±979. Bridges W. (1991). Managing Transitions ± Making the Most of Change. Addison-Wesley Publishing Company Inc, Massachusetts, pp. 2±35. Broome A.K. (1990). Managing Change. Chapter 3. MacMillan Press Ltd, UK. Burnard P. (1987). Towards an epistemiological basis for Experimental learning in nursing education. Journal of Advanced Nursing, 12, 189±193. Burnard P. (1991). Experimental learning in action. Avebury, Aldershot, UK. Carey M.A. & Smith M.W. (1994) Capturing the group effect in focus groups. Qualitative Health Research, 4 (1), 123±127. Carnell C. (1995). Managing Change in Organisations. Prentice Hall International Ltd, UK. Clarke A. & Garside J. (1997) The development of a best practice model for change management. European Management Journal, 15 (5), 537±545. Cutcliffe J.R. (1997) Introducing change in nursing: the case of research. Journal of Nursing Management, 5, 241±247. Damanpour F. (1987) The adoption of technological, administrative and ancillary innovations: impact of organisational factors. Journal of Management, 13, 675±688. Flanagan J. (1954) The critical incident technique. Psychological Bulletin, 51, 327±358. Glynn J. (1989) Management of change: an essential skill for nursing in the 1990s. Journal of Nursing Management, 5, 199±205. Greenwood J. (1993) Re¯ective practice: a critique of the work of Argyris and Schon. Journal of Advanced Nursing, 18, 1183±1187.

Conclusion
The concepts and processes involved in the process of managing change are complex. The identi®cation of the components and the key variables that must be managed well to ensure success are subjective and varied. Individuals make subjective opinions regarding how f 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 265±272

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Holloway I. & Wheeler S. (1996) Qualitative Research for Nurses Blackwell Science. Oxford. Jarvis P. (1992) Re¯ective practice and nursing. Nurse Education Today, 18, 192±194. Jones P.R. (1995) Hindsight bias in re¯ective practice: an empirical investigation. Journal of Advanced Nursing, 21, 783±788. Kanter R.B. (1995) World Class: Thriving locally in a global economy Simon and Schuster, New York. Kingry J.M., Tiedje L.B. & Friedman L.L. (1990) Focus groups: a research technique for nursing. Nursing Research, 39 (2), 124. Kompf M. & Bond W.R. (1995) Through the looking glass: some criticisms of re¯ective practice in teaching and teacher education. Paper presented at the American Education Research Association Annual Meeting. 18±22 April, San Francisco, California. Kotter J.P. & Schlesinger L.A. (1979) Choosing strategies for change. Harvard Business Review, 57, 106±114. Kottkamp R. (1990) Means for facilitating re¯ection. Education and Urban Society, 22 (2), 182±203. Leavitt H.J. (1964) Applied Organisation Change in Industry. In Management (Grif®n R.W. ed). Houghton Mif¯in, USA., pp. 363±364. Lewin K. (1951) Frontiers in Group Dynamics: In Management (Grif®n R.W. ed). Houghton Mif¯in, USA, pp. 359±370. Limo-Basto M. (1995) Implementing change in nurses professional behaviours: limitations of the cognitive approach. Journal of Advanced Nursing, 22, 192±200. Mannion J. (1994) Managing change: the leadership challenge of the 1990s. Seminars for Nurse Managers, 2, 203±208. McPhail G. (1997) Management of change: an essential skill for nursing in the 1990s. Journal of Nursing Management, 5, 199±205. Minghella E. & Benson A. (1995) Developing re¯ective practice in mental health nursing through critical incident analysis. Journal of Advanced Nursing, 21, 205±213. Mulholland J. (1994) Competency-based learning applied to nursing management. Journal of Nursing Management., 2, 161±166.

Muller P.A. (1992) Change, con¯ict and coping. Journal of Post Anasthesia Nursing., 7, 54±55. Norman I.J., Redfern S.J., Tomalin D.A. & . & Oliver S. (1992) developing Flanagan's critical incident technique to elicit indicators of high and low quality nursing care from patients and their nurses. Journal of Advanced Nursing, 17, 590±600. Osterman K. (1990) Re¯ective practice: a new agenda for action. Education and Urban Society, 22 (2), 133±152. Pearson A., Vaughan B. & Fitzgerald M. (1996) Nursing Models for Practice. 2nd edn. Butterworth Heinemann. UK. pp.2±11. Poggenpoel M. (1992) Managing change. Nursing RSA, Verpleging, 7, 28±31. Post N. (1989) Managing human energy: an ancient tool of change experts. Managing change: the leadership challenge of the 1990s. Seminars for Nurse Managers, 2, 203±208. Pryjmachuk S. (1996) Pragmatism and change: some implications for nurses, nurse managers and nursing. Journal of Nursing Management, 4, 201±205. Redstone J. & Wilson J. (1993) Managing change. British Journal of Theatre Nursing 10±11. Reed J. & Procter S. (1993) Nurse Education: a Re¯ective Approach. Edward Arnold, London. Riley-Doucet C. & Wilson S. (1997) A three-step method of self-re¯ection using re¯ective journal writing. Journal of Advanced Nursing, 25, 964±968. Scanlan J.M. & Chernomas W.M. (1997) Developing the re¯ective teacher. Journal of Advanced Nursing, 25, 1138±1143. Schon D.A. (1983) The Re¯ective Practitioner. Jossey Bass, San Francisco. Schon D.A. (1987) Educating the Re¯ective Practioner. Jossey Bass, San Francisco. Smith A. & Russell J. (1991) Critical incident technique. In Nurse Education: A Re¯ective Approach (Reed J. & Proctor S., eds. Edward Arnold. London, pp. 119±130. Zukowski B. (1995) Managing change ± before it manages you! Medsurg Nursing, 4, 325±330.

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