Divergent Organizational Change in Hospitals: Exploring how hospital leaders and employees can contribute to successful outcomes.

This thesis consists of three papers that aim to increase our understanding of how divergent changes to organizational structures and management systems in hospitals may be handled by leaders and employees in order to achieve outcomes that contribute towards organizational goals of service quality improvement. Reforms, new policies and the continuous large- and/or small-scale changes aiming for service quality improvement that they manifest in within hospital organizations have been identified as a move away from professional dominance and autonomy, and a move towards a health care system where managerial and market logics are influential. These changes have challenged the organizing principles of professional power in decisions regarding hospital organizational structures and management systems, and professional services are increasingly subject to organizational reform, budgetary control and managerial supervision. Organizational changes that break with existing institutions in a field of activity are defined as divergent. Despite decades of managerial logic initiatives, health care organizations are still heavily influenced by the professional logic. Introducing changes that are based in a managerial or market logic into the work of health service professionals could therefore be considered as divergent, and potentially conflictual, organizational change which would be met with resistance rather than readiness for change and willing participation. We know from previous research that quality improvement initiatives in hospitals very often fail to produce the intended results. We also know that involving health care professionals in processes aimed at improving hospital services is widely considered as a critical factor for achieving goals of quality improvement. However, the most widely documented reaction to divergent change from clinical staff is resistance or active opposition to new arrangements, and this is often identified as the reason for failure in achieving the improvements that change projects aim for. There are few studies of successful outcomes of divergent changes in health care organizations. There are also few empirical studies of professional engagement in such organizational change efforts. This means that there is an identified need for studies that shed light on how successful outcomes occur in a variety of contexts and related to a variety of different types of changes, as well as for more in-depth research on how divergent changes may be handled by hospital leaders and employees in order to achieve outcomes that contribute towards organizational goals of service quality improvement. This thesis raises the two following research questions: How are frequent organizational changes in hospitals and middle manager change-oriented leadership related to organizational and employee outcomes relevant to hospital service quality? How can hospital leaders and employees contribute to processes of implementing divergent changes to organizational structures and management systems in order to achieve outcomes that contribute towards organizational goals of service quality improvement? The first question is answered by Paper 1, titled “Changing to improve? Organizational change and change oriented leadership in hospitals.” The second question is answered by Papers 2 and 3, and an overall discussion of the findings from all three papers

Readiness for change and good translations

Translation studies have shown that management ideas and practices change as they travel between contexts, and that there are regularities in how they are translated through editing. We, however, know less about what facilitates good translations, i.e. the translation of new ideas and practices into working practices or routines that contribute to the attainment of organizational goals. This study investigates how the concept of readiness for change can increase our understanding of translation processes and translation outcomes through following an intra-organizational translation of a new management idea and practice in a hospital. The aim is to identify how the use of editing rules in a strategic translation process impacts readiness for change. It is also to identify how readiness influences the use of editing rules and translation practices in an operative translation process and the resulting differences in the quality of translation outcomes. This study finds that strategic translations may foster readiness for change. Readiness furthermore enables inclusive operative translation processes in which editing practices and translation rules are used to thoroughly rework a new management idea and practice into a good translation.publishedVersio

General practitioners’ perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL. Methods We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. Results GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. Conclusion Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel.publishedVersio

Understanding registered nurses’ career choices in home care services: a qualitative study

Background: The anticipated growth in number of older people with long-term health problems is associated with a greater need for registered nurses. Home care services needs enough nurses that can deliver high quality services in patients’ homes. This article improves our understanding of nurses’ career choices in home care services. Methods: A qualitative study using individual semi-structured interviews with 20 registered nurses working in home care services. The interviews were audio-recorded, transcribed and thematically analyzed. Results: The analysis resulted in three themes emphasizing the importance of multiple stakeholders and contextual factors, fit with nurses’ private life, and meaning of work. The results offer important insights that can be used to improve organizational policy and HR practices to sustain a workforce of registered nurses in home care services. Conclusion: The results illustrate the importance of having a whole life perspective to understand nurses’ career choices, and how nurses’ career preferences changes over time.publishedVersio

Changing to improve? Organizational change and change-oriented leadership in hospitals.

outcomes relevant to hospital service quality (performance obstacles and physician job satisfaction) and in one’s knowledge of the role of middle manager change-oriented leadership in relation to the same outcomes. Further, the authors aim to identify how physician participation in decision-making is impacted by organizational change and change-oriented leadership, as well as how it mediates the relationships between these two variables, performance obstacles and job satisfaction. Design/methodology/approach – The study adopted a cross-sectional survey design including data from Norwegian hospital physicians (N 5 556). A hypothetical model was developed based on existing theory, confirmatory factor analysis was carried out in order to ensure the validity of measurement concepts, and the structural model was estimated using structural equation modelling. Findings – The organizational changes in question were positively related to performance obstacles both directly and indirectly through participation in decision-making. Organizational change was also negatively related to job satisfaction, both directly and indirectly. Change-oriented leadership was negatively related to performanceobstacles,but onlyindirectlythroughparticipationindecision-making, whereasitwaspositively related to job satisfaction both directly and indirectly. Originality/value – The authors developed a theoretical model based on existing theory, but to their knowledge no other studies have tested these exact relationships within one model. These findings offer insights relevant to current and ongoing developments in the healthcare field and to the question of how hospitals may deal with continuous changes in ways that could contribute positively towards outcomes relevant to service quality.publishedVersio

Competence Development and Collaborative Climate as Antecedents of Job Performance, Job Commitment and Uncertainty: Validation of a Theoretical Model across Four Hospitals

Knowledge is lacking regarding how organizational factors are associated with uncertainty in patient treatment. Thus, the aim of the current study was to investigate how competence development and collaborative climate relates to job performance and job commitment, and further whether job performance and job commitment relate to uncertainty. Additionally, we examined whether these associations differed between four different hospitals. We applied data from 6445 hospital workers who provided care to patients. Basic statistics and structural equation modelling (SEM) were used to test the validity of the theoretical model developed in the study and the hypothesized associations. All hypothesized paths between the latent variables were significant and in accordance with the model across the four hospitals. The current study has implications for practical human resource management and indicates that competence development should be strengthened at the individual level and collaborative climate should be strengthened at the ward level. Strengthening competence development and collaborative climate can increase job performance and job commitment of individual workers and reduce uncertainty during care in hospital settings.publishedVersio

Reforming for trust and professionalism in municipal healthcare services: implications for human resource management

Abstract Background Many countries face an increasing demand for home-based healthcare services, and consequently experience a mismatch between expectations and available financial and human resources. It is therefore important to utilize human resources more efficiently, while at the same time offer jobs that attract the professionals they need. This article reports a study of the development and piloting of a new organizational model for home-based healthcare services in a Norwegian municipality, which addresses the need to provide efficient services and enhance trust and professionalism within healthcare services by improving work autonomy and involvement of employees. Methods The research project this article draws its empirical material from was commissioned by the municipality piloting the new organizational model and executed in collaboration with the municipality based on an evaluative trailing research (ETR) design. The data consists of interviews with key personnel and knowledge exchange between researchers and the involved actors in the pilot project. 20 semi-structured interviews involving a total of 34 informants were conducted. The analysis emphasises how different employee groups and management perceived and experienced various aspects of the work situation, as they were introduced to working and managing within the new organizational model. The aim is to shed light on how these employees and managers feel about it, interpret it, and respond to it. Results Overall, the results indicate that the model holds potential for realizing the benefits it aims for. However, there were also challenges that need resolving for the model to fulfil this potential. Central elements include clarification of roles and responsibilities for employees and managers, competence specification and development, and development of structures for inter-professional cross-team collaboration and information provision. Conclusions Trust reform initiatives may be a strategy for fostering high-involvement work systems. To achieve this, sufficient attention must be paid to ensuring structures for information exchange and knowledge development in the early phases of implementation, or preferably prior to implementation. The theoretical model applied in this study could potentially be a useful managerial tool in preparing for and implementing trust reforms in healthcare services

General practitioners’ perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL. Methods We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. Results GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. Conclusion Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel

Evaluering av samarbeidet mellom NAV og helsetjenesten om Individuell jobbstøtte (IPS)

Prosjektet «Evaluering av samhandlingen mellom NAV og helsetjenesten i samarbeidet om Individuell jobbstøtte (IPS)» har blitt utført mellom slutten av september 2020 og slutten av april 2021, på oppdrag fra Arbeids- og sosialdepartementet. Evalueringens hovedmål er å gi svar på hvordan behandlere og jobbspesialister samarbeider i integrerte behandlingsteam som tilbyr IPS. Dette besvares gjennom 9 intervjuer med behandlingsteam som samarbeider om IPS-tjenester, og spørreskjemaer til metodeveiledere og ledere av behandlingsteam i helse- og omsorgstjenesten som tilbyr IPS. Metodeveiledere er ansvarlige for faglig kvalitetssikring og veiledning av jobbspesialister i henhold til IPS-metodikken. Vi har også nyttiggjort oss oppfølgingsdata fra effektevalueringen i 2016, og ser på hvordan langtidseffekten av IPS er for de ulike pilotsentrene som den gang var med i studien.publishedVersio

Helsetjenesteteam og omsorgsteam

Denne rapporten beskriver organisatoriske barrierer og muligheter ved implementering av en ny organiseringsmodell for hjemmebaserte tjenester i Bergen kommune. Modellen innebærer at ansatte med høyere helsefaglig utdanning (sykepleiere, fysioterapeuter og ergoterapeuter) organiseres i Helsetjenesteteam (HT), mens ansatte med helsefagutdanning og assistenter organiseres i Omsorgsteam (OT). Dette medfører en viss endring i oppgaver og ansvarsområder, og formålet med omorganiseringen er økt utnyttelse av sykepleierressurser og forbedring av tjenestekvalitet, samt økt opplevelse av profesjonsutøvelse blant ansatte. Modellen piloteres over 12 måneder i bydelene Fana og Ytrebygda.publishedVersio