Eight Steps, Ninety Days, Two Units: A Kotter-Based Plan to Let Bedside Nurses Order Pressure-Redistribution Surfaces Without Waiting for Approval
Student Name
American College of Education
NUR5043: Nursing Leadership: Organizational Systems
Module 5 Assignment
Instructor Name
November 9, 2026
Why Kotter's Model
Kotter (1996) built his eight steps from the ways he had seen organizational change fail: too little urgency, no powerful coalition behind the change, no clear vision, too little communication, obstacles left in place, no early wins, victory declared too soon and changes never anchored in the culture. The model suits this change for a specific reason. The nurse-driven mattress protocol crosses five departments and depends on people whom the director of nursing does not supervise, and the first three steps of Kotter's model are about building the shared urgency and the coalition that a leader without direct authority needs before any process changes.
The model has limits that the plan must respect. Appelbaum et al. (2012) reviewed research on each of Kotter's steps and concluded that while several steps have support in the wider literature, the model as a whole has had little direct empirical testing, and its sequence can be too rigid for changes that need rapid adjustment. For that reason this plan uses the eight steps as the organizing frame for leadership work and uses plan-do-study-act cycles, described by Langley et al. (2009), for the process details inside the pilot, so that problems found in the first weeks can be corrected without restarting the whole sequence.
Steps One to Three: Urgency, Coalition, Vision
Step one, creating urgency, begins in week one and belongs to the director of medical-surgical nursing. Urgency will come from one page, built with the budget analyst, that shows what no group in the hospital has seen together: the median 19-hour wait for a surface, an injury rate on the medical-surgical units that has climbed by more than two thirds since the approval rule began, and the falling rental spending that each group has been watching separately. Padula and Delarmente (2019) estimated that more than half of the cost of hospital-acquired pressure injuries comes from stage 3 and 4 wounds, and the page will put a local cost beside that estimate. The measure of this step is simple: the finance director and the chief nursing officer agree in writing that the problem belongs to both departments.
Step two, the guiding coalition, is formed in weeks two and three. Its members are the director, the wound nurse, the budget analyst, the supply chain contract manager, the respected night charge nurse from the worst-affected unit, and one house supervisor. The chief nursing officer sponsors the group and the finance director receives its reports. This membership follows directly from the stakeholder analysis in Module 4: each member either holds a decision the change needs or holds influence over people who will carry it out.
Step three, the vision, is written by the coalition in its first meeting and kept to one sentence that a nurse could repeat at 0300: any nurse can get the right surface to a high-risk patient within four hours, and the hospital will know every month what that costs and what it prevents. The vision names both the clinical promise and the financial accountability, because a vision that speaks only to nursing would lose the finance director at the first meeting.
Steps Four to Six: Communication, Obstacles, Early Wins
Step four, communicating the vision, runs through weeks four to six on the two pilot units. Huddles led by the two unit managers, with the night charge nurse leading on nights, run at every shift change for two weeks, around a one-page protocol card that lists the criteria, the extension to call and the next-day review. The director attends one night huddle on each unit in person. The measure is that at least 85% of registered nurses on the two units sign that they have read the card by the end of week six.
Step five, removing obstacles, has three parts, each with an owner. The chief nursing officer, with the finance director's agreement, suspends the advance approval rule for the two pilot units for 90 days. The supply chain contract manager asks the vendor to start the delivery clock when the bedside order is placed and to send weekly delivery times while the pilot runs. The transport supervisor assigns delivery and placement of the surface to transport staff, so that nurses do not have to find a second person to move the patient onto it, an obstacle the climate assessment in Module 3 identified as likely to make the protocol feel like extra work.
Step six, short-term wins, is planned rather than hoped for. At the end of weeks four and eight of the pilot, the director will report two numbers back to both units and to finance: the median time from order to surface and the number of orders made after 1530 or on a weekend. The first win nurses need to see is not a lower injury rate, which will take months to show, but a Friday night order that arrived before Saturday breakfast.
Steps Seven and Eight: Building On and Anchoring
Step seven, consolidating gains, begins at day 90 with a decision meeting. If the pilot meets its targets, the coalition will propose extending the protocol to the remaining three medical-surgical units and the rehabilitation unit, with the finance director's approval of a revised rental budget. If spending rises beyond the agreed ceiling, the coalition will study which orders drove the increase before extending, rather than abandoning the protocol. Kotter (1996) listed premature declarations of victory among the errors that undo change efforts, and a single good quarter would be exactly that temptation here.
Step eight, anchoring the change, is mainly about structure. The approval rule is removed from the equipment policy rather than suspended, the combined monthly report becomes a standing item for both the nursing quality council and the system finance review, and the protocol is added to orientation for new nurses and house supervisors. The vendor contract is amended at renewal to define delivery from the order time. A change that lives only in the memory of the coalition members will not survive their next job change.
Measures
Langley et al. (2009) recommend a small family of measures for any improvement: an outcome measure, process measures and a balancing measure. The outcome measure for the pilot is how often patients on the two units develop a new pressure injury of stage 2 or worse, expressed per thousand patient days and tracked monthly on a run chart against the previous 12 months. Two process measures will be tracked weekly: the median hours from a nurse's order to a patient on the surface, with a target of four hours or less, and the share of high-risk patients, meaning a Braden total at or under 12, who are on a pressure-redistribution surface within 24 hours of scoring, with a target of 90%.
The balancing measure answers the finance director's legitimate concern and the wound nurse's worry about misuse: rental surface days per 1,000 patient days, and the percentage of surfaces still in place more than 48 hours after a patient's Braden score rises above 12. The pilot's spending ceiling is set at 30% above the pre-pilot monthly rental average for the two units; crossing it triggers a review, not an automatic stop.
Resistance and Where the Model Fits Badly
The most likely resistance is quiet rather than open. Nurses who have learned that after-hours requests go nowhere may simply not use the protocol, and the process measure for after-hours orders will show that within the first month. The response is local and personal: the night charge nurse will prompt orders during her rounds for the first two weeks, and every delayed or missed surface will be reviewed with the unit rather than filed. A second likely source of resistance is the wound nurse's workload, since next-day review of every order adds to her day; if reviews exceed 45 minutes a day, the coalition will ask the chief nursing officer for a part-time second reviewer during the pilot.
The model also fits the hospital badly in one respect. Kotter's steps assume a leader with enough authority to drive the sequence from the top, and the director here has authority over only one of the five departments involved. The plan compensates by giving the chief nursing officer the formal sponsor role and by building the coalition around people who each own a piece of the process, but if the chief nursing officer's attention moves elsewhere, the plan has no second sponsor. Naming that dependency now is the best protection against it, and the coalition's first report to the finance director will ask her to act as co-sponsor.
References
Appelbaum, S. H., Habashy, S., Malo, J., & 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. (1996). Leading change. Harvard Business School Press.
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634-640. https://doi.org/10.1111/iwj.13071
How this NUR 5043 Module 5 example is structured
NUR 5043 Module 5 commonly builds a change plan on a stated model, with phases, owners and measures; your classroom's instructions decide the model and whether a timeline table is required. This example justifies the model, works through each step with the people and dates attached, sets outcome, process and balancing measures, plans for the most likely forms of resistance, and names the model's weak points in this setting. It carries forward the stakeholder analysis from Module 4.
NUR5043 Module 5 questions, answered
What does NUR5043 Module 5 usually ask for?
NUR5043 Module 5 commonly asks for a change plan built on a named change model, with each phase or step applied to a specific change, people responsible, a timeline and measures of success. Your classroom's instructions decide the model and whether a table or timeline is required.
Do I have to use Kotter's model?
Not unless the prompt says so. Lewin's three stages, the ADKAR model, Rogers's diffusion of innovations and others are all accepted. Choose the model whose assumptions fit your change, say why, and name at least one way it fits your setting badly.
How specific should the owners and dates be?
Specific enough that someone else could run the plan: a role for every step, a week or date range, and a measure that shows the step is finished. Graders mark down plans that assign steps to leadership or the team without naming who.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.