Journal of Clinical Nursing 1994; 3; 57-61

Change in process: bringing about change in health care through

action research \ NJ > ^..K.

A report on the diagnostic stage of a 2-year study commissiotted by Trent Regional Health Authority and carried out hy theDepartment of Nursing and Midtvifery Sttidies, University of Nottingham

\ LINDA EAST BSc (Hons) RGN\ Lecturer in Nursing Studies

JANE ROBINSON MA PhD MIPM RGN RHV HVT Cert Ed.._ Professor and Head of Department of Nursing and Midwifery Sttidies

Department of Nursing and Midwifery Studies, Medical School, Qiieen's Medical Centre,.,, ,: Nottingham NG7 2UH, UK

•' ' Accepted for publication 2 August 1993

-<: bni. ii-M

Summary

• A 2-year action-research project aiming to facilitate the management of changewas carried out in a district general hospital. ' '

• Hospital managers and senior ward nurses had very different views concerningthe source of challenges and problems within the hospital organization.

• A case-study of nurses' experience of change at ward level was produced as partof the diagnostic phase of the action research.

• The results of the case-study indicated that general managers and professionalshad different agendas for change but that there is common ground between them.

Keywords: action research, management of change.

Introduction

The question of how to bring about change has become amajor preoccupation of health-care practitioners andmanagers. As individuals, we are called upon to developour personal skills in order to provide reflective, research-based, client-centred care. As hospital and communityemployees, we are expected to work towards institutionalstandards reflecting both costs and quality. Yet, as indic-ated by the furore which greeted Eric Caines' recentsuggestion that the number of NHS professionals shouldbe cut by 20%, the obstacles to achieving both personaland institutional change may look very different dependingon your starting point (Caines, 1993).

Such divergence in perspectives was clearly illustratedduring a 2-year action-research project commissioned tofacilitate the process of change within a district healthauthority. The project began in 1990, a time when standardsof care were a major source of concern. The healtb authorityhad recently received an unfavourable external report onaspects of service delivery and, like many others, had alsoexperienced severe financial constraints. Add to this thechallenge of translating the Government White paperHorki?tg for Patients into practice, and the question of howto bring about the change became imperative (DoH, 1989).

As researchers concerned with the process of change, wecould not afford to ignore this context. Pettigrew et at.(1988) provided a useful framework within which to

57

58 L. East and J. Robinson 1 . 1 ".••

Context Diagnosingtdentifying the problem

Content Process

F'igurc 1 The context/content/process framework. |FromPettigrew A. t'/a/. (1988)J

analyse organizational change, giving as much weight tothe context and process of change (the 'why' and the 'how')as to the content, or the 'what', of change.

Within this framework the outer context refers toGovernment directives and other outside forces to whichthe district health authority must respond. The innercontext refers to aspects of internal structures, strategy andleadership styles. For Pettigrew, the inner context stops atthe level of strategic management — the chief executivesand their senior colleagues. It is a sad fact that the work ofnurses is all but invisible in the work of Pettigrew andother writers on NHS policy and management in spite ofour crucial contribution to service delivery.

i..i(inq l*aiAction research

Contrary to the usual expectations in the conduct ofresearch, it was not possible to spell out the precise natureof the research problem at the start of the project. Theresearch was commissioned in a dynamic and politicallysensitive context w hich demanded a high degree of flexibi-lity. Action research was therefore the method of choice,enabling the researchers to adapt to changing circum-stances as the research process unfolded.

Action research, as a method, has recently attractedconsiderable attention in the British nursing researchliterature (Webb, 1990; Holtcr & Schwartz-Barcott, 1993;Nolan & Grant, 1993). It has been seen as a highlycompelling way of bridging the gap between theory,research and practice and thus appeals to both education-alists and practitioners (Owen, 1993). Action research hasalso been advocated as a method which empowers nursesthrough the supportive collaboration of researchers andresearched (Webb, 1989).

Developing from the work of post-war change theoristKurt Lewin in the USA, action research is usually pres-ented as a cyclical or spiral process and the increasingpopularity of this approach amongst nurses may possibly

SpecifyingieamingExploring

general findings

Researchinto action

\

ActionpianningSelecting

Interventions

EvaiuatingReviewing theconsequences

JAction tai<ing

Implementing change

Figure 2 The cyclical process of action research | Adapted from.Su.sman G. & F.vered R. (1978)1

be partly attributed to its similarity to the elements of thenursing process.

However, as with the nursing process, actually applyingthe action-research cycle is not always as straightforwardas it appears on paper. Simply identifying the researchproblem can become a major undertaking when conflictingperspectives must be identified and worked through; it iswith the 'diagnosis' stage of the cycle that this report isprimarily concerned.

Defining the problem

As stated in the introduction, this study began in a contextof concern surrounding standards of care. Interviewscarried out with senior tnanagers during the diagnosticstage of the research revealed that some believed nursingstaff themselves to be the very root of the problem. Seniorward nurses (ward sisters/charge nurses) in particular,were portrayed as log jams in the current of change byvirtue of their long service records.

With the backing of the research steering group, the.senior ward nurses became the main focus for the 'aclion'part of the action research. Easing their transition from thetraditional senior ward nurse role to the new style, Ggraded, standard setting, budget holding 'ward managers'was a developmental process to which action researchcould be fruitfully applied. !r

I Iowever, as the researchers began work with the seniorward nurses, a rather different view of the organizationbegan to emerge from that of those senior managers whoconsidered the nursing staff were resistant to change. As abasis for a 2-day 'diagnostic workshop' with the senior

Change in process 59

nurses, the project leader administered a standard psycho-logical tool known as the Occupational Stress Indicator(Cooper et al., 1988). The findings revealed remarkahlyhigh levels of joh-related stress among this particulargroup of senior nurses, much of which centred around thefeeling that they were victims of organizational forces overwhich they had no control. The senior ward nurses feltthat, far from resisting change, there were many improve-ments and innovations they would wish to make on theirwards. However, there were structural constraints whichprevented them from achieving their desired aims.

The inner eontext .

In attempting to fiicilitate change, the researchers were notundertaking a simple task. We had to address the discrep-ant views of senior managers and senior ward nurses as towhere problems concerning standards of care originated.As action researchers we felt it was important to exploreboth sides of the story, recognizing the participativeemphasis in the research methodology. Also, as academicresearchers we were interested in the theoretical im-plications of this 'gap' between strategic and operationalmanagers. We were concerned to understand the nature ofthe inner context of the change process through theculture, beliefs and values expressed by the ward nursingstaff. For us, the inner context of the project had to beright at the heart of care delivery, set against the outercontext of changes taking place within the NHS.

We therefore decided to add a case-study of change atward level to the interview data collected during thediagnostic phase of the action-research project. Drawingon a background in both social science and clinical nursing,the research assistant worked on the wards as part of thenursing team for a total of . 0 shifts. Using the researchstrategies of participant observation, interviews with wardstaff and documentary analsyis the researcher attempted toaddress the question: 'What are the factors which inhibitor promote change at ward level?'.

In addressing this question, the lindings of the studywill be discussed in three parts. First, we will explore theimpact of managerial and professional agendas for changeon the ward-based staff. Second, some of the possibilitiesfor opening up the common ground between ward nursesand hospital managers will be identified. In conclusion, wewill highlight some ofthe diflicuhies we experienced in theprocess of researching change.

Agendas for change

In the attempt to uncover what was really important to thestaff working within the 'inner context' it was necessary to

keep an open mind. However, the researchers were alsoeager to explore the effect on the ward staff of manageriallydriven change processes, including the introduction ofinformation technology, implementing a quality strategyand taking forward NHS Trust proposals.

An important finding of the study was that these issueswere rarely discussed in detail, and were certainly notgrasped as a major challenge or opportunity for change.

The resource-management initiative simply meant'computers' to the ward nurses; just another task to bedone. 'Computers' were, in this case, quite an excitingdevelopment. The hospital was pioneering a brand newsystem of data management which was eventually boughtby a major London teaching hospital. However, this wasnot picked up by the ward staff as a development whichheld any meaning for them.

Similarly, the way in which the quality strategy wasbeing implemented on the wards through a process of in-service training days was somehow missing the mark. Atypical comment would be: 'It's quality this, quality that—they should cotne and spend sotne time on the wards!'

This is not to suggest that the nurses were activelyresisting change in the way that some of their managersappeared to suspect. They were not actively sabotagingthese new developtnents as sociologists have described inindustrial settings; no one was, literally or tnetaphorically,throwing a spanner in the works. Rather there was sense ofresignation on the whole and, amongst many ofthe staff, agrudging willingness to 'give things a go'.

What could not be identified atnongst the ward nurseswas any sense of ownership for these changes; any enthusi-asm or dynamism or excitement generated by the processesof resource management or quality assurance. It seemedthat these initiatives were poorly understood and thereforea weak motor for change.

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Professional agendas

However, new initiatives arising from yVorking, for Patientswere not the only new developments beaming in from theouter context; there was also nursing's professional agendafor change to be considered. What Jane Salvage haslabelled 'New Nursing' —the world of primary nursing,therapeutic nursing, nursing development units — was, infact, the main inspiration for change on the wards (Sal-vage, 1990).

On the medical ward, in particular, the staff were trying tointroduce team nursing as a w ay of organizing their workloadin order to maximize individual patient care. Their enthusi-asm was spilling over into other areas as they sought toupdate their practice. Each nurse had responsibility for

60 L. East and J. Robinson

keeping up to date on a specific aspect of clinical nursingand together they were putting a great deal of personaltime and effort into developing their knowledge base.

De-skilling in practice ^'" I'^n-

However, nurses' efforts to introduce team nursing andthus to individualize patient care, were being thwarted bythe way in which their staffing levels were managed. Theskill mix seemed poor for a 33-bed acute medical wardincluding six designated coronary-care beds. Sometimesonly two trained staff and four auxiliaries would be on dutyon a shift. This meant one nurse and two auxiliaries as ateam had to care for 17 patients. The qualified nurse wouldhave 17 sets of drugs to administer, 17 rounds of observa-tions to carry out, not to mention the demands of caring forthe newly admitted and acutely ill patients. It was notsurprising that a major problem identified by the nurses onthis ward was that of 'auxiliary-led care' — the auxiliariescarried out the bulk of the physical care of patients.However, they had not been trained in the use of rehabili-tation techniques with stroke patients or promoting inde-pendence in the frail elderly. Inevitably, routine, task-orientated nursing care dominated despite the nurses'expressed aim to individualize patient care.

This problem was further compounded by what wasdescribed as the 'keeping up the numbers' approach,according to which nurses were regarded as virtuallyinterchangeable. To maintain minimum safety, nurseswere constantly moved between wards to 'cover' and therewas an ever-changing army of bank and agency staffmarching through the shifts. This situation can be directlyattributed to the aftermath of overspend, when vacancieswere frozen across the board. The staff might haveaccepted the logic of this, were they not aware of themoney paid out to nursing agencies to fill in the gaps.

It is interesting to note that this impression was con-firmed in the report of the financial consultant involved inthe action research process (Hillman, 1991), Not only hadthe health authority experienced under-resourcing relativeto activity, but also the measures taken to control anoverspend situation had exacerbated pre-existing financialproblems. The measures, including the accommodation of asteady rise in the level of patient activity over time and theuse of a vacancy freeze, were coupled with the emergencyemployment of bank and agency staff in the ensuing staffingcrises. This combination only served to make matters worse.

Local matters

Overall, however, it seemed that the changes which mat-tered most to be ward staff were local issues such as the

closure of a much loved community hospital and thefeeling that the elderly were being short changed as aresult. This was amplified during the course of the studywhen a newly appointed clinical director a physician —almost overnight moved a care of the elderly ward from itspurpose built unit on to a ward known as one of the 'huts'in order to create extra medical beds. He simultaneouslyreshuffled several of the senior ward nurses so they had totake on completely new wards, a process which had a hugeknock-on effect on morale and motivation; as one nurse putit, 'we were skittled'.

Making change relevant

In order to engage fully the staff at the heart of caredelivery in the change process it is necessary to demon-strate the relevance of the proposed change to the improv-ing the care of their patients. Despite all the effort put intoteam briefing, letters to the staff from the Chief Executive,in-,service training on quality and special projects forresource management the staff remained, for the most part,unconvinced.

Of relevance to more of the nurses was the drive toimprove professional standards and to make their nursingcare patient centred. However, they were frustrated intheir efforts by the way in which they were managed.

What was relevant to everyone were the changes whichdirectly affected the material nature and conditions of theirdaily work. Over these changes, staff at ward level felt theyhad virtually no control. It seemed ihal they could beshunted from one area to another simply on the basis of amanager's whim.

Finding the common ground

As action researchers, we had no doubt that findingcommon ground was possible. For what is the consumerorientation of the Government's Patients' Charter and thepatient-centred care ideal in the 'New Nursing' if notcommon ground between managers and practitioners.'

The quality initiative should be the meeting poinl forsuch concerns. In our study there was evidence that, in thepast, an approach to quality based around the quality circlehad excited some enthusiasm and engendered the feelingthat 'things were moving'. Unfortunately, quality circleshad fizzled out when the particular manager who had setthem up left. However 'bottom up' as opposed to 'topdown' change strategies have been highly effective else-where. Even sleepy backwaters can become flagships ofchange with innovative leadership, as the work of clinicalnurse leaders such as Alan Pearson and Steve Wright has

Change in process 61

shown (Wright, 1991; Pearson, 1992). What these leadersacknowledge is the importance of a supportive outer con-text. Indeed, it is the King's Fund policy to recognizeNursing Development Units only when they are convincedof the full commitment of senior managers. Such managersknow how to listen to nurses and make the links between themanagerial and professional agendas, l' qually important,such managers know when to let go of the reins in order toenable clinicians to act. They are the 'enabling' managers sobeautifully described in the 1991 Audit Comtnission Re-port, 'The Virtue of Piitient.<;' (Audit C^ommission, 1991).

There are many analogies between organizations andfamilies. Family therapists often find that one memberof the fatnily gets scapegoated and that even when thatmember really wants to change his family won't let him. Isthe steireotyping and blaming that goes on in hospitalsreally much different.'

We found little evidence that nurses were resistant tochange and much to suggest that many were anxious toimprove standai ds of care. What was against them werestructural factors with an economic basis; the tremendousday-to-day fluctuation that delied all attempts at con-tinuity of care arising from financial constraint and crisismanagement. If these issues were clearly addressed andthere is no reason why resource managetnent and thequality initiative should not be the tnotors for change—then the managerial and professional agendas might reallypull together towards the goal of putting patients first.

Conclusion

Facilitating change is not a simple process. There weretimes when feeding back our research became extretiielytense and dillicult. Indeed, there were occasions when itappeared that the sensitive nature ofthe conflicting perspec-tives we identified would prevent us proceeding with theresearch. Perhaps this was inevitable when the complexityofthe different change agendas is taken into account.

However, the lesson we always return to is that it isessential that nurses get out of what Jane Robinson hascalled the 'black hole' in health-service policy (Strong &Robinson, 1990). Much of nursing research is inwardlooking and acontextual, as if nothing important happensbeyond the ward door or even the individual patient'sbedside. Yet, in equal measure, most management research

ignores nursing. In so doing it ignores what goes on at thevery heart of care delivery; at the point of contact betweenconsumer and service where real change in the healthservice is designed to have an impact.

The future of health-services research will be bleakunless the political issues of poser and control in thedifferent agendas are addressed. Researching the process ofchange requires us to make these issues explicit and toexplore to the very limits the common ground whichexists. We need to make clear when the differences aremore apparent than real, and where everyone must joinforces in order to overcome the genuine stumbling blocks.Nurses should not underestimate the pain which isinvolved for everyone engaged in the process.

Refercnees

Audit Commission (1991) The I'irluc of Patients:: Makini; Best Useof Ward Nursini; Rcsotincs. HMSO, London.

C aincs lv (199. ) Amputation is crucial to the patient's health. TheGuardian 11 May 93, p20.

Cooper C , Sloan S. .& Williams S. (1988) Occupational StressIndicalor; .Management Guide. NFF.R-Nclson, Windsor.

1 department of 1 Icalth (19S9) I ('mi-ini; for Patients. I IMSO, London.Hillman R. (1991) Review ot" lnnancial Management 1987-1991.

Department of Nursing and Midwifery Studies, University ofNottingham. Unpublished Report.

Holter I. M. & Schwart/.-Barcott D. (1993) Action research: what isit.' how has it been u.sed and how can it be used in nursing?^oi/rna/of Advanced Nursing 18, 298-304.

Nolan M. & Grant G. (1993) Action research and quality of care: amechanism tbr agreeing basic values as a precursor to change.Journal of .-idiaiurd h'ursing 18, 3O.S-311.

Owen S. (1993) Identifying a role for the nurse teacher in the clinicalarea. Journal of Advanced Nursing 18, 816-825.

Pearson A. (1992) Nursing al Burford; a Story of Change. ScutariPress, London.

Pettigrew A., Ferlie E. & McRee L. (1988) Wind of Change Blowstlirough NHS Research. The Health Service Journal 98, 5125,1296-1299.

Salvage J. (1990) The theory and practice of the 'New Nursing'.Nursing Times 86(1), 42 45.

Strong P. & Robinson J. (1990) The NHS Under New .Management.Open University Press, Milton Keynes.

Susman G. & T.vered R. (1978) An as.se.ssment of the .scientific meritsof action research. .-Idminislrative Science Quarterly 23, 582-603.

Webb C. (1989) Action research: philosophy, methods and personalexperiences. Journal of .-idvanced Nursing 14, 403—^10.

Webb C. (l')')()) Partners in research. Nursing Times 86(32), 4(M4.Wright S. (1991) Tameside Nursing Development Unit; a decade of

success. Nursing Statidard 6(7), 49-56.