Management of change for nurses: lessons from the discipline of organizational studies

Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine

INTRODUCTION

Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.

METHODS

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.

RESULTS

Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.

DISCUSSION

EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.

Nurse Manager's Responsibilities in Creating Supportive Working Conditions Post Implementation of Everyday Coping: A Hermeneutic Research Study of District Nurses' Experiences

Aim

To gain knowledge about how district nurses experience changes in working conditions and discuss nursing manager's responsibility in facilitating working conditions for district nurses following the implementation of everyday coping.

Background

To overcome the challenges related to the sustainability of the healthcare sector, everyday coping was implemented in district nursing. The implementation was set by the government and implemented by the municipality. The nursing manager has an overall responsibility to facilitate working conditions so that everyday coping can be applied into district nursing practice.

Method

This descriptive and interpretative study involved 19 interviews and 19 observations on 10 nurses. Kvale and Brinkmann's three levels of understanding were employed in the analysis.

Results

Three categories were established based on the results of the data analyses: (i) time and space are not considered, (ii) crossfire of conflicting expectations, and (iii) nursing manager's commitment to everyday coping.

Conclusion

The working conditions of district nurses are not adapted for them to work according to the everyday coping mindset. The nursing manager has a key role in supporting nurses and addressing challenges the nurses meet in their daily work, where everyday coping is implemented. The study highlights the importance for healthcare managers, at various levels in the healthcare sector, to be conscious of the district nursing practice, its complexity, and quality of health services when implementing change. This knowledge is important when planning future healthcare and nursing practice.

Effects of organisational restructuring of hospitals on nurses

AIM

The study aims to determine the thoughts, feelings and attitudes of nurses towards organisational change in hospitals, and the effects of organisational cynicism, job satisfaction, organisational commitment and work alienation on nurses' attitudes towards change.

BACKGROUND

Changes and employees' thoughts, attitudes and behaviours can be mutually affected in the process of transformation.

METHODS

The descriptive, correlative and cross-sectional study was conducted with 1,000 nurses in 52 public hospitals in Turkey.

RESULTS

Of the nurses, 59% explained that their workload had increased, and 57% experienced uncertainty and confusion due to the organisational changes in the hospitals. Nurses' total scale scores were 2.86 ± 0.65 for attitude towards change, 2.98 ± 0.52 for work alienation, 2.97 ± 0.84 for organisational cynicism, 2.98 ± 0.70 for job satisfaction and 2.74 ± 0.92 for organisational commitment. Organisational cynicism had a significant effect on the attitude towards change of nurses (R²  = 0.486; F = 235.528; p < .001).

CONCLUSION

The nurses had a moderate level of attitude towards change, organisational cynicism, job satisfaction, organisational commitment and work alienation. The primary influence on their attitude against change was their cynical thinking.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings of the study can be used to test strategies to reduce cynicism regarding effective management of change.

Change Management in Health Care and Mental Health Nursing

Since Nightingale implied that progress was inherent in good nursing, change has slowly but surely accelerated to a frenetic pace in health care and to a degree in nursing. However, the healthy progress and implications associated with change in the nursing profession are not as readily embraced as this pace may imply. Rather, embracing change at the core of nursing and health care is a challenge as this is a group who it is suggested are not only resistant but also adept at reinforcing the status quo. Using mental health nursing as an example this position paper addresses the concept of change management, explores the facilitators and inhibitors to explain why change is not effectively managed at times. Further, case studies provided exemplify how change in mental health nursing has occurred and demonstrate how the concept of change management effectively has been achieved. Key strategies for change management are outlined in this article, noting the need to be sensitive to the culture and specifics of that organisation, because change takes place within people rather than within the organisation itself. Part of the challenges and strategies faced in the profession are related to the movement of information and knowledge from the point of research to implementation of evidence-based best practice. Leaders, therefore, should adopt change management principles and strategies, to further drive the developments which have changed mental health nursing over a relatively short period.

Effective organisational change to achieve successful ITIL implementation

Purpose

Although an increasing number of organisations implement the Information Technology Infrastructure Library® (ITIL®) with the aim to improve provision of information technology services to their customers, a significant number of ITIL implementations do not achieve the expected outcomes. The organisational change strategies of organisations during ITIL implementation initiatives may have an effect on success, but empirical research on this topic is scarce. The paper aims to discuss these issues.

Design/methodology/approach

A multiple case study methodology comprising successful ITIL implementations in eight large Australian organisations is used. A socio-technical systems approach represented by Leavitt’s Diamond is adopted as a lens to shed light on the attributes of effective organisational change strategies for successful ITIL implementation.

Findings

This paper identifies organisational change strategies employed by organisations that have effected a successful ITIL implementation. The authors identified that the ITIL implementation required changes to the four components of the socio-technical work system (STS) identified in Leavitt’s Diamond. Changes to one STS component affected other STS components when implementing ITIL; and that effort applied to the STS components did not need to be equal, but appropriate to the requirements of the ITIL implementation and the organisation.

Research limitations/implications

The sample size of eight ITIL implementation cases studied may limit the generalisation of findings.

Practical implications

This research provides IT service management researchers and ITIL practitioners, for the first time, information about organisational change strategies as applied to successful ITIL implementations.

Originality/value

This research has developed novel insights into organisational change strategies and ITIL implementation that had not previously been explored.

Nurse managers' attributes to promote change in their wards: a qualitative study

Aim

The aim of this study was to explore the processes that nurse managers use to promote change in their wards.

Design

Qualitative research.

Methods

A grounded theory approach was used. Participants were 23 nurse managers and 17 nurses in Japan. Interviews were conducted between March 2014 – December 2015. Mainly, nurse managers’ data was analysed.

Results

The change process led by the nurse managers was depicted as a four‐phased process of “having beliefs and empathizing with staff nurses to achieve goals explored by self.” Four attributes of nurse managers, “having both micro and macro perspectives,” “respecting own beliefs and external standards,” “being proactive,” and “having empathy for staff nurses,” were identified as indispensable factors promoting change in their wards.

Nursing administrators should support the cultivation of nurse managers’ attributes for successful change.

Exploring senior nurses' experiences of leading organizational change

Purpose - The aim of this paper is to explore Senior nurses' experiences of leading organizational change. There is a substantial literature reporting middle-level nurse managers' experiences of change; however, there is less evidence concerning senior nurses' perspectives. In view of this, interview data collected from senior nurses, as part of a study of major organizational change, were analysed to redress this imbalance. Design/methodology/approach - In-depth semi-structured interviews (n = 14) were conducted with senior nurses (between 2009 and 2012). Findings - Senior nurses' activity centred on leadership and workforce issues, internal influences and external pressures. In periods of change, appropriate leadership was vital, and "weak" leaders were considered to have an adverse effect on teams. Concerns were expressed about financial strictures and their impact on patient care and service provision. The senior nurses were striving to provide the best quality of service delivery with the limited resources available. Concentration on operational matters was necessary to maintain stability in periods of change. However, this prevented senior nurses from influencing strategic decision-making in their organizations. Practical implications - If senior nurses are to realise their potential to operate at a strategic level, they need to be given time and support to lead, rather than just react to change. This research emphasises the importance of a "nursing voice" to inform board-level decisions and maintain a focus on patient care. Originality/value - This research sheds light on the work of a key group of staff in health-care organizations. Understanding senior nurses' experience of and contribution to change is a useful contribution to health services research.

Leading change: a concept analysis

AIM

To report an analysis of the concept of leading change.

BACKGROUND

Nurses have been called to lead change to advance the health of individuals, populations, and systems. Conceptual clarity about leading change in the context of nursing and healthcare systems provides an empirical direction for future research and theory development that can advance the science of leadership studies in nursing.

DESIGN

Concept analysis.

DATA SOURCES

CINAHL, PubMed, PsycINFO, Psychology and Behavioral Sciences Collection, Health Business Elite and Business Source Premier databases were searched using the terms: leading change, transformation, reform, leadership and change. Literature published in English from 2001 - 2015 in the fields of nursing, medicine, organizational studies, business, education, psychology or sociology were included.

METHODS

Walker and Avant's method was used to identify descriptions, antecedents, consequences and empirical referents of the concept. Model, related and contrary cases were developed.

RESULTS

Five defining attributes of leading change were identified: (a) individual and collective leadership; (b) operational support; (c) fostering relationships; (d) organizational learning; and (e) balance. Antecedents were external or internal driving forces and organizational readiness. The consequences of leading change included improved organizational performance and outcomes and new organizational culture and values.

CONCLUSION

A theoretical definition and conceptual model of leading change were developed. Future studies that use and test the model may contribute to the refinement of a middle-range theory to advance nursing leadership research and education. From this, empirically derived interventions that prepare and enable nurses to lead change to advance health may be realized.

Empowering Sustained Patient Safety: The Benefits of Combining Top-down and Bottom-up Approaches

Implementation of TeamSTEPPS for improving patient safety is examined via descriptive qualitative analysis of semistructured interviews with 21 informants at 12 hospitals. Implementation approaches fit 3 strategies: top-down, bottom-up, and combination. The top-down approach failed to develop enough commitment to spread implementation. The bottom-up approach was unable to marshal the resources necessary to spread implementation. Combining top-down and bottom-up processes best facilitated the implementation and spread of the TeamSTEPPS safety initiative.

Implementing a telehealth service: nurses' perceptions and experiences

BACKGROUND

Telehealth is defined as the remote surveillance of a patient's health to aid early diagnosis and timely intervention. Understanding how the stakeholders perceive telehealth can influence its acceptability and diffusion.

INTRODUCTION

A primary care trust (PCT) in south London has been providing telehealth services for chronic obstructive pulmonary disease (COPD) and heart-failure patients for the past 22 months. The aim of this study was to elicit practice nurses' perceptions of the telehealth service provided by this PCT.

MATERIALS AND METHODS

A descriptive qualitative design was chosen to elicit practice nurses' perceptions. A semi-structured email interview was used to investigate their experiences of the service to date and their views about the future of the service.

RESULTS

Seven nurses, working on telehealth for an average of 15 months and providing the service to 34 patients, were interviewed. Overall, the nurses described their experience with telehealth to be positive. Lack of resources, organisational support, patient selection criteria and technical support were identified as barriers to effective implementation of telehealth. Additional team members, more input and training, and expanded patient selection criteria were suggested by the nurses to enhance and ensure the success of telehealth.

DISCUSSION AND CONCLUSIONS

The challenges and barriers to the implementation of telehealth identified by the practice nurses need to be addressed by health services to ensure its continuity and success.

Nurse leaders' experiences of implementing regulatory changes in sexual health nursing practice in British Columbia, Canada

Most research about regulatory policy change concerning expanded nursing activities has emphasized advanced practice roles and acute care settings. This study is a contribution to the small pool of research concerned with regulatory policy implementation for nurses undertaking expanded nursing practice activities in a public health context. Using the regulatory changes in certified nursing practice in one Canadian province as our starting point, we investigated the experiences of nurse leaders in implementing this change. Using a qualitative interpretive descriptive approach informed by tenets of complexity theory, we examined the experiences of 16 nurse leaders as situated within the larger public health care system in which nurses practice. Two interrelated themes, (a) preparing for certification and (b) the certification process, were identified to illustrate how competing and contrasting demands between health care and regulatory organizations created substantial barriers to policy change. Implications for health service delivery and future research are discussed.

Nurse leaders' perceptions of an approaching organizational change

The aim of the study was to achieve more profound understanding of nurse leaders' perceptions of an approaching organizational change. We used a three-dimensional hermeneutical method of interpretation to analyze text from 17 interviews. The results suggest that nurse leaders were positive toward and actively engaged in continual change to their units, even though they perceived themselves as mere spectators of the change process. The nurse leaders believed that change might benefit patients and patient care, yet their adaptation lacked deeper engagement. The approaching merger affected the nurse leaders' identities on a deeply personal level. They experienced uneasiness and anxiety with regard to being nurse leaders, the future of nursing care, and their mandate as patient advocates. Nurse leaders are in a critical position to influence the success of organizational change, but the organizations covered in this study were not incorporating their knowledge and experiences into the change.

The implementation and evaluation of an oral healthcare best practice guideline in a paediatric hospital

The oral health of the New Zealand population now compares unfavourably with other countries. A number of strategies have been introduced at a government and health provider level to improve the oral health status of children. One such strategy was the introduction of a recommended best practice (RBP) within Starship Children's Hospital. Nursing practice was evaluated 2 weeks prior and 6 months post-implementation of the RBP using a survey technique. While there was no significant change in practice post-introduction of the RBP, awareness regarding the oral health care needs of children while in hospital has been improved. This study provides increased understanding in regard to the oral healthcare practices of paediatric nurses, the influences on evidence-based practice change and health education and promotion within an acute paediatric hospital.

Improving inpatient postnatal services: midwives views and perspectives of engagement in a quality improvement initiative

BACKGROUND

Despite major policy initiatives in the United Kingdom to enhance women's experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought.

METHODS

A Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset.

RESULTS

Questionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the women's physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required.

CONCLUSIONS

This was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services.