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

BMC Health Services Research volume 20, Commodity number:147 (2020) Cite this article

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Abstract

Background

Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing illness patterns, new discoveries for the handling of diseases and political reforms and policy initiatives. Changes tin can be challenging because they contradict humans' basic demand for a stable environment. The present written report poses the question: what characterizes successful organizational changes in health intendance? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful.

Methods

The study was based on semi-structured interviews with xxx health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health intendance system. An inductive approach was applied using questions based on the existing literature on organizational modify and change responses. The questions concerned the interviewees' experiences and perceptions of any changes that they considered to have afflicted their piece of work, regardless of whether these changes were "objectively" large or small changes. The interviewees' responses were analysed using directed content assay.

Results

The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the alter; beingness 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 preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to exist implemented unexpectedly and/or without prior advice. They conveyed that it was important for them to understand the demand for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients.

Conclusions

Organizational changes in health intendance are more likely to succeed when health care professionals have the opportunity to influence the alter, experience prepared for the change and recognize the value of the change, including perceiving the do good of the alter for patients.

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Groundwork

The only constant in wellness intendance organizations, as the maxim goes, is change. Technological advancements, ageing populations, changing illness patterns and new discoveries for the treatment of diseases require health care organizations and professionals to modify almost constantly [1,2,3,four]. Organizational changes are also needed to account for evolving societal norms and values, some of which have yielded higher expectations for admission to wellness care, improved patient feel and increased patient interest in care conclusion making [5, 6]. Continuous professional educational activity has become increasingly important to ensure that wellness care professionals' competencies keep pace with current standards and to maintain and enhance the knowledge and skills needed to stay abreast of the newest evidence [vii].

Organizational changes affecting health care professionals as well relate to political reforms and policy initiatives. The advent of New Public Direction (NPM) has challenged the traditional professional potency, introducing a logic of managerialism into health intendance, i.eastward. work should be organized and controlled by managers to achieve organizational goals of a cost-effective and efficient health care [viii]. Health care professionals are increasingly expected to document their work, take on administrative tasks and participate in management-led quality comeback initiatives [9]. Changes also relate to the show-based motility, which has emerged in the wake of NPM, with ambitions to provide a stronger scientific foundation for professional person exercise [vii].

In general, changes can be challenging because they contradict humans' basic need for a stable environment [x, 11]. Research has shown that organizational changes are often associated with employees' psychological doubt most how the changes volition affect their piece of work situation, function and overall life [3, 12, 13]. High rates of organizational change have well-documented effects on employee health and well-being, equally assessed by a range of indicators, e.1000. reduced organizational delivery, loss of productivity, work-related stress, emotional exhaustion, mental health problems, change fatigue, poor self-rated health, agin sleep patterns, sickness absence, hospital admissions and stress-related prescriptions [xiv,15,sixteen].

Many changes in organizations fail to achieve desired goals; a 70% failure rate is commonly cited [17]. While generic success or failure rates can be questioned due to the context-dependent nature of change and challenges regarding definitions and measurement, there is however a considerable proportion of changes that practise not fail. This is the premise for the present paper: what characterizes successful organizational changes in health care? Based on interviews with wellness intendance 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 weather condition associated with successful organizational modify has the potential to improve selection, planning, implementation and management of ubiquitous changes in health care organizations.

Methods

Study setting, pattern and participants

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

We conducted semi-structured individual interviews with xi physicians, 12 registered nurses and seven assistant nurses – 30 health care professionals full (Table 1). The health care professionals were employed in 6 dissimilar health care units located in small- to mid-sized cities in 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 wide spectrum of perceptions and experiences apropos changes in health care – i.eastward., working in principal, secondary and 3rd wellness care facilities serving patients who varied in terms of health condition and duration of stay – we used a purposeful sampling strategy.

To recruit frontline health intendance professionals, we used an email that briefly described the written report. We sent the e-mail request to the manager of each work unit, with a request that they frontward our request to physicians, registered nurses and assistant nurses. We then sent an informational letter of the alphabet describing the study to those who responded to our email. No 1 declined to participate afterwards receiving the information alphabetic character. Nosotros scheduled interviews at a time (between Jan and September 2018) and in a location user-friendly to participants, where they could experience comfortable nearly speaking honestly (east.g. role 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 available as an Additional file. Interview questions were based on the existing literature on organizational alter and change responses [15, eighteen,xix,twenty] and concerned the participants' experiences and perceptions of any changes that they considered to have affected their work. Of note, nosotros asked participants to consider changes ranging from "objectively" large organizational changes, e.g. a re-structuring of the organization, to small changes, due east.one thousand. modification of an already existing workplace routine. This approach immune u.s. to assess both wide, more full general changes equally well as more specific examples of changes, such equally the merging of the informant'south piece of work unit with some other unit of measurement, introduction of new it systems, or moving to new localities.

Although individuals' subjective experience may not correspond with more objective measures of organizational outcomes of changes, information technology is crucial to understand health intendance professionals' views on changes in health intendance because their attitudes towards changes may influence changes' success [21, 22]. Equally such, instead of asking about specific changes or providing lists or examples of changes, we allowed the participants to discuss any changes they considered to be relevant to their piece of work; this approach reflects inquiry that shows that experiences of are often private (east.one thousand., i change may be attractive and imply advantages for some and be a source of stress and disadvantages for others) [23].

We began each interview with questions virtually the participant, the content of their work, and their workplace. We then asked participants to depict examples of organizational changes that they considered to be successful. And then, nosotros asked participants to offer a rationale for these changes' success. We asked a final open-ended question to capture any 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 exist used in different health care contexts, that the diction was articulate, and that the interview fit inside participants' maximum bachelor time (60 min). We included the 2 pilot interviews in the study.

Individual interviews were conducted by all the authors except SB, who does not speak Swedish, and were digitally recorded. Before the start of an interview, the participant was asked to re-read the information letter and requite written informed consent to participate. Each interview lasted between 28 and 104 min (mean, 50.5 min). The interviews were transcribed verbatim by a professional transcription bureau and were and so reviewed past the researcher who conducted the interview.

Information analysis

Using an anterior 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 next stride, each researcher performed a first analysis condensing meaning-bearing units and creating codes and subcategories. PN, IS, CE and KS and so met to hash out 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 US) to discuss the preliminary findings. This give-and-take 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 past PN, IS, CE and KS. PN, who is fluent in English, and then translated the quotations from Swedish to English, which were then examined by IS, CE and KS for accuracy. Finally, SB, whose offset 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 change; being prepared for the change; valuing the modify. The findings regarding these characteristics were equally applicative to the physicians, registered nurses and assistant nurses, with few notable differences amid the iii professional 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 modify

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 role of health care professionals. A physician (4P) described the importance of "bottom-upwardly" changes, "I recall one is particularly responsive to issues that are being raised in the organization from the footing up. It is from there, I remember, most oft the smartest ideas will emerge, just and so it is of import to ensure that you are responsive and assess [the ideas]." An banana nurse (1AN) expressed a similar view, "It'south a skilful change, I believe, [if] it's a modify that has occurred with me beingness involved from the start and built [from there]." The health intendance professionals suggested that they are about knowledgeable near their work, putting them in an optimal position to place relevant problems and initiate appropriate changes.

Concerning organizational changes initiated by the health care direction and/or the higher political leadership level in the region, the health care professionals suggested that being involved early in the alter process and being able to have an influence throughout the change process contributed to the modify's success. For example, a registered nurse (2RN) said, "If employees are involved from the start and believe this [change] is interesting, so I think at that place is a adventure to succeed [with the change]." However, many complained about the difficulty of influencing changes because of the hierarchy of the health care system and the long altitude to those in power over about changes. A doc (13P) opinioned, "We don't have any channels to the political level or other college direction levels. You're restricted to the caput of the clinic to exist your spokesperson." Another physician (23P) complained, "There are administrators or controllers or economists who expect into the [health care] system, but they lack knowledge well-nigh the actual care work, which makes me angry. They beginning their project, but don't involve us."

Being prepared for the modify

According to the wellness care professionals, organizational changes that were conspicuously communicated to let for preparation increased the chances for successful changes. An assistant nurse (22AN) argued that a relatively slow tempo of change is of import when implementing change, "It [i.e. the change] has to go along at a calm pace so that everyone is part of it, so that yous have a shared plan, that'due south the most important matter, I think." A registered nurse (5RN) talked about the importance of how changes are communicated, "I can't take it all in, I tin't handle it. You get this menstruation of mails with data, 'Now we volition do this and that, now this will modify and this is the starting date…' It can exist from day to twenty-four hours, we cannot take hold of up."

The health care professionals did non support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. Ane of the physicians (3P) described such a change: "Discussions were ongoing during the autumn, but you felt that the management didn't mind. So came Jan with the decision: 'You will be split, in ii weeks you will be two different clinics.' We felt so powerless and uninformed. Nosotros had ii weeks to develop new systems and that results in considerable consequences." A registered nurse (21RN) too lamented a lack of time for preparation, "Nosotros had quick meetings. Sure, we met and talked virtually information technology [the modify], but we didn't have much fourth dimension. We had to solve information technology anyhow."

Valuing the alter

The health intendance professionals conveyed that it was of import for them to understand the need of organizational changes and how they benefitted themselves and/or the patients. The changes might otherwise exist perceived equally meaningless and unjustified, which may create modify resistance. A doctor (24P) stated, "I desire to see a purpose for it [i.e. the alter], and if I practise [recognize the value of the change], and it works, then I'm satisfied." Similarly, a registered nurse (5RN) emphasized the importance of the health care professionals recognizing the value of the change, "We demand to experience that this change is non done considering the region has decided it, merely because nosotros really believe that it volition make things better."

In particular, health care professionals valued and perceived as successful organizational changes with a patient focus, with articulate benefits to patients. Co-ordinate to a registered nurse (12RN), "As long as you see that it [i.e. the change] benefits our patients, I think you lot have quite considerable motivation." Further, an banana nurse (22AN) said that "one does it to make information technology easier for the patients and maybe for the staff, that's the about important."

Word

Change is pervasive in modern health care. This report aimed to identify characteristics of successful organizational changes from the perspective of health intendance professionals at the frontline level of health care. An important premise for the study was that the health intendance 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 change to exist considered successful according to the statements of the wellness care professionals who were interviewed: that health intendance professionals (1) have the opportunity to influence the change, (two) are prepared for the change and (iii) recognize the value of the change. Many of the statements by the participants were representative of more than 1 category, suggesting an interdependency betwixt the 3 categories of this triad of successful change characteristics. For case, a slower alter allows for grooming, which facilitates involvement and influence, thus enabling an appreciation for the change. Alternatively, recognizing the value of a change, east.k. its patient benefits, likely contributes to increased motivation among health intendance professionals to become engaged and participate in carrying out the alter. This interdependence implies that successful modify is more likely if more than one of the three categories is accounted for when planning and implementing changes. The importance of preparation for and interest in a change has been associated with decisional latitude [26] and valuing the change in terms of experiencing personal gains has been linked with involvement in the change [27]. However, we accept not been able to discover any previous study, either in health intendance settings or in other environments, which has identified the relevance of this detail triad of characteristics or how they are interlinked. Although our findings suggest these interdependencies, nosotros did not collect data to specifically investigate the underlying mechanisms; thus, exploring these interdependencies would be an important area for future research.

The health care professionals in our report attached swell 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 up" from themselves and/or the frontlines of health care. Many of the wellness care professionals complained about the ability differential between those who are afflicted by the changes and higher management and political levels of the wellness care system who usually decide on what changes to implement. Physicians in Sweden have often raised complaints that policy making and decisions concerning the medical profession are made without physicians or their professional organizations existence involved in the decision-making process [28]. These findings underscore the importance of changes having frontline back up and being perceived equally legitimate among the employees affected by the changes.

Organizational research has shown that participation in changes can yield increased acceptance. Indeed, widespread participation in the change procedure is perhaps the most frequently cited approach to overcoming resistance to change [29, xxx]. Fifty-fifty assuming a well-justified and well-planned alter initiative, inquiry underscores the importance of managers building internal support for alter by ways of employee participation in the change process [31]. These are common findings in organizational research in general, simply they seem particularly applicative in health intendance organizations because of the strong professional discretion in performing the work.

Health care professionals emphasized the importance of predictability for them to perceive organizational changes as successful. Individuals are better able to adjust their behaviour accordingly when they are prepared [3]. The importance of managers' communication of information to prepare employees for organizational changes is frequently pointed out in the organizational alter literature [31]. Still, despite the relevance of predictability, many changes in our study seemed to be characterized by a lack of preparation. 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 Alter, a theory that posits that readiness depends on organisation members' resolve to pursue the courses of activeness involved in implementing change (change commitment) and their beliefs in their capabilities to execute these actions (alter efficacy). Contextual factors such equally resources and civilization also influence their preparedness to implement alter [33].

The importance of management communicating the motives for changes was stressed by the health care professionals in our written report. Consistent with our findings, organizational change research has demonstrated that changes have a greater run a risk of succeeding if employees consider them to exist 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 change literature also stresses the importance of change initiatives resting on coherent and audio causal thinking [34,35,36]. Employees who practise not sympathize why a change is pursued will be reluctant to comply with the management's requirement for the change [25]. The wellness care professionals in our report argued that the changes must benefit patients to have value. This is consistent with research that shows that wellness care professionals' office identity is largely defined by patients and patients' needs [37].

The overall findings of our study may reflect a tension between the traditional logic of professionalism and the managerial logic introduced into health care with the emergence of NPM. Whereas the logic of managerialism assumes that work should be direction 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 direction systems, eastward.k. auditing, guidelines, recommendations, agin upshot reporting systems and various incentive tools [38] that challenge the logic of professionalism in terms of professionals' autonomy and freedom of judgement in performing their work [39,40,41]. Co-ordinate to professional theory, truthful professionals such equally physicians and lawyers independently treat individual cases (eastward.g. patients and clients) and make decisions based on their knowledge and skills; they are highly educated and trained to apply knowledge and expertise in solving circuitous problems [42, 43]. Research suggests that physicians due to their stronger identification with professional person logic are more probable than nurses to be critical of direction-initiated changes [9]. Several studies have shown how physicians respond with scepticism or suspicion to unlike forms of management-led changes in wellness intendance [44, 45].

Sweden has seen a lively public fence on NPM in recent years, with many scholars, policy makers and both physicians and registered nurses critiquing cadre NPM principles and their consequences for health care professionals [46,47,48,49,50]. In response to the criticism of NPM principles, the Swedish authorities has recently introduced the concept of "trust-based governance," intended to integrate aspects of professional logic with NPM-based managerial logic, thus providing an alternative to governing health care professionals through auditing, control and performance direction [26, 51]. Governance by trust is intended to let "the professionals be professional" [52]. This initiative is new and we are not enlightened of whatever studies of the concept, but research is warranted to investigate how this concept is realized in practice. Futurity research should assess whether wellness care professionals perceive changes as more successful nether trust-based governance than under NPM principles.

The results of our study should be evaluated in the context of the methods that we chose to address our study question. We chose a qualitative approach because little is known about responses to changes in Swedish health care. For this reason, we considered interviews with physicians, registered nurses, and assistant nurses to gain a deeper understanding of the topic. Participation was voluntary; the interviewees were selected and asked past their respective supervisors about participation in the study, which ways that the participants may have been particularly interested in the subject.

The multidisciplinary research team was a strength of the study, because it immune dissimilar perspectives on the issue of changes in wellness care. The team consisted of the following professions: behavioural economist (PN), political scientist (IS), registered nurse (KS), behavioural scientist (CE) and organizational sociologist (SB). Some other forcefulness was the relatively loftier number of interviews (n = 30), although Malterud et al. [53] emphasizes that the force of the information received (information ability) is more important than the size of the sample. Regardless, this enabled us to use quotations from many dissimilar participants, calculation transparency and trustworthiness to the findings.

The master 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 inquiry on organizational changes, no previous study has identified this particular triad of interdependent characteristics. The written report provides of import cognition for wellness care organizations to plan and implement changes with amend chances of being successful.

Conclusions

In conclusion, organizational changes in health care are more likely to succeed when health intendance professionals take the opportunity to influence the alter, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients. Although changes in wellness intendance organizations are inevitable, there are more or less effective means to deport out changes. Our results provide important implications for health care organizations concerning how changes in health intendance can exist planned, implemented and managed to increase the chances that they will exist supported by health intendance professionals, which is crucial for successful changes.

Availability of data and materials

All interview data analysed during the current written report are available from the corresponding author on reasonable request.

Abbreviations

AN:

Assistant 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:

The states

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Acknowledgements

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

Funding

Open up access funding provided past Linköping Academy. Dr. Birken's effort was supported by the National Center for Advancing Translational Sciences, National Institutes of Wellness, through Grant KL2TR002490. The content is solely the responsibility of the authors and does non necessarily represent the official views of the NIH.

Author information

Affiliations

1. Department of Medical and Health Sciences, Partition of Community Medicine, University of Linköping, Linköping, Sweden

   Per Nilsen & Carin Ericsson

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

   Ida Seing

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

   Carin Ericsson

4. Department of Health Policy and Direction, Gillings School of Global Public Wellness, The University of North Carolina at Chapel Loma, Chapel Hill, North Carolina, U.s.

   Sarah A. Birken

5. Department of Health and Care Sciences, Linnaeus Academy, Kalmar, Sweden

   Kristina Schildmeijer

Contributions

All authors (PN, IS, CE, SB, KS) made meaning contributions to the manuscript. PN, IS, CE and KS nerveless the data. All analysed the data. PN drafted the manuscript, but it was reviewed and critically revised for important intellectual content by all authors. All authors read and gave final blessing of the version of the manuscript submitted for publication.

Corresponding writer

Correspondence to Per Nilsen.

Ethics declarations

Ethics approval and consent to participate

The written report was canonical past the Local Ideals committee in Linköping, Sweden, Dnr: 2018/112–31. All the participants gave their written and oral consent to participate in the interviews. The study was performed co-ordinate to Globe Medical Association Announcement of Helsinki ethical principles for medical research involving human subjects. To maintain the principle of non-maleficence, the participants were guaranteed confidentiality, which was taken into account when reporting the findings through abstracted findings presented at the group level. In accordance with respecting the participants' autonomy, all the participants were informed that they had the correct to withdraw from the project at whatsoever time without suffering any consequences for their future care. In the interviews, the researchers were enlightened of ability problems, in that an interview is not a chat between two equal individuals. The interview time was taken into careful consideration. The participants were given opportunity to reverberate on what they said in the interviews, and fourth dimension was also available for the participants to ask 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 health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res xx, 147 (2020). https://doi.org/x.1186/s12913-020-4999-eight

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• Received: 19 November 2019

• Accepted: 14 February 2020

• Published: 27 Feb 2020

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

Keywords

• Organizational change
• Implementation
• Influence
• Preparedness
• Patient benefit

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

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