How Should The Registered Nurse Be Responsive To The Changing Health Care Needs Of Society?

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• Published: 27 February 2020

Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and banana nurses

BMC Health Services Research volume 20, Article number:147 (2020) Cite this commodity

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Abstract

Background

Health care organizations are constantly irresolute every bit a result of technological advancements, ageing populations, changing affliction patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can exist challenging because they contradict humans' basic demand for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the piece of work of health care professionals that they deemed successful.

Methods

The study was based on semi-structured interviews with xxx health care professionals: xi physicians, 12 registered nurses and vii banana nurses employed in the Swedish health care organization. An anterior approach was practical using questions based on the existing literature on organizational modify and change responses. The questions concerned the interviewees' experiences and perceptions of whatever changes that they considered to accept affected their work, regardless of whether these changes were "considerately" large or small changes. The interviewees' responses were analysed using directed content analysis.

Results

The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for training increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the demand for and benefits of organizational changes. They peculiarly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients.

Conclusions

Organizational changes in health care are more than likely to succeed when health care professionals accept the opportunity to influence the change, feel prepared for the modify and recognize the value of the alter, including perceiving the benefit of the change for patients.

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Background

The only constant in health intendance organizations, as the saying goes, is change. Technological advancements, ageing populations, changing disease patterns and new discoveries for the handling of diseases require health care organizations and professionals to change almost constantly [one,2,three,4]. Organizational changes are likewise needed to account for evolving societal norms and values, some of which take yielded college expectations for access to health care, improved patient experience and increased patient involvement in care decision making [v, 6]. Continuous professional education has get increasingly of import to ensure that health care professionals' competencies proceed pace with electric current standards and to maintain and enhance the knowledge and skills needed to stay abreast of the newest evidence [7].

Organizational changes affecting health care professionals as well relate to political reforms and policy initiatives. The appearance of New Public Direction (NPM) has challenged the traditional professional person authorization, introducing a logic of managerialism into health care, i.east. work should be organized and controlled by managers to reach organizational goals of a price-constructive and efficient health care [viii]. Health intendance professionals are increasingly expected to document their work, take on administrative tasks and participate in management-led quality improvement initiatives [nine]. Changes likewise relate to the evidence-based motion, which has emerged in the wake of NPM, with ambitions to provide a stronger scientific foundation for professional practice [vii].

In general, changes tin be challenging because they contradict humans' basic demand for a stable surroundings [10, 11]. Research has shown that organizational changes are oft associated with employees' psychological uncertainty about how the changes will impact their work situation, role and overall life [iii, 12, thirteen]. High rates of organizational change have well-documented effects on employee health and well-existence, as assessed by a range of indicators, e.g. reduced organizational commitment, loss of productivity, work-related stress, emotional exhaustion, mental health problems, alter fatigue, poor self-rated health, adverse slumber patterns, sickness absence, hospital admissions and stress-related prescriptions [14,fifteen,16].

Many changes in organizations fail to reach desired goals; a lxx% failure rate is usually cited [17]. While generic success or failure rates tin can exist questioned due to the context-dependent nature of change and challenges regarding definitions and measurement, at that place is nonetheless a considerable proportion of changes that do not fail. This is the premise for the present paper: what characterizes successful organizational changes in health care? Based on interviews with health care professionals in Sweden, we aimed to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful. Noesis of conditions associated with successful organizational change has the potential to improve selection, planning, implementation and direction of ubiquitous changes in health care organizations.

Methods

Study setting, design and participants

Study data come from interviews with Swedish health care professionals (physicians, registered nurses, assistant nurses). In the Swedish health care system, residents are insured by the regime, with equal access to health care for the entire population, although private health care also exists. Sweden's 21 regions are responsible for providing health intendance.

We conducted semi-structured individual interviews with 11 physicians, 12 registered nurses and 7 banana nurses – 30 health intendance professionals total (Table 1). The wellness care professionals were employed in six different health intendance units located in small- to mid-sized cities in due south-eastern Sweden (populations of 67,000, 135,000 and 150,000 inhabitants, respectively).

Table 1 Participant characteristics

Full size table

To achieve a sample of health care professionals that represented a broad spectrum of perceptions and experiences concerning changes in health care – i.eastward., working in primary, secondary and third health care facilities serving patients who varied in terms of wellness status and duration of stay – we used a purposeful sampling strategy.

To recruit frontline health care professionals, we used an e-mail that briefly described the study. Nosotros sent the east-mail request to the manager of each work unit, with a request that they forward our asking to physicians, registered nurses and assistant nurses. Nosotros then sent an advisory letter of the alphabet describing the study to those who responded to our e-mail. No one declined to participate afterward receiving the information letter. We scheduled interviews at a time (between January and September 2018) and in a location convenient to participants, where they could feel comfy about speaking honestly (e.grand. office with a closed door).

Data collection

We used an inductive approach to data collection, with a semi-structured interview guide developed by the authors. The interview guide is bachelor as an Additional file. Interview questions were based on the existing literature on organizational change and change responses [fifteen, 18,nineteen,20] and concerned the participants' experiences and perceptions of whatever changes that they considered to have afflicted their work. Of annotation, we asked participants to consider changes ranging from "objectively" large organizational changes, east.g. a re-structuring of the system, to small changes, e.g. modification of an already existing workplace routine. This approach allowed united states of america to assess both broad, more than general changes likewise as more specific examples of changes, such as the merging of the informant'due south piece of work unit of measurement with another unit, introduction of new it systems, or moving to new localities.

Although individuals' subjective feel may non correspond with more objective measures of organizational outcomes of changes, it is crucial to empathize wellness care professionals' views on changes in health care because their attitudes towards changes may influence changes' success [21, 22]. Equally such, instead of request about specific changes or providing lists or examples of changes, we allowed the participants to talk over whatever changes they considered to exist relevant to their work; this approach reflects research that shows that experiences of are often private (e.thousand., one alter may exist bonny and imply advantages for some and be a source of stress and disadvantages for others) [23].

We began each interview with questions almost the participant, the content of their work, and their workplace. We then asked participants to describe examples of organizational changes that they considered to be successful. Then, we asked participants to offer a rationale for these changes' success. We asked a concluding open-concluded question to capture whatsoever other reflections that participants had.

In two interviews, we pilot tested the questions to assess their meaningfulness and clarity of concepts. Pilot interview results suggested that the questions could be used in different health intendance contexts, that the wording was clear, and that the interview fit within participants' maximum available time (60 min). We included the two pilot interviews in the study.

Individual interviews were conducted by all the authors except SB, who does non speak Swedish, and were digitally recorded. Before the offset of an interview, the participant was asked to re-read the information letter and give written informed consent to participate. Each interview lasted betwixt 28 and 104 min (hateful, fifty.v min). The interviews were transcribed verbatim past a professional transcription agency and were then reviewed by the researcher who conducted the interview.

Information analysis

Using an inductive approach, participants' responses were analysed using directed content analysis co-ordinate to descriptions by Hsieh and Shannon [24]. All authors except SB read the transcripts of the interviews individually to create a holistic view of the material. In the adjacent pace, each researcher performed a commencement assay condensing significant-begetting units and creating codes and subcategories. PN, IS, CE and KS then met to discuss and compare their respective interpretations of the material. Tentative findings were reported to and discussed with SB. Following her input, PN, IS, CE and KS met again (as SB is located in the The states) to hash out the preliminary findings. This word led to a proposal concerning the categories of analysis, which was then fed dorsum to SB for her comments. Eventually, consensus was reached on the categories and PN suggested labels which were accepted by the whole group. Representative quotations for reporting were jointly identified by PN, IS, CE and KS. PN, who is fluent in English language, so translated the quotations from Swedish to English, which were then examined by IS, CE and KS for accurateness. Finally, SB, whose get-go language is English, reviewed the English-language quotations for clarity.

Results

The assay yielded three categories concerning characteristics of successful changes: having the opportunity to influence the modify; existence prepared for the modify; valuing the change. The findings regarding these characteristics were equally applicable to the physicians, registered nurses and assistant nurses, with few notable differences among the three professional person categories. The quotes are attributed to the physicians (P), registered nurses (RN) and assistant nurses (AN), who were interviewed, numbered from 1 to 30.

Having the opportunity to influence the change

The health care professionals emphasized the importance of having the opportunity to influence organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and rarely encountered resistance on the part of health care professionals. A doctor (4P) described the importance of "lesser-up" changes, "I think one is peculiarly responsive to bug that are being raised in the system from the ground upward. Information technology is from there, I recall, about oft the smartest ideas will sally, only then it is important to ensure that y'all are responsive and appraise [the ideas]." An assistant nurse (1AN) expressed a similar view, "Information technology's a good change, I believe, [if] it'south a change that has occurred with me existence involved from the start and congenital [from at that place]." The health intendance professionals suggested that they are most knowledgeable about their work, putting them in an optimal position to place relevant problems and initiate appropriate changes.

Concerning organizational changes initiated past the health care direction and/or the higher political leadership level in the region, the wellness care professionals suggested that beingness involved early in the modify procedure and existence able to have an influence throughout the alter process contributed to the modify's success. For example, a registered nurse (2RN) said, "If employees are involved from the beginning and believe this [change] is interesting, and then I think there is a chance to succeed [with the change]." However, many complained about the difficulty of influencing changes considering of the hierarchy of the health care system and the long distance to those in power over most changes. A physician (13P) opinioned, "Nosotros don't have any channels to the political level or other higher direction levels. You're restricted to the caput of the clinic to exist your spokesperson." Some other physician (23P) complained, "There are administrators or controllers or economists who await into the [health care] system, just they lack noesis nearly the bodily care work, which makes me angry. They start their project, but don't involve us."

Beingness prepared for the change

Co-ordinate to the health care professionals, organizational changes that were clearly communicated to allow for preparation increased the chances for successful changes. An banana nurse (22AN) argued that a relatively slow tempo of change is important when implementing change, "It [i.e. the alter] has to go along at a calm pace so that anybody is function of it, so that you take a shared plan, that's the most important thing, I think." A registered nurse (5RN) talked well-nigh the importance of how changes are communicated, "I tin't accept information technology all in, I can't handle information technology. Y'all get this menses of mails with information, 'Now nosotros will practise this and that, at present this will change and this is the starting date…' It can be from twenty-four hour period to day, we cannot catch upward."

The health intendance professionals did non support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. One of the physicians (3P) described such a alter: "Discussions were ongoing during the autumn, but you felt that the management didn't heed. Then came January with the decision: 'Yous will be carve up, in two weeks you lot will be ii unlike clinics.' We felt and so powerless and uninformed. We had two weeks to develop new systems and that results in considerable consequences." A registered nurse (21RN) also lamented a lack of time for grooming, "We had quick meetings. Sure, we met and talked near it [the change], but we didn't have much time. We had to solve it anyway."

Valuing the change

The health care professionals conveyed that it was important for them to sympathise the need of organizational changes and how they benefitted themselves and/or the patients. The changes might otherwise be perceived equally meaningless and unjustified, which may create alter resistance. A physician (24P) stated, "I want to encounter a purpose for it [i.eastward. the change], and if I practice [recognize the value of the change], and information technology works, then I'm satisfied." Similarly, a registered nurse (5RN) emphasized the importance of the wellness care professionals recognizing the value of the change, "We need to feel that this change is non done because the region has decided it, just because we really believe that it will make things meliorate."

In item, health care professionals valued and perceived every bit successful organizational changes with a patient focus, with clear benefits to patients. According to a registered nurse (12RN), "As long as you encounter that it [i.e. the change] benefits our patients, I retrieve you accept quite considerable motivation." Farther, an assistant nurse (22AN) said that "i does it to get in easier for the patients and possibly for the staff, that'southward the nigh important."

Give-and-take

Change is pervasive in modern wellness intendance. This study aimed to place characteristics of successful organizational changes from the perspective of health care professionals at the frontline level of health care. An important premise for the study was that the health care professionals' subjective experiences of changes influence the likelihood of achieving successful changes. The importance of individual responses to organizational changes has been increasingly emphasized [25].

Three categories (i.e. characteristics of successful changes) were found to be of central importance for a modify to exist considered successful according to the statements of the health care professionals who were interviewed: that wellness care professionals (one) have the opportunity to influence the change, (2) are prepared for the modify and (iii) recognize the value of the modify. Many of the statements by the participants were representative of more than 1 category, suggesting an interdependency between the three categories of this triad of successful change characteristics. For case, a slower change allows for training, which facilitates involvement and influence, thus enabling an appreciation for the change. Alternatively, recognizing the value of a change, e.g. its patient benefits, likely contributes to increased motivation among wellness care professionals to become engaged and participate in carrying out the change. This interdependence implies that successful change is more probable if more than than one of the iii categories is accounted for when planning and implementing changes. The importance of preparation for and involvement in a alter has been associated with decisional breadth [26] and valuing the alter in terms of experiencing personal gains has been linked with involvement in the change [27]. However, we have not been able to find any previous study, either in health care settings or in other environments, which has identified the relevance of this particular triad of characteristics or how they are interlinked. Although our findings propose these interdependencies, nosotros did non collect data to specifically investigate the underlying mechanisms; thus, exploring these interdependencies would be an important area for time to come research.

The wellness intendance professionals in our study fastened great importance to being able to influence changes that may influence their piece of work. They expressed positive attitudes to changes that have been adult and emanate "bottom upwards" from themselves and/or the frontlines of health care. Many of the health intendance professionals complained almost the power differential betwixt those who are affected past the changes and college management and political levels of the health care arrangement who usually determine on what changes to implement. Physicians in Sweden have oft raised complaints that policy making and decisions concerning the medical profession are made without physicians or their professional organizations being involved in the decision-making procedure [28]. These findings underscore the importance of changes having frontline support and being perceived equally legitimate among the employees affected by the changes.

Organizational research has shown that participation in changes tin yield increased credence. Indeed, widespread participation in the change procedure is peradventure the most often cited approach to overcoming resistance to alter [29, thirty]. Even bold a well-justified and well-planned change initiative, research underscores the importance of managers edifice internal support for alter by means of employee participation in the change process [31]. These are common findings in organizational research in general, but they seem particularly applicative in health care organizations considering of the strong professional discretion in performing the piece of work.

Health care professionals emphasized the importance of predictability for them to perceive organizational changes as successful. Individuals are better able to conform their behaviour appropriately when they are prepared [3]. The importance of managers' advice of information to prepare employees for organizational changes is often pointed out in the organizational change literature [31]. Still, despite the relevance of predictability, many changes in our study seemed to be characterized by a lack of grooming. When individuals are unprepared, they have difficulties aligning their thoughts, feelings and behaviours with the expectations of those who lead the changes [12, 32]. Our findings are consistent with Organizational Readiness to Modify, a theory that posits that readiness depends on organization members' resolve to pursue the courses of action involved in implementing modify (modify commitment) and their behavior in their capabilities to execute these actions (change efficacy). Contextual factors such as resources and culture also influence their preparedness to implement modify [33].

The importance of management communicating the motives for changes was stressed by the health care professionals in our study. Consistent with our findings, organizational change enquiry has demonstrated that changes have a greater take chances of succeeding if employees consider them to be well thought out and respect the managers responsible for the changes, whereas resistance to changes is more likely if employees consider the changes to have little or no value for themselves [31]. The organizational modify literature too stresses the importance of change initiatives resting on coherent and audio causal thinking [34,35,36]. Employees who do non understand why a change is pursued volition be reluctant to comply with the direction's requirement for the change [25]. The wellness care professionals in our study argued that the changes must benefit patients to have value. This is consistent with enquiry that shows that health care professionals' role identity is largely defined by patients and patients' needs [37].

The overall findings of our written report may reflect a tension between the traditional logic of professionalism and the managerial logic introduced into wellness care with the emergence of NPM. Whereas the logic of managerialism assumes that work should be management led to achieve organizational goals, health care professionals tend to be loyal to their profession and their emotional rewards at work are primarily associated with their patients [9]. NPM has led to an increase in the use of management systems, east.one thousand. auditing, guidelines, recommendations, agin upshot reporting systems and diverse incentive tools [38] that claiming the logic of professionalism in terms of professionals' autonomy and freedom of judgement in performing their piece of work [39,40,41]. According to professional person theory, true professionals such as physicians and lawyers independently treat individual cases (e.1000. patients and clients) and brand decisions based on their knowledge and skills; they are highly educated and trained to apply cognition and expertise in solving complex bug [42, 43]. Research suggests that physicians due to their stronger identification with professional logic are more than likely than nurses to be critical of management-initiated changes [nine]. Several studies have shown how physicians respond with scepticism or suspicion to different forms of direction-led changes in health care [44, 45].

Sweden has seen a lively public debate on NPM in recent years, with many scholars, policy makers and both physicians and registered nurses critiquing core NPM principles and their consequences for health intendance professionals [46,47,48,49,50]. In response to the criticism of NPM principles, the Swedish government has recently introduced the concept of "trust-based governance," intended to integrate aspects of professional person logic with NPM-based managerial logic, thus providing an alternative to governing health care professionals through auditing, command and functioning management [26, 51]. Governance past trust is intended to permit "the professionals exist professional" [52]. This initiative is new and we are non enlightened of any studies of the concept, but inquiry is warranted to investigate how this concept is realized in practice. Future enquiry should assess whether health care professionals perceive changes as more successful under trust-based governance than under NPM principles.

The results of our study should exist evaluated in the context of the methods that we chose to address our study question. Nosotros chose a qualitative arroyo because little is known virtually responses to changes in Swedish health intendance. For this reason, nosotros considered interviews with physicians, registered nurses, and assistant nurses to gain a deeper agreement of the topic. Participation was voluntary; the interviewees were selected and asked by their corresponding supervisors virtually participation in the report, which means that the participants may have been peculiarly interested in the discipline.

The multidisciplinary enquiry team was a force of the study, because it immune unlike perspectives on the issue of changes in wellness care. The team consisted of the post-obit professions: behavioural economist (PN), political scientist (IS), registered nurse (KS), behavioural scientist (CE) and organizational sociologist (SB). Another force was the relatively loftier number of interviews (northward = 30), although Malterud et al. [53] emphasizes that the strength of the information received (data power) is more important than the size of the sample. Regardless, this enabled us to employ quotations from many different participants, adding transparency and trustworthiness to the findings.

The main contribution of the study lies in identifying a "triad of successful change characteristics" from the change recipients' point of view. While many findings of the study are in line with existing research on organizational changes, no previous study has identified this particular triad of interdependent characteristics. The study provides important knowledge for health intendance organizations to plan and implement changes with meliorate chances of being successful.

Conclusions

In determination, organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the modify, experience prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients. Although changes in health care organizations are inevitable, there are more or less effective ways to conduct out changes. Our results provide of import implications for health care organizations apropos how changes in wellness care can be planned, implemented and managed to increase the chances that they volition exist supported by health care professionals, which is crucial for successful changes.

Availability of data and materials

All interview data analysed during the current study are available from the respective author on reasonable request.

Abbreviations

AN:

Banana nurses

CE:

Carin Ericsson

IS:

Ida Seing

KS:

Kristina Schildmeijer

NPM:

New Public Management

P:

Physicians

PN:

Per Nilsen

RN:

Registered nurses

SB:

Sarah A. Birken

US:

United States

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Acknowledgements

The authors would like to give thanks all the participating physicians, registered nurses and assistant nurses who participated in the interviews.

Funding

Open access funding provided by Linköping University. Dr. Birken's effort was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR002490. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Author information

Affiliations

1. Department of Medical and Health Sciences, Sectionalisation of Customs Medicine, University of Linköping, Linköping, Sweden

   Per Nilsen & Carin Ericsson

2. Department of Behavioural Sciences and Learning, Academy of Linköping, Linköping, Sweden

   Ida Seing

3. Cardiology and Speciality Medicine Centre, Region Östergötland, Linköping, Sweden

   Carin Ericsson

4. Department of Health Policy and Direction, Gillings School of Global Public Health, The University of North Carolina at Chapel Colina, Chapel Colina, North Carolina, United states of america

   Sarah A. Birken

5. Section of Health and Intendance Sciences, Linnaeus University, Kalmar, Sweden

   Kristina Schildmeijer

Contributions

All authors (PN, IS, CE, SB, KS) fabricated significant contributions to the manuscript. PN, IS, CE and KS collected the data. All analysed the data. PN drafted the manuscript, but it was reviewed and critically revised for of import intellectual content past all authors. All authors read and gave final approving of the version of the manuscript submitted for publication.

Corresponding author

Correspondence to Per Nilsen.

Ethics declarations

Ethics approval and consent to participate

The report was canonical past the Local Ethics committee in Linköping, Sweden, Dnr: 2018/112–31. All the participants gave their written and oral consent to participate in the interviews. The report was performed according to World Medical Association Proclamation of Helsinki ethical principles for medical enquiry involving human being subjects. To maintain the principle of not-maleficence, the participants were guaranteed confidentiality, which was taken into business relationship when reporting the findings through abstracted findings presented at the grouping level. In accordance with respecting the participants' autonomy, all the participants were informed that they had the right to withdraw from the project at any time without suffering any consequences for their future care. In the interviews, the researchers were enlightened of power issues, in that an interview is non a conversation between two equal individuals. The interview time was taken into conscientious consideration. The participants were given opportunity to reflect on what they said in the interviews, and time was also bachelor for the participants to inquire questions.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Nilsen, P., Seing, I., Ericsson, C. et al. Characteristics of successful changes in wellness care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res xx, 147 (2020). https://doi.org/10.1186/s12913-020-4999-8

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• Received: xix Nov 2019

• Accepted: 14 February 2020

• Published: 27 Feb 2020

• DOI : https://doi.org/10.1186/s12913-020-4999-8

Keywords

• Organizational modify
• Implementation
• Influence
• Preparedness
• Patient benefit

Source: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-4999-8

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