Change is pervasive in modern health care. This study aimed to identify characteristics of successful organizational changes from the perspective of health care professionals at the frontline level of health care. An important premise for the study was that the health care 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 be considered successful according to the statements of the health care professionals who were interviewed: that health care professionals (1) have the opportunity to influence the change, (2) are prepared for the change and (3) recognize the value of the change. Many of the statements by the participants were representative of more than one category, suggesting an interdependency between the three categories of this triad of successful change characteristics. For example, a slower change allows for preparation, which facilitates involvement and influence, thus enabling an appreciation for the change. Alternatively, recognizing the value of a change, e.g. its patient benefits, likely contributes to increased motivation among health care professionals to become engaged and participate in carrying out the change. This interdependence implies that successful change 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 involvement 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 have not been able to find any previous study, either in health care settings or in other environments, which has identified the relevance of this particular triad of characteristics or how they are interlinked. Although our findings suggest these interdependencies, we 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 study attached great importance to being able to influence changes that may influence their work. They expressed positive attitudes to changes that have been developed and emanate “bottom up” from themselves and/or the frontlines of health care. Many of the health care professionals complained about the power differential between those who are affected by the changes and higher management and political levels of the health 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 being involved in the decision-making process [28]. These findings underscore the importance of changes having frontline support and being perceived as 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 process is perhaps the most frequently cited approach to overcoming resistance to change [29, 30]. Even assuming a well-justified and well-planned change initiative, research underscores the importance of managers building internal support for change by means of employee participation in the change process [31]. These are common findings in organizational research in general, but they seem particularly applicable in health care 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 often pointed out in the organizational change literature [31]. However, 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 Change, a theory that posits that readiness depends on organization members’ resolve to pursue the courses of action involved in implementing change (change commitment) and their beliefs in their capabilities to execute these actions (change efficacy). Contextual factors such as resources and culture also influence their preparedness to implement change [33].
The importance of management communicating the motives for changes was stressed by the health care professionals in our study. Consistent with our findings, organizational change research has demonstrated that changes have a greater chance of succeeding if employees consider them to be 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 sound causal thinking [34,35,36]. Employees who do not understand why a change is pursued will be reluctant to comply with the management’s requirement for the change [25]. The health care professionals in our study argued that the changes must benefit patients to have value. This is consistent with research that shows that health care professionals’ role 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 management 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 management systems, e.g. auditing, guidelines, recommendations, adverse event 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]. According to professional theory, true professionals such as physicians and lawyers independently treat individual cases (e.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 complex problems [42, 43]. Research suggests that physicians due to their stronger identification with professional logic are more likely than nurses to be critical of management-initiated changes [9]. Several studies have shown how physicians respond with scepticism or suspicion to different forms of management-led changes in health care [44, 45].
Sweden has seen a lively public debate on NPM in recent years, with many scholars, policy makers and both physicians and registered nurses critiquing core NPM principles and their consequences for health care professionals [46,47,48,49,50]. In response to the criticism of NPM principles, the Swedish government 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 management [26, 51]. Governance by trust is intended to let “the professionals be professional” [52]. This initiative is new and we are not aware of any studies of the concept, but research is warranted to investigate how this concept is realized in practice. Future research should assess whether health care professionals perceive changes as more successful under 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 by their respective supervisors about participation in the study, which means that the participants may have been particularly interested in the subject.
The multidisciplinary research team was a strength of the study, because it allowed different perspectives on the issue of changes in health care. The team consisted of the following professions: behavioural economist (PN), political scientist (IS), registered nurse (KS), behavioural scientist (CE) and organizational sociologist (SB). Another strength was the relatively high number of interviews (n = 30), although Malterud et al. [53] emphasizes that the strength of the information received (information power) is more important than the size of the sample. Regardless, this enabled us to use quotations from many different participants, adding transparency and trustworthiness to the findings.
The main 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 research on organizational changes, no previous study has identified this particular triad of interdependent characteristics. The study provides important knowledge for health care organizations to plan and implement changes with better chances of being successful.
