NURS 721 Week 5 Leadership and Change Theory Synthesis Paper Example

Why the Third Attempt Will Be Different: A Synthesis of Leadership and Change Theory Applied to Bedside Shift Report on Four Medical-Surgical Units

Introduction

Over two years, the four medical-surgical units I direct introduced bedside shift report twice, and twice it faded. Both rollouts followed a familiar pattern: a script designed by leaders and educators, training for every nurse, weekly audits and recognition for high compliance. Both reached about 80% compliance within a month, and both fell below 30% within six months of the audits ending. Our nurses are skilled and caring, and the evidence for bedside report is reasonable. Something in how we led the change failed, and the leadership and change literature offers several ways to explain what.

This paper synthesizes four leadership theories, transformational leadership, servant leadership, complexity leadership and Clawson's Level Three leadership, with three change theories, Lewin's three-stage model, Kotter's eight-stage process and Rogers's diffusion of innovations. Rather than describing each in turn, it organizes them around three questions any practice change must answer: Where does change begin? Who leads it? How is it sustained? The paper then grounds the synthesis in research on bedside handover and applies it to a third attempt, which our unit practice councils will begin designing next month.

Approach to the Synthesis

The theories were chosen because each addresses the bedside report problem from a different angle and because each has been widely used in nursing. Transformational and servant leadership are the relational styles most studied in nursing leadership research. Complexity leadership was included because a hospital unit is a complex adaptive system in which no leader controls outcomes. Clawson's model is the course's central text and speaks directly to why behavior change fails. Lewin, Kotter and Rogers represent three distinct views of change: as a stage process, as a leadership sequence and as social spread. For each theory, I read the original or authoritative source, then examined how the theories agree and conflict on the three questions, and finally tested the resulting themes against systematic reviews and studies of bedside handover.

The Theories in Brief

Leadership Theories

Burns (1978) distinguished transactional leadership, an exchange of rewards for performance, from transforming leadership, in which leaders and followers raise one another to higher levels of motivation and morality. Bass and Riggio (2006) developed this into transformational leadership, whose four components describe leaders who earn trust as role models, articulate a compelling purpose, invite followers to question assumptions and attend to each follower's growth. Greenleaf (1977) reversed the usual order, holding that leadership should grow out of a prior desire to serve; the test he proposed is whether those served grow healthier, wiser, freer and more likely themselves to become servants. Uhl-Bien et al. (2007) argued that in knowledge-era organizations, leadership is not only what managers do but an emergent, interactive dynamic among people, and they described three functions: administrative leadership in formal roles, adaptive leadership that produces change through interaction, and enabling leadership that creates conditions for adaptive leadership to flourish. Clawson (2012) distinguishes influence on what people do, on what they consciously think and on the convictions underneath both, and argues that leaders who work only at the surface obtain compliance without commitment.

Change Theories

Lewin (1947) pictured a group's current behavior as a balance between forces pushing for change and forces resisting it, and proposed that lasting change requires unfreezing the present level, moving to a new level and freezing group life at the new level. Kotter (2012) set out eight stages for leading organizational change, starting from a felt need to act and a powerful leadership group and ending with anchoring new approaches in the culture, and argued that skipping stages creates an illusion of speed without results. Rogers (2003) explained how innovations spread through social systems over time, noting that adoption depends on an innovation's perceived relative advantage, compatibility, complexity, trialability and observability, and that people adopt at different rates, from innovators and early adopters to laggards.

Theme 1: Change Begins Below the Surface

The first point of agreement across the theories is that lasting change begins with what people believe, not with what they are told to do. Clawson (2012) says so directly: behavior is driven by values, assumptions, beliefs and expectations, and leaders who change only behavior obtain compliance that lasts as long as their attention. The unfreezing stage in Lewin (1947) makes the same claim in different language. A group's current behavior is held in equilibrium by forces, including group norms, and until those forces shift, any change will spring back. The first stage in Kotter (2012), establishing urgency, is a practical version of unfreezing: people must feel that the status quo is more dangerous than change. Transformational leadership's intellectual stimulation, in which leaders invite followers to question assumptions (Bass & Riggio, 2006), is a leadership behavior that serves the same purpose.

Our failed rollouts skipped this step entirely. We announced bedside report as the new standard, explained its benefits and trained the behavior, but we never surfaced what nurses believed about report. When I later held conversations with nurses on each unit, four beliefs emerged: that report is a private professional conversation, that patients would hear frightening or inappropriate information, that bedside report takes longer, and that management cared about the audit rather than the nurses. Each is a Level Three belief, and each is a restraining force in Lewin's terms. Training did nothing to change them, so when the audits ended, behavior returned to equilibrium. One night nurse put it plainly in a council conversation: she had done bedside report correctly every time a manager was on the unit and never once when one was not, because she believed the patients slept better without it. Her belief may or may not be accurate, but it was never asked about, tested or answered, and so it won.

The theories differ on how beliefs change. Kotter (2012) emphasizes urgency created by leaders, which risks becoming a pressure campaign. Clawson (2012) and Burns (1978) place more weight on engagement and mutual influence, suggesting that beliefs change through dialogue in which leaders also listen and are changed. Rogers (2003) adds that beliefs about an innovation change when people can try it and see its results, through trialability and observability. Synthesizing these, I conclude that urgency alone is insufficient; beliefs change when people examine them in conversation, test the new practice themselves and see its effects. Unfreezing is not something leaders do to nurses; it is something nurses do with their own assumptions when leaders make room for it.

The evidence on bedside handover supports this conclusion. A systematic review of 30 studies of handover that included patients or carers found benefits for patient satisfaction, engagement and information exchange, but also found that providers reported barriers, cognitive load and declining compliance over time, and that perceived increases in workload could undermine the advantages (Maher et al., 2025). The barriers named in the review, privacy, time and workload, closely match the beliefs our nurses described, which suggests that they are common restraining forces that any implementation must address directly.

Theme 2: Leadership of Change Is Distributed, Not Only Positional

The second theme concerns who leads change. The classic theories assume a leader at the center. The guiding coalition in Kotter (2012) is a group of powerful people assembled by a leader, and the model in Lewin (1947) is often read as something a change agent does to a group. Transformational leadership, as most research operationalizes it, also centers on the formal leader's behavior. Ystaas et al. (2023), synthesizing 23 studies, traced the effect of transformational leadership on nurses' work environment to intermediate factors such as empowerment, commitment and satisfaction, and noted that in no included organization did nurses rate their managers' transformational behavior as excellent. A review of 12 reviews similarly found relational leadership styles, led by transformational leadership, to be the most studied in nursing and linked mainly to staff outcomes such as job satisfaction (Hult et al., 2023).

Servant leadership and complexity leadership shift the center. Greenleaf (1977) measures leadership by the growth of those served, which implies that a leader's success is partly the emergence of leadership in others. Uhl-Bien et al. (2007) go further, arguing that change in complex organizations emerges from interactions among many people, and that formal leaders contribute mainly by enabling those interactions: creating space, connecting people and protecting adaptive work from bureaucratic pressure. In this view, a director cannot install bedside report; she can only create conditions in which nurses work out a version that fits their units.

These views conflict with the classic models, and the conflict is useful. Our two rollouts were designed by a positional coalition in exactly the way Kotter describes, and they failed partly because the people who had to change had no part in designing the change. Rogers (2003) explains why: an innovation's compatibility with existing values and practices strongly affects adoption, and compatibility is easier to achieve when the adopters shape the innovation themselves. Rogers also notes that innovations are often reinvented by adopters as they spread, which the complexity view welcomes rather than resists. The synthesis I draw is that change needs both kinds of leadership. Formal leaders must provide what Uhl-Bien et al. (2007) call administrative and enabling functions: setting boundaries, providing resources and removing obstacles. The design and spread of the practice itself should be led by frontline nurses, through shared governance councils and peer champions who function as Rogers's early adopters.

A multisite study of nursing handover illustrates this blend. Researchers implemented a tailored ward-level intervention on seven wards in three hospitals, informed by interviews, focus groups and recordings of 233 handovers, and afterward found that nurses conducted more handovers at the bedside with more patient interaction and more structured, comprehensive information (Chien et al., 2024). The authors concluded that practice change required strong executive leadership and project governance combined with ward-level leadership, collaboration and mentoring, and that nurses were more likely to give patient-centered bedside handovers when they understood the value of handover and had practical strategies. Executive sponsorship and frontline ownership were both necessary; neither was sufficient alone.

Theme 3: Sustaining Change Requires Adaptation, Not Only Freezing

The third theme concerns how change lasts. The freezing stage in Lewin (1947) and the final stage in Kotter (2012), anchoring change in the culture, both treat sustainability as consolidation: once the new practice is established, structures, norms and rewards should hold it in place. Our second rollout tried to freeze bedside report by rewarding whichever unit posted the best audit numbers. It held only as long as the recognition program ran.

Complexity leadership offers a different view. Uhl-Bien et al. (2007) see organizations as networks of interacting people whose practices keep shifting as they work together, so that sustaining a change means building the capacity to keep adapting it rather than freezing it in its original form. Rogers (2003) likewise treats reinvention as normal. The bedside handover literature suggests why this matters. Maher et al. (2025) found compliance declining over time across studies, and a systematic review of 13 studies found bedside handover associated with better patient-perceived safety, satisfaction, reduced anxiety and involvement, and with shorter handovers, less shift overtime and fewer call-light requests, while noting that privacy concerns and variable implementation were barriers and that training was needed for consistency (Daicampi et al., 2025). Variable implementation is often treated as failure, but in a complexity view it may be adaptation to different units' patients and workflows.

The synthesis I draw is that sustainability requires both stability and adaptation. The core of the practice, such as including the patient in a safety check at the bedside, should be anchored in policy, orientation and competency checks, as Lewin and Kotter suggest. Around that core, units should have freedom to adapt how report is done, with a regular forum, such as quarterly council review, where nurses examine what is and is not working and revise the practice. Training must also be renewed rather than delivered once. A quasi-experimental study in six intensive care units found that bedside handover training raised head nurses' and staff nurses' knowledge and observed handover performance markedly, with gains sustained but slightly reduced at three months (Ahmed et al., 2025), which suggests that even effective training fades without reinforcement.

Where the Theories Fall Short

A synthesis should also say what the theories together still miss. None of the seven gives much attention to the workload that a new practice adds, although the handover literature repeatedly identifies time and workload as barriers (Maher et al., 2025). Leadership theories treat followers' resistance mainly as a matter of belief or motivation, but some resistance is a rational response to a practice that adds minutes to an already overloaded shift change. A leader who treats every objection as a Level Three belief to be engaged may miss an objection that is simply true. The plan below therefore treats nurses' concern about time as an empirical question to be measured, not only as an assumption to be discussed.

The theories also say little about patients, who are participants in bedside report rather than bystanders to it. Daicampi et al. (2025) found patient benefits in perceived safety, satisfaction and involvement, and Maher et al. (2025) found mixed patient-oriented outcomes, yet none of the leadership or change theories considers how patients' expectations might help sustain a practice. If patients come to expect that the nurses will introduce each other and check the plan with them at the bedside, that expectation becomes a force for the new equilibrium that Lewin did not anticipate. Finally, all seven theories were developed largely in Western, often corporate, settings. They translate reasonably well to American hospital units, but the evidence base on bedside handover itself spans many countries and cultures, and units with many internationally educated nurses may hold different expectations about authority and voice than the theories assume.

Synthesis Matrix

The matrix below summarizes what each theory contributes to the three themes and what it misses.

An Integrated Change Plan for the Third Attempt

The synthesis produces a plan different from our first two attempts in each theme.

Beginning Below the Surface

Each unit practice council will begin with structured conversations, on every shift, about what nurses believe report is for and what worries them about bedside report. The four beliefs already identified will be addressed explicitly: the council will agree which information is shared at the bedside and which is shared privately, a pilot will measure actual handover times on two units, and the audits that nurses saw as surveillance will be replaced by peer observation with feedback. Urgency will come from data the nurses themselves review, including handoff-related safety events on their units, rather than from leadership announcements.

Distributing Leadership

I will set three boundaries: the patient must be included in a safety check at the bedside, all four units must share one core structure so that nurses who float between them meet a familiar routine, and a pilot must begin within eight weeks. Within those boundaries, the four councils will design the process, and each unit will identify two early adopters per shift, chosen by peers rather than managers, to model and coach the practice. My role, in the language of Uhl-Bien et al. (2007), is enabling: providing time for council work, data and evidence, and removing obstacles such as staffing at shift change. The chief nursing officer has agreed to act as executive sponsor, reflecting the finding that executive and ward-level leadership are both needed (Chien et al., 2024). Her role is deliberately limited: she will attend the launch of each council's work, review progress monthly with me and remove obstacles that sit above my authority, such as the shift-change overlap that staffing policy currently does not fund. The early adopters, in turn, will meet together every two weeks during the pilot to compare what is working across units. Rogers (2003) observed that adopters are most persuaded by peers similar to themselves, so these meetings are where the practice is most likely to spread from unit to unit, and where local reinventions can be judged and shared. In this arrangement, formal authority protects the work while influence among peers carries it, which is the combination the synthesis recommends.

Measuring Whether Beliefs Changed

Because the synthesis locates the failure of the first two attempts in beliefs, the evaluation must try to measure beliefs as well as behavior. Before the pilot and again at six months, nurses on each unit will complete a short anonymous survey asking whether they see bedside report as useful for safety, whether they worry about privacy or time, and whether they feel the process belongs to them or to management. The councils will design the questions, and the results will be shared with every unit. A change in those answers would be the strongest sign that the third attempt has worked where the first two did not.

Sustaining Through Adaptation

The core elements will be written into unit policy, orientation and annual competencies. The councils will review bedside report quarterly using patient experience comments, handoff-related events, handover times and peer observation results, and they will revise the process as needed. Training will be repeated with each orientation cohort and refreshed annually, since training gains fade without reinforcement (Ahmed et al., 2025). At the six-month and one-year reviews, success will be measured not only by compliance but by whether nurses report that bedside report helps them and their patients, which would indicate change at the level of belief rather than behavior.

Christian Worldview

When James and John asked for places of honor, Jesus answered that greatness among his followers would be measured by service, and he pointed to his own mission of giving his life for others (English Standard Version Bible, 2001/2016, Mark 10:35-45). Greenleaf (1977) drew on a similar insight, but for a Christian leader it is more than a theory; it is an imitation of Christ. Applied to change, servant leadership means that the leader's plan matters less than its fruit: patients receive safer care and nurses grow in their capacity to shape their practice. Paul's call to count others more significant than ourselves and to look to their interests (English Standard Version Bible, 2001/2016, Philippians 2:3-4) describes the posture this third attempt requires of me: listening to nurses' concerns as legitimate rather than as resistance to be overcome.

Conclusion

Synthesizing seven leadership and change theories around three questions produced conclusions none of them reaches alone. Change begins below the surface, in the beliefs that hold current behavior in place, and those beliefs change through dialogue, trial and observed results rather than urgency alone. Leadership of change must be distributed: formal leaders set boundaries and enable, while frontline nurses design and spread the practice. Sustaining change requires a stable core anchored in structures, surrounded by room for continuing adaptation. Our first two attempts at bedside shift report failed on all three counts. The third attempt is designed to succeed on each, and its success will be measured by what nurses believe about report as well as by what they do.

References

Ahmed, W. E., Fakhry, S. F., & Mohamed Badran, F. M. (2025). Bedside handover training and its effects on nurses' knowledge and compliance. BMC Nursing, 24(1), Article 1472. https://doi.org/10.1186/s12912-025-04075-9

Bass, B. M., & Riggio, R. E. (2006). Transformational leadership (2nd ed.). Lawrence Erlbaum Associates.

Burns, J. M. (1978). Leadership. Harper & Row.

Chien, L. J., Slade, D., Goncharov, L., Taylor, J., Dahm, M. R., Brady, B., McMahon, J., Raine, S. E., & Thornton, A. (2024). Implementing a ward-level intervention to improve nursing handover communication with a focus on bedside handover: A qualitative study. Journal of Clinical Nursing, 33(7), 2688-2706. https://doi.org/10.1111/jocn.17107

Clawson, J. G. (2012). Level three leadership: Getting below the surface (5th ed.). Pearson.

Daicampi, C., Veronese, M., & Cesaro, E. (2025). Impact of bedside handover on patient perceptions and hospital organizational outcomes: A systematic review. Journal of Nursing Management, 2025(1), Article 3803491. https://doi.org/10.1155/jonm/3803491

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Greenleaf, R. K. (1977). Servant leadership: A journey into the nature of legitimate power and greatness. Paulist Press.

Hult, M., Terkamo-Moisio, A., Kaakinen, P., Karki, S., Nurmeksela, A., Palonen, M., Peltonen, L. M., & Häggman-Laitila, A. (2023). Relationships between nursing leadership and organizational, staff and patient outcomes: A systematic review of reviews. Nursing Open, 10(9), 5920-5936. https://doi.org/10.1002/nop2.1876

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

Maher, A., Hsu, H., Ebrahim, M. E. B. M., Vukasovic, M., & Coggins, A. (2025). Implementation of bedside handover that includes patients or carers in hospital settings: A systematic review. Journal of Evaluation in Clinical Practice, 31(6), Article e14223. https://doi.org/10.1111/jep.14223

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.

Uhl-Bien, M., Marion, R., & McKelvey, B. (2007). Complexity leadership theory: Shifting leadership from the industrial age to the knowledge era. The Leadership Quarterly, 18(4), 298-318. https://doi.org/10.1016/j.leaqua.2007.04.002

Ystaas, L. M. K., Nikitara, M., Ghobrial, S., Latzourakis, E., Polychronis, G., & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients' outcomes: A systematic review. Nursing Reports, 13(3), 1271-1290. https://doi.org/10.3390/nursrep13030108