Sara Christian

Achieving change in health care practice

This study evaluated a practice development programme consisting of nine projects together known as STEP (South Thames Evidence-Based Practice Project). The aim of STEP was to establish and assess evidence-based practice in nursing and other health care practice areas. Objectives of the independent evaluation were to identify and assess outcomes from the process of change and investigate the association between these intermediate outcomes and patient outcomes. Outcomes were measured before and after the changes were introduced. Data collection methods included interviews with the change agents and other stakeholders, and a questionnaire to staff in each centre. Patient outcome data were collected from each centre. The findings revealed ‘dissemination’ of information to staff and ‘adherence’ by staff to new practice guidelines to be important intermediate outcomes in the process of change. The need emerged for a supportive organizational culture and commitment, recognition of the importance of change and a credible change agent. There was some evidence of linearity in the process of change in that a logical route appeared from dissemination of information to staff through adherence to the change guidelines to improvement in patient outcome in six of the nine centres. Linearity was less apparent in the other three centres, where the process of change seemed more dynamic and chaotic. These three centres were affected more than the others by organizational barriers to change. Our conclusions support the view that the linear model of change can work in settings with high levels of certainty but complexity theory is more likely to underpin the process of change in organizations characterized by uncertainty.

An evaluation of nursing development units

The aims of this study, which is still in progress, are to assess the value that nursing development units add to nursing and health care and to describe the essence of an NDU. The areas investigated cover: resources and costs, research and audit activities, networking activities, staff morale, staff development and supervision, and clinical leadership. The research took a staged approach with four phases: consultation, profiling the NDUs, comparing NDUs with units without NDU status and case studies of five high-performing NDUs. This paper provides an overview of the study and findings from Phases 1-3. It was important for clinical leaders to be clinically credible, to have authority and to be free from day-to-day care provision and management. Quantitative differences between NDUs and comparison units emerged for research and dissemination activity (NDUs were more active), and sickness absence (more long-term sickness in NDUs) but not for audit and staff development activity, nor for the financial context. Data from the final phase will give a more detailed understanding of the significance of these differences and the different pathways that can be taken to achieving success as an NDU.

People and Teams Matter in Organizational Change: Professionals’ and Managers’ Experiences of Changing Governance and Incentives in Primary Care

OBJECTIVES To explore the experiences of governance and incentives during organizational change for managers and clinical staff. STUDY SETTING Three primary care settings in England in 2006-2008. STUDY DESIGN Data collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation. PRINCIPAL FINDINGS Integrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty. CONCLUSIONS Eliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

Leading opinion and managing change in complex organizations: Findings from the South Thames Evidence-based Practice project

Opinion-leaders have been described in the research literature as credible experts, capable of supporting, facilitating or advocating change and influencing health professionals to adopt innovatory, evidence-based approaches to their practice (Lomas et al., 1991; Thomson et al., 1999). However, information is lacking on the complexity of selection and training, and of the role support that is necessary to enable opinion-leaders to function effectively. This paper focuses on the experience of using opinion-leaders to implement practice change as part of a multi-faceted approach within the South Thames Evidence-based Practice project (STEP), drawing on information integrated from a cross-case analysis and the independent evaluation. Key findings are that the opinion-leader role is complex and challenging, and requires a broad balance of research, management and leadership competences to inform selection and training.

The impact of nursing innovations in the context of governance and incentives.

This discursive paper is a structured analysis of four completed national and regional studies carried out in the UK. It sets out retrospectively to explore the impact of key contextual, professional and personal features and mechanisms on innovation and outcomes in nursing and the extent to which these are common or diverge across the studies (cases). As successive governments across the world turn their attention to developing nursing as a means of increasing productivity and effectiveness in health care, there is a need for evidence to inform workforce policy and planning about the circumstances that enable positive levers and mechanisms, which influence outcomes to operate. This analysis takes advantage of recent conceptual work on organisational governance and incentives by asking new questions of established data to illuminate our understanding of the pathway to innovation in nursing. Data from the four evaluations (cases) were aggregated and explored thematically within Davies et al.’s framework (Studying health care organisations — links between governance, incentives and outcomes: a review of the literature. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). http://www.sdo.nihr.ac.uk/files/project/66-final-report.pdf, 2005) of governance, incentives and outcomes. The themes were grouped into three categories: contextual, professional and personal, and interrogated by inter-researcher scrutiny. Taking account of the limitations of comparing studies carried out for different purposes and in different policy circumstances, there are compelling messages emerging about the organisational support, professional leadership and factors that motivate change and innovation in nursing. The analysis suggests that separating governance from incentives oversimplifies what is a complex interplay between organisational governance and the professional and personal enabling factors supporting innovation. The nature of these relationships deserves further study.