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

Abstract

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. Key Words. Emotions, chronic illness, relationships, health care, health policy/ policy analysisIn this article we discuss findings from a three-center study in England, which explored the professional experience of evolving organizational and governance structures in primary health and social care, in relation to the 1 These governance structures include incentives to achieve local service reconfiguration of community teams similar to the North American "medical home" policy ( Jackson et al. 2012). We argue that these rapidly changing governance systems create uncertainty for interprofessional teams. Integrating new interprofessional teams to work effectively is a slow process, especially if structures do not acknowledge the emotions involved or support staff during periods of uncertainty. The experiences that emerge from the formation of new community-based interprofessional teams, sometimes together in new physical locations but often apart, distance managers and frontline staff, and reinforce existing divisions between health and social care (Allan et al. 2005;Hall 2005;Baxter and Brumfitt 2008). We discuss the experiences of clinical staff and their managers in relation to the literature on teamwork, governance, and incentives in primary health care. We focus on the emotional reactions to the changes which were expressed by both managers and staff.

What happens when healthcare innovations collide?

“…The resolution may involve selecting a single project, or defining a process by which multiple organisational initiatives can be evaluated and supported 14. While well intentioned from a patient care perspective, the decision to merge the three AHS initiatives could threaten front-line engagement during implementation by eroding trust and fostering uncertainty about changing roles 10 15 16. Organisational leaders may be perceived as lacking strategic vision and having suspicious motives for changing the existing innovation 2.…”

“…Top-down change management approaches that do not account for local contexts can paradoxically stifle change and innovation,17 and frustrate front-line staffs who wish to take an active role in improving patient care processes 15. When an organisational initiative is planned, devolving operational control to departments and front-line providers can facilitate the tailoring of organisational initiatives to the local context, thereby fostering local ownership of initiatives and improving the likelihood of success 4 18 19.…”

The Critical Bricolage

“…The conceptual reframing I have proposed is congruent with Brown and Gilligan's (1992) suggestion that the theoretical framework should guide what questions are to be asked about what concepts throughout the analysis phase. The VCRMDA can serve to explore the sense of self that is defined by relational experiences among employees of health-care organizations, experiences rarely explored in organizational research (Allan et al, 2014;Paliadelis & Cruickshank, 2008). Brown and Gilligan's (1992) method will serve to explore the experiences of nurses while simultaneously exploring the complexity of organizational change.…”

“…This will also facilitate the exploration organizational experiences as shaped by multiple relations with others and the organizations nurses work within. Such contextual understanding is imperative in acknowledging the complexity of organizations and the experiences of individuals within them (Allan et al, 2014). When theoretically guided by CMS.…”

“…Frontline health-care staff experience organizational change differently when compared to management (Allan et al, 2014) and have different commitments that shape their experiences of organizational change. During periods of organizational change, nurse managers describe their commitments to ensuring financial accountability, where frontline nurses speak of the stresses experienced when attempting to keep their commitments to patients within financially driven corporate discourses (Allan et al, 2014). The lack of frontline nursing representation is worrisome because it reflects a strong affiliation with a set of presumptions about what kinds of knowledge about organizational phenomena are desirable and acceptable (Kincheloe, 2001(Kincheloe, , 2005.…”