Et sic operatur? : Exploring outcomes of organizational change in comtemporary hospitals

Abstract

Background and aims: Emergent trends in society and the expectations of authorities influence activities in public hospitals. The thesis has an overarching aim to contribute to knowledge on how changes in task management and organizational design influence individual and organizational outcomes in hospital setting. The first part of this thesis is based on qualitative studies, including interviews and observations of meetings in a health region project called; ‘Implementing an advanced task planning system’. This new health ICT-system should improve long term planning for clinical personnel and physicians, and be compatible with other ICT systems such as the electronic patient journal system (DIPS) and Outlook. The rationale behind this change-project was if one succeeds in developing and integrating better health information systems one can save time and money, distribute work tasks more efficiently and treat patients with complicated diagnoses acquiring medical help from different departments and professions in a more streamlined and effective way (Kellermann and Jones, 2013). Task planning is an important strategic and operational management function that is decisive to the efficiency of an organization. Task planning enables management to respond to needs for change, to prioritize scarce resources, to allocate the right resources to the right place at the right time, to stimulate knowledge transfer and learning and to distribute a sensible division of tasks between leaders, professionals and patients. The qualitative interviews done in this early phase of the project revealed something interesting; top management used a very special type of goal-setting regime when implementing the advanced task planning system, a type of goals called hairy goals. They also used a special type of project implementation style, called agile project management. The purpose of article 1 was to examine the role of big, visionary hairy goals on employee motivation in change management. We followed the implementation of an advanced ICT task planning system in eight pilot departments in a hospital region. Hairy goals are a type of goal setting that might be useful in multirational organizations consisting of different professions with different work situations such as a hospital, because this type of goal setting is visionary in what it wants to achieve, but vague in how to get there. This allows different professions in the organization to interpret the goals according to their own values and visons. The top management had developed this type of goal setting to avoid professional conflicts and different institutional logics to stop the change process prematurely. Article I in the thesis focuses on what types of goal setting strategies and project implementation style are most useful in implementing an organizational change, with focus on individual work motivation and organizational outcomes. The participating action research in the second article in this thesis was also a result of top management going new ways to succeed in organizational changes. The development of day care surgery as a field, and establishing a new day care surgery department, had been a goal for this hospital for decades. Top management for the surgical department realized that it was going to be hard to develop an efficient multidiscipline department with an improved and patient- centered workflow, without a process which involved breaking up of professional cultures and traditional management structures. This was met with considerable resistance from different professions, not only from the physicians, but also from the anesthesia nurses. The study in article 2 explores how task responsibility changes when setting- up a new day care surgery department (DCS) at a Norwegian University Hospital. The goal was to establish a multidisciplinary work environment with sustained focus on the safeguarding of patients and their needs, and on the creation of management principles that support this focus. The qualitative interviews in article 1 and 2, allowed us to get a deeper insight in where task planning and workflow stopped up, what problems different professions experienced in collaboration within their professions and with other professions, what types of work tasked they found stressful, and what motivated them at work. We got information of how they experienced their psychosocial work environment and what types of negative acts and ethical dilemmas they had experienced at work. This information was vital for us in developing the survey that article 3 and 4 in this thesis are based on. This survey was not only a data collection process for research purposes, it was also a work environment survey for the 22 883 employees in the health region. The interest for the type of stress we label as ‘institutional stress’ and how this was related to job performance, came early in the data analysis process. In the qualitative interviews, several informants had complained that the hospital had been too focused on numbers, business and reports. ‘Quality’ was measured by the wrong parameters and they informed us that they did not think their organization developed in the right direction. Change processes can be experienced as physical, environmental or psychological stressors and lead to strain among the employees. The aim of the study in article 3 is to investigate if stress related to disagreement on the strategy, policy and management practice of the hospital, what we label institutional stress, is related to perceptions of job resources and job demands, and how this stress influences organizational outcomes such as job performance. In work environment surveys it is normal to include questions about self-perceived bullying, experienced negative acts and psychosocial work environment in general. Workplace bullying is not expected to exist in a vacuum, as it is influenced by and evolves from different characteristics of the organization (Einarsen, 1999; Leymann, 1996). In article 4 in this thesis, our focus is to increase our understanding of workplace bullying in relation to work climate and different outcomes among one profession in the hospital setting, the nurses. In this article, we examined a proposed bullying model including both job resources and job demands, as well as nurse outcomes reflected in job performance, job satisfaction and work ability.