Organizational culture towards change in a hospital setting: a nursing perspective

Abstract

Objective

To evaluate the organizational readiness of a hospital to support knowledge translation and its incorporation into clinical practice; to identify the priority dimensions to be developed to support knowledge translation and its incorporation into clinical practice.

Methods

This was a quantitative, descriptive, exploratory, and correlational study, using the Organizational Readiness for Knowledge Translation questionnaire in a non-probability sample of 275 nurses from a hospital.

Results

The “Organizational Climate for Change” dimension achieved the greatest consensus, suggesting cohesion and openness towards change (mean of 34.07 out of 50 points) in the teams. The “Leadership” dimension (mean of 31.26 out of 50 points) accumulated the least representation, highlighting the participants’ neutral perception about most of the items in this dimension; the mean value of the answers was above the mean value in the global analysis of the scale.

Conclusion

A good level of organizational preparation for the knowledge translation was found, translating a positive nurses’ perception. Some difficulties were identified in the process of planning and evaluation by the leadership, as well as in the activities that promote the involvement of collaborators.

Organizational culture; Hospital administration; Health organizations; Change management

Resumo

Objetivo

Avaliar a preparação organizacional de um hospital para suportar a translação do conhecimento e a sua incorporação na prática clínica; Identificar as dimensões prioritárias a desenvolver, capazes de suportar a translação do conhecimento e a sua incorporação na prática clínica.

Métodos

Estudo descritivo, exploratório e correlacional, enquadrado no paradigma quantitativo, com aplicação do questionário Organizational Readiness for Knowledge Translation, numa amostra não probabilística de 275 enfermeiros de uma instituição hospitalar.

Resultados

A dimensão “Clima Organizacional para a Mudança”, foi a que reuniu maior consenso, sugerindo, nas equipes, a presença de coesão e abertura orientada para a mudança (média de 34,07 em 50 pontos). A dimensão da “Liderança” (média de 31,26 em 50 pontos) acumulou a menor representação, destacando-se a percepção neutra dos participantes sobre a grande maioria dos itens que compõem esta dimensão; quando analisada o global da escala, a média das respostas situaram-se acima do valor médio.

Conclusão

Evidenciou-se, bom nível de preparação organizacional para a translação do conhecimento, traduzindo uma percepção positiva dos enfermeiros. Verificámos, nas lideranças, dificuldades no processo de planeamento e avaliação, bem como nas atividades promotoras do envolvimento dos colaboradores.

Cutura organizacional; Administração hospitalar; Organizações em saúde; Gestão de mudança

Resumen

Objetivo

Evaluar la preparación organizacional de un hospital para apoyar la transferencia de conocimiento y su incorporación en la práctica clínica. Identificar las dimensiones prioritarias a desarrollar, capaces de apoyar la transferencia de conocimiento y su incorporación en la práctica clínica.

Métodos

Estudio descriptivo, exploratorio y correlacional, enmarcado en el paradigma cuantitativo, con aplicación del cuestionario Organizational Readiness for Knowledge Translation en una muestra no probabilística de 275 enfermeros de una institución hospitalaria.

Resultados

La dimensión “Clima organizacional para el cambio” fue la que reunió mayor consenso, lo que sugiere la presencia de cohesión y apertura al cambio de los equipos (promedio de 34,07 en 50 puntos). La dimensión “Liderazgo” (promedio de 31,26 en 50 puntos) presentó la menor representación, lo que indica la percepción neutra de los participantes sobre la gran mayoría de los ítems que componen esta dimensión. Al analizar el global de la escala, el promedio de las respuestas fue superior al valor promedio.

Conclusión

Se evidenció un buen nivel de preparación organizacional para la transferencia de conocimiento, lo que se traduce en una percepción positiva de los enfermeros. Se observaron dificultades en el proceso de planificación y evaluación por parte de los líderes, así como también en las actividades para promover la participación de los colaboradores.

Cultura Organizacional; Administración hospitalaria; Organizaciones en salud; Gestión del cambio

Introduction

One of the greatest challenges that nurses are currently experiencing transcends the generation of evidence. It especially includes its use in clinical practice.(¹) This knowledge translation process is essential to implement research-based practices that are able to meet the challenges faced by any health care system.(²-⁵)

Knowledge translation is a complex process with multiple challenges at different levels related to organizational structures, activities and practices.(⁶,⁷) The gap between knowledge generation and implementation is partially due to a failure to understand organizational factors affecting the adoption and implementation of innovation.(⁸)

A growing interest in the importance of “organizational change” in healthcare organizations is a fundamental concept to improve healthcare quality and safety, which is any change in organizational composition, structure or behavior.(⁹) This concept is based on the evidence that organizations need to be prepared and motivated to integrate research results, i.e., organizations should have a certain degree of organizational readiness for change.(²,¹⁰)

The concept of Organizational Readiness for Change (ORC) includes two levels. The first describes ORC in psychological terms (attitudes, beliefs and intentions of organizational members), the second comprises structural terms, emphasizing organizational capabilities and resources.(¹¹)

This combination of individual and organizational components shapes the definition of the concept of ORC, as a shared psychological state in which organizational members feel motivated to implement organizational change and are confident in their collective abilities to do so(²) or the degree to which organizational members are psychologically prepared to implement change.(¹²)It is reasonable to consider that assessing organizational readiness for change is an essential step in its implementation.(¹³,¹⁴)However, assessing this level of readiness is complex, challenging, and inconsistent.(⁸)

In view of this situation, researchers(¹³)developed, adapted and validated the Organization Readiness for Knowledge Translation (OR4KT), an instrument designed to assess organizational readiness for knowledge translation in healthcare organizations. The scientific community considers the OR4KT as a remarkable, promising and very useful tool to provide a diagnosis of the organizational situation when some evidence-based change is to be implemented, as well as to monitor changes over a certain period of time.(¹²,¹⁵,¹⁶)

The objectives of this study in the nursing area were: To assess the organizational readiness of a hospital to support knowledge translation and its incorporation into clinical practice; to identify the priority dimensions/subdimensions to be developed, capable of supporting knowledge translation and its incorporation into clinical practice.

Methods

This was a quantitative, descriptive, exploratory, and correlational study,. The inclusion criterion was nurses who had been working for at least six months, in the hospital where the study was conducted. A non-probability sample was used, and 347 questionnaires were issued for self-completion, 275 valid documents were returned, resulting in a 79.25% compliance rate, which guarantees a 95% confidence level, with a 3% margin of error.

The study was approved by the Ethics Committee No. 2 /2020 of the hospital. Nurses voluntarily agreed to participate in the study by completing an informed consent form. The anonymity and confidentiality of data were ensured, as well as their exclusive use within the scope of this research. The questionnaires were administered for a 2-week period, between February and March 2020.

In this study, the main variable was “Organizational Readiness for Knowledge Translation”, which was measured using the Portuguese test/preliminary version of the OR4KT questionnaire (Chart 1), as part of a multicenter project for the future validation of the OR4KT instrument for the Portuguese context, after assessing its psychometric properties. The secondary variables identified were the sociodemographic (gender; age; education) and professional variables (professional title; Advanced Management Competence; specialization area; director, manager or coordinator functions; area/context of clinical activity; time of professional practice; time working in the institution; time working in the area/context where clinical practice is predominant).

Chart 1
OR4KT tool

Dimensions/Subdimensions
Organizational climate for change Staff cohesion Staff work-related stress Communication about change Manager`s openness to change	Leadership Leadership Strategic planning process Decision making process Adequate level of involvement
Organizational contextual factors Adequate human resources to support change Adequate material resources to support change Organizational culture	Organizational support Support organizational climate Monitoring Evaluation process Feedback
Change Content Attributes of change Perceived complexity of change Patient experiences and preferences Clinical evidence supporting change	Motivation Pressure for change Training and education needs Adequate knowledge and skills Commitment

The questionnaire for individual completion consists of two groups of questions. The first is a set of 59 questions grouped into six dimensions, with a total of 24 sub-dimensions, which were rated using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire is complemented by a second group of questions related to the nurses’ sociodemographic and professional characterization. For descriptive and inferential statistical analysis, SPSS software version 22 was used. After statistical analysis, the results showed that this version, which maintains the 59 items and six subscales of the original version, had an overall Cronbach’s alpha of 0.949.

Results

Of the 275 nurses included in the study, most (79.6%) were female. There was heterogeneity regarding the age of the participants, with the highest percentage representation in the group between 31 and 40 years old, with 43.3% and a mean of 40.13 years. Regarding academic qualifications, 93.8% of the participants had a degree, 78.9% were general care nurses, and 21.1% had earned a nursing specialization. By analyzing the data on the OR4KT subscales, the nurses’ perception of the dimensions and subdimensions that represent the organizational readness for knowledge translation are shown in figure 1.

Figure 1
Distribution of nurses’ opinion/perception of the OR4KT dimensions

In the organizational climate for change dimension, the staff cohesion achieved the three highest percentile representations. The participants agree with the statement “staff work together as a team”(47.3%), followed by “staff are usually quick to help one another when necessary” (49.8%) and in third, “mutual trust among staff is strong” (44.7%). In the organizational context factors dimension, “staff members have a sense of personal responsibility for improving patient care and outcomes”, “ staff members cooperate to maintain and improve effectiveness of patient care”, and “staff members are willing to innovate and/or experiment to improve clinical procedures” were the most significant with the highest percentage values. In these three items, the nurses’ responses reached percentage values around 60%, towards the answer “I agree”. Additionally, 49.1% of the nurses disagreed with the statement that “they have the necessary support in terms of training”.

The change content dimension, which aims to assess how participants perceive the complexity of change, 57.5% of the nurses agreed that “typically there is ability to adapt new standards or procedures, even those forced upon us”, followed, respectively, by 53.5% and 49.5% of the nurses agreeing with the statement “people are willing to adjust usual routines in response to what is happening around them” and that “there is flexibility to deal with change”. In the leadership dimension, the following items accumulated the highest percentage values: “external stakeholders are involved in the planning process” with 60%, “there is an innovation decision maker on key organizational administrative committees” with 54.9%, and “there is a innovation decision maker on key organizational clinical committees” with 51.6%.

The other items that evaluated the participants’ perception, the subdimension “Adequate level of involvement”, showed that about 50% of the nurses have a neutral perception in the 3 items evaluated.

In the organizational support dimension , it was found that “team members provide practical support for new ideas and their application”, “team members cooperate in order to help develop and apply new ideas”, and “team members provide and share resources in the application of new ideas”, which accumulated the highest percentages, with 61.5%, 56%, and 50.5%, respectively, and were grouped in the answer “I agree”.

The results obtained in the motivation dimension show that, once again, 9 out of 10 items received a neutral response from the participants, making this dimension the one with the second lowest mean score, just behind the leadership dimension. Overall, the mean response in the total scale was 193.44 points, ranging between 121 and 276. The OR4KT projects a range between 59 and 295.

Considering the ease of interpretation, and repeating the procedure performed in another study,(¹⁷) the value of the OR4KT scale was normalized in 0 to 100 scale, which allowed us to observe that our sample obtained a value of 65.57.. The same researchers(¹⁷) suggested, as an optimal cut-off point to classify an organization with a good level of organizational readiness for change, a value higher than 64.48 (sensitivity=0.75; specificity=1). Therefore, in the context of our study, we can assume that we can be classified as having a good level of organizational readiness for knowledge translation and its incorporation into clinical practice. Regarding the distribution of the dimensions and sub-dimensions of organizational culture about knowledge translation in the sociodemographic and professional variables, a series of correlations are observed (Chart 2) between the various subscales and the total scale with some of the professional variables.

Chart 2
Difference in the distribution of the occupational components and the OR4KT subscales

OR4KT-PT Test Version Professional/Dimensions Variables	Professional title	Functions of direction, leadership or coordination	Time of professional practice	Time of professional practice in the institution	Professional experience in the area where clinical practice is predominant
	p-value	p-value	p-value	p-value	p-value
Organizational climate for change	0.262	0.761	0.005**	0.015*	0.407
Organizational contextual factors	0.059	0.683	0.087	0.011*	0.213
Change content	0.183	0.743	0.266	0.073	0.176
Leadership	0.006**	0.045*	0.004**	0.002**	0.049*
Organizational support	0.002**	0.223	0.002**	0.001**	0.106
Motivation	0.056	0.888	0.119	0.115	0.42

• Note: *p < 0.05; ** p <0.01

Regarding the total scale, the results with statistically significant differences are associated with professional title, length of professional practice, and length of professional practice in the institution

Discussion

A possible limitation of the study is the use of a test/preliminary version of the Portuguese version of the OR4KT. Although it showed adequate psychometric properties, a confirmatory factor analysis based on a multicenter sample, which is currently in progress, is needed for its full validation. The analysis of the organizational climate for change dimension, showed a positive “attitude” of nurses towards this condition, recognizing that positive professional relationships based on trust, before and during implementation, are facilitating elements.(¹⁸,¹⁹)

However, the degree was high of indifference or being neutral towards the questions on communication about change and the attitude of the managers towards change, items that accumulated the highest frequencies in the neutral degree, between the agreement and rejection, an attitude that appears to be common in health professionals who have already experienced changes in their workplace and were considered a failure.(¹⁹,²⁰)As an aggravating factor, we emphasize that 70% of change initiatives in organizations are not successful, which may tend towards an attitude of cynicism and pessimism by the professionals in relation to the processes of change.(¹⁵,¹⁹)

The data on the Organizational Contextual Factors dimension suggest a nurses’ commitment to their social purpose and professional nature, which reveals accountability, professional awareness and an appreciation of the importance assigned to continuous improvement of the quality of care provided to the person and the achievement of health improvement. These results are similar to those presented by other studies,(²¹) in which nurses also demonstrated high conviction that a evidence-based practice (EBP) will result in better care and clinical practice, associating this dimension with greater professional development.(¹⁴)

Additionally, the data revealed a significant percentage of 49.1%, showing that nurses do not agree with the statement that they “have the necessary support in terms of training”. This is an important finding because it demonstrates the nurses’ perception on the importance of continuing education in their professional practice. However, in line with other authors,(²²) it reflects the need for more support from the organization and leaders.

In the “Change content” dimension, the participants’ attitudes towards change management was considered positive, taking into account the evidence obtained,(²³-²⁵)which assesses personal and interpersonal confidence, awareness and recognition of the necessary need for change, values and expectations as facilitating determinants of change management.

The Leadership dimension was different from the previous ones, being the dimension with the lowest score, similar to the study developed to validate the Spanish version of the OR4KT.(¹⁷)

In a philosophy of change management, the results obtained in the sub-dimensions of the strategic planning process should be reason for reflection. Because this is one of the four instrumental functions of management (Planning, Organizing, Leading and Controlling), 60% of the participants expressed a neutral perception, which seems to suggest difficulties in this process within the leadership. There is evidence that the implementation of the planning process in the health services contributes to the pursuit of solid and innovative solutions, capable of aspiring a cycle of organizational changes. Fulfilling this assumption may allow a process of quality improvement of the nursing team, and for this reason, we understand that the nurse manager should be an agent of change, leading these efforts.(²⁶)

This relationship allows us to evolve to the importance of the managers involvement subdimension, which received a less positive perception by the participants. This attitude deviates from the literature on the implementation of change in healthcare organizations, where the condition “involvement” meets broad consensus as to its role in change processes, particularly in the implementation of a EBP.(⁶,¹⁴,²⁷,²⁸)

These data demonstrate the importance of leaders in promoting change, pushing for change and promoting a work climate that uses the EBP process to inquire, acquire, evaluate, implement and analyze information.(²⁴) This evidence deserves special attention, considering that only 44% of nurses agree with the statement “managers are involved in change processes”.

In the Organizational support dimension, we found a slightly positive perception. The interpretation of these results highlights the professionals’ favorable attitude towards change, considering the use of evidence as an organizational resource, opposed to lack of confidence about the value and quality of evidence, or even resistance to change, considered as barriers to evidence implementation.(²³)

However, in the Monitoring, Evaluation and Feedback subdimensions, the instrumental function of management is perceived by the participants as neutral, suggesting a less positive perception of the functions performed by nurse managers, which is a complicating factor, considering that in the organizational context, monitoring, evaluation and dissemination of results are crucial components for the use of research in nurses’ practice.(²⁹)

The Motivation dimension accumulated the second worst mean, just behind the Leadership dimension. This level of motivation is a reason for concern, considering that, in nurses’ daily practice, motivation emerges as a fundamental condition in the search for greater efficiency and, consequently, higher quality in care, determinants that we can combine with professional satisfaction.(²⁶,³⁰)

The development of the relationship between leadership and motivation within nursing, constitutes a key element for the dynamics of work teams, and the nurse manager has a fundamental role, as a manager of leadership, crucial for effective functioning of organizations, and a manager of motivation, an essential need for the proper functioning of work groups (³¹-³⁴)

Conclusion

The results demonstrate a good level of organizational readiness to implement change in the context studied. Although we can individualize facilitating/difficult conditions for the process of change implementation, it is essential that they are seen as a whole, in a systematic, integrated and integrative perspective..

The development of leadership skills by nurse managers should be oriented towards the instrumental functions of management, planning and controlling, namely in the skills related to strategic planning and development of projects and programs in the area of quality, and in the competences related to methodologies of evaluation and measurement of results and monitoring of indicators.

There is a need to develop training interventions that meet the reported needs, empowering nurses to use research in an attitude of proactivity and permanent questioning of practices. Multi-method approaches should also be explored through individualized and targeted interventions for each practice situation and context, according to which EBP can be promoted.

Organizational support is a catalyst for future organizational efforts to address the training needs of nurses and the availability of resources. It is essential to promote cultures of involvement and empowerment of professionals aligned with a transformational leadership, which is a predictor of quality of care in health care organizations.

Acknowledgements

The authors are thankful to the many entities and personalities involved in this project, recognizing and expressing particular gratitude to all nurses who agreed to participate in this project.

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Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Paulista School of Nursing, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  06 Feb 2023
• Date of issue
  2023

History

• Received
  13 Mar 2022
• Accepted
  29 Aug 2022