Culture as a predictor of resistance to change: A study of competing values in a psychiatric nursing context

Midwives' perceptions of communication at antenatal care using a bilingual digital dialog support tool- a qualitative study

BACKGROUND

Sweden has a large population of migrant women, which contributes to communication challenges and, consequently, suboptimal maternity care. Compared with native-born women, migrant women have an increased prevalence of adverse pregnancy outcomes. Miscommunication and language barriers are among the reasons for these results. Thus, language barriers can also lead to providing less information to migrant women. A digital Swedish-Arabic dialog support tool was developed and tested at antenatal care, to facilitate communication between midwives and Arabic-speaking women. This study aimed to describe midwives' perceptions of communication via Swedish-Arabic dialog support (Sadima) in antenatal care.

METHODS

A qualitative study was conducted with 14 midwives in antenatal care with experience communicating using a Swedish-Arabic dialog support tool. The data were collected via semi structured individual interviews and were analyzed via phenomenographic analysis.

RESULTS

The analysis resulted in three categories: (1) Dialog support - the skill of constructing bridges, comprised the main finding that dialog support facilitated communication by providing a multimodal way of communication including intercultural evidence-based content;(2) Dialog support - challengingly implementing adaptive efficiency, represented the implementation of dialog support to be time-consuming and, eventually, time-efficient when midwives gained digital skills; and (3) Women and their partners - the ability to be empowered, included the main finding of increased women's empowerment and control over their lives by being less dependent on interpreters.

CONCLUSIONS

The findings contribute to the understanding of communication via dialog support based on midwives' experiences. This study highlights that communication via dialog support facilitates communication between midwives and Arabic-speaking women and enhances midwives' working conditions. Within our increasingly heterogeneous societies, health care could provide support for communication via digital dialog support that is women-centered and culturally sensitive to avoid misunderstandings and delayed or incorrect treatment of migrant women.

Routines mediate educational solutions in clinical practice: A discussion paper on design-based research

AIM

This study aimed to explore the appropriateness of using a design-based research approach in inducing change by exploring the research question: How can implementing new learning tools in hospital practice lead to sustainable change?

BACKGROUND

Although design-based research is conducted with the idea of bridging the theory/practice gap, we perceived a gap between design, enactment and sustainable change. We assume that context-particularly routines-plays a decisive role in this gap.

DESIGN

Qualitative design-based educational research METHODS: Discussion of the design-based research approach based on a case study. The results of the case study are interpreted with a theoretical explanatory model.

RESULTS

We explored theories about practice, routines and routine dynamics. The identified elements of routine dynamics could be related to our context, findings and experiences. From the case data, an eye-opening insight emerged. Context, especially the prevailing routines and new routines to be developed in this context, are significant constituents in all phases of design-based research. Furthermore, elements of routine dynamics can explain the variance in enactment and the difficulties involved in establishing a new educational routine in nursing clinical practice.

CONCLUSION

The inclusion of routine dynamics in the DBR research protocol is a necessary addition to ensure the successful design and implementation of a new educational tool in clinical practice.

Rethinking organizational culture in intersectoral coordination: the perspective of boundary work

PURPOSE

The purpose of this paper is to rethink the concept of organizational culture as something that emerges bottom-up by using the sociological concepts of boundary object and boundary work as an analytical lens and to show how this approach can help understand and facilitate intersectoral coordination.

DESIGN/METHODOLOGY/APPROACH

We used observations and qualitative interviews to develop "deep" knowledge about processes of intersectoral coordination. The study draws on a conceptual framework of "boundary work" and "boundary objects" to show how a bottom-up perspective on organizational culture can produce better understanding of and pave the way for intersectoral coordination. We use a case of health professionals engaged in two Danish intersectoral programs developing and providing health promotion services for women with gestational diabetes mellitus (GDM).

FINDINGS

The study showed how boundary work revolves around negotiations on how to define, understand and act on the diagnosis of GDM. This diagnosis has the characteristics of a "boundary object", being more loosely structured in general terms, but strongly structured in local settings. Boundary objects help connect different professionals and facilitate coordination. The analysis showed how the introduction of time and the concept of "lifelong health promotion" helped to transgress existing organizational and professional boundaries.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination and collaboration. While the theoretical implications will be general applicable when studying organizational culture, the implications for practice are sensitive to context and the processes we have described as the outcomes of boundary work are generated from cases that were most likely to provide deep insight into our research topic.

PRACTICAL IMPLICATIONS

For practice this can build bridges between organizational and professional boundaries.

ORIGINALITY/VALUE

The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination. This may build bridges between organizational and professional boundaries in practice settings.

Reasons for resistance to change in nursing: an integrative review

BACKGROUND

Change is a very complex and multifaceted phenomenon that is intertwined with the understanding of nursing practice, so, resistance to change in nursing can be considered as an important challenge. Knowing the reasons for this resistance can help in solving it in nursing. Therefore, the present study was conducted with the aim of investigating the reasons for resistance to change in nursing as an integrated review.

METHODS

This integrative review was conducted using the Whittemore & Knafl method in 5 stages, including problem identification, searching the literature, evaluating primary sources, analyzing data, and presenting the results. Databases like SID, Irandoc, Magiran, Google Scholar, Web of Science, PubMed, CINAHL, and Scopus were searched using the keywords; "Resistance", "Change", "Nursing", "Resistance to Change" and their Persian equivalents in the time range of 2000 to January 2023. After applying inclusion criteria and assessing the articles using Bowling's Quality Assessment Tool, finally, 15 papers were included from 2964.

RESULTS

After reviewing and critically appraisal of the qualified articles, the findings were placed in three main categories including; (1) individual factors, (2) interpersonal factors, and (3) organizational factors and six subcategories.

CONCLUSION

Undoubtedly, change is an integral component in nursing care, and resistance to it is the result of a set of individual, interpersonal and organizational factors that change managers should pay special attention to in order to make changes due to the reasons of this resistance, and the development process of developing changes in the clinical field is easily possible.

Organizational culture and barriers to change in University of Gondar Comprehensive Specialized Hospital Cardiac Unit

BACKGROUND

Cardiovascular disease is a major contributor to high mortality in Ethiopia. Hospital organizational culture affects patient outcomes including mortality rates for patients with cardiovascular disease. Therefore, the purpose of this study was to assess organizational culture and determine barriers to change in the Cardiac Unit of University of Gondar Comprehensive Specialized Hospital.

METHODS

We used a mixed methods approach with a sequential explanatory design. We collected data through a survey adapted from a validated instrument measuring organizational culture (n = 78) and in-depth interviews (n = 10) with key informants from different specialty areas. We analyzed the quantitative data using descriptive statistics and the qualitative data through a constant comparative method of thematic analysis. We integrated the data during the interpretation phase to generate a comprehensive understanding of the culture within the Cardiac Unit.

RESULTS

The quantitative results indicated poor psychological safety and learning and problem solving aspects of culture. On the other hand, there were high levels of organizational commitment and adequate time for improvement. The qualitative results also indicated resistance to change among employees working in the Cardiac Unit as well as other barriers to organizational culture change.

CONCLUSION

Most aspects of the Cardiac Unit culture were poor or weak, signaling opportunities to improve culture through identifying culture changing needs, implying the need to be aware of the subcultures within the hospitals that influence performance. Thus, it is important to consider hospital culture in planning health policy, strategies, and guidelines.

RECOMMENDATIONS

It is of paramount importance to strengthen organizational culture through fostering a safe space that enables workers to express divergent views and actively considering such views to improve the quality of care, supporting multidisciplinary teams to think creatively to address problems, and investing in data collection to monitor changes in practice and patient outcomes.

Participation, Confirmation and Challenges: How Nursing Staff Experience the Daily Conversations Nursing Intervention in Psychiatric Inpatient Care

Mental health nursing focuses on patients' experiences, accessed through narratives developed in conversations with nursing staff. This study explored nursing staff's experiences of using the nursing intervention Daily Conversations in psychiatric inpatient care. We used a qualitative questionnaire and received 103 responses. Qualitative content analysis of the data resulted in three themes describing both advantages and obstacles with Daily Conversations: Promotes participation, Contributes to confirming relations and Challenges previous structures. To illuminate the significance of confirming acts and make nursing staff more comfortable, the intervention could benefit from being more flexible and allowing in its structure. For the intervention to succeed, nursing staff need training in conversation, thorough preparation, shared reflections on values in mental health nursing, and structures to maintain its implementation and use.

Sustainability in Clinical Practice: A Cross-National Comparative Study of Nursing Students in England and Sweden

BACKGROUND

Delivering health care negatively influences the environment and contributes to climate change. This study examined how nursing students in England and Sweden can make changes in clinical practice to enhance environmental sustainability.

METHOD

Third-year undergraduate nursing students at English and Swedish universities responded to open-ended questions on the Sustainability Attitudes in Nursing Survey. Data were analyzed using inductive content analysis.

RESULTS

Students in both countries identified lack of confidence as the main barrier to challenging unsustainable practice, followed by a resistance to change in practice. English students predominantly changed their own behavior or influenced the practice of others. Swedish students either changed their own behavior or their own attitudes to sustainability.

CONCLUSION

There is a need to ensure students have confidence to act as change agents to enhance sustainable practice in the clinical environment. [J Nurs Educ. 2022;61(7):390-393.].

Change Resistance and Clinical Practice Strategies in Audiology

BACKGROUND

Audiology is experiencing pressure from market forces that may change the profession's nature. Research suggests that understanding resistance needs to change and organizational culture may provide insights that can facilitate change.

PURPOSE

This study was designed to examine audiologists' resistance to change, organizational culture, and clinical practices related to hearing aid pricing and audiology assistants.

RESEARCH DESIGN

This study utilized a cross-sectional and nonexperimental survey design.

STUDY SAMPLE

Participants were 205 U.S. audiologists, representing diversity across experience, work setting, and location.

DATA COLLECTION

This survey examined demographics and clinical practice strategies. Resistance to change (RTC) scale examined disposition toward change. Organizational culture profile (OCP) examined organizational culture perspectives.

RESULTS

The majority (52%) of respondents use bundled pricing but 42% of these repondents anticipate transitioning to unbundling. Use of hybrid pricing is increasing. Service-extender personnel were reported by 41%. Although the majority (66%) do not work with audiology assistants currently, 32% of these participants anticipate they will do so in the future. Results indicated lower RTC and greater years of experience were associated with more positive perceptions about organizational culture. Pricing structure was related to experience.

CONCLUSION

Trends indicate use of bundled pricing is decreasing, use of hybrid pricing is increasing, and employment of audiology assistants is increasing. Experienced audiologists are more likely to report unbundled and hybrid pricing compared with less experienced audiologists.

The Lived Experience of the Audiologist: Connections Between Past, Present, and Future

PURPOSE

The purpose of the study was to use qualitative research methods to explore connections between audiologists' lived experiences and perceptions of the future and change.

METHOD

This research was based on a constructivist grounded theory approach. A semistructured interview guide inspired 30 audiologists to share their stories via virtual interview. A theoretical framework evolved from grounded theory analysis techniques.

RESULTS

The majority of audiologists interviewed in this study entered audiology via the undergraduate-stumble pathway, usually after leaving speech-language pathology. This pathway was associated with poorer perceptions of the future compared with early-purposeful and later-purposeful pathways. Generation differences, value juxtaposition, professional identity, and student debt also influenced perspectives of the future. Participants described high value-of-self relative to patient care and joy stories associated with meaningful relationships with patients. Most participants reported responding actively to changes in the marketplace at the individual work setting level; however, change response was complex and difficult to quantify when broader issues impacting the profession were considered. Participants expressed concern about the future, including the need to address high student debt, perceived lack of unity across the profession, and value-by-others.

CONCLUSION

Grounded theory exploration of the lived experience of 30 audiologists supported a theoretical framework that connects perceptions of the future with origin story, generation perspectives, value juxtaposition, professional identity, and student debt.

Contextual Analysis for Practical Action (CAPA): a framework for understanding how context works and how to apply it for practical learning and implementing change in complex systems

Background: This concept paper presents Contextual Analysis for Practical Action or ‘CAPA’ as an action-oriented tool to understand and implement interventions in real-life service delivery contexts. Understanding how contexts work is a critical challenge for Health and Social Care Systems seeking to become more integrated. CAPA is a tool for understanding and empowering agents in local contexts. The local context is understood here as a key factor in implementation success. This concept paper offers rich theorising to underpin the translation of systems reform initiatives into meaningful local engagement and change. Methods: Analysis of the ‘implementation conundrum’ highlights the problem, while a review of the organisational learning literature identifies ‘sensemaking in organisation’ as a powerful mechanism to address it. Based on earlier phenomenological research the dynamics of organisational sensemaking are presented.  Finally, applications for CAPA are explored and next steps outlined. Results: CAPA makes tangible the implicit and interpretive nature of organisational life as ‘sensemaking in context’. This phenomenon is analysed as a determinant of implementation success. As such, CAPA opens a path to working with contextual complexity by framing it as a dialectic pattern of topical, ecological, dialogical, and pragmatic modes that ‘contextualise’. CAPA is a tool for researchers and practitioners to explore the complexity of local contexts and their implementation challenges, and working-with local agents for learning and change. Conclusions: Health reform needs new approaches for understanding implementation in context. CAPA is a tool for understanding and working-with contextual factors central to the complexity of policy or knowledge translation for example. This paper outlines its rationale, principles, and functionality. Possible applications are explored for co-designed practical learning experiences. It concludes with a call to policy makers, service managers and researchers to use the approach in specific settings so it can be developed and refined.

Resistance to change: A concept analysis

The purpose of this concept analysis is to explore the concept of resistance and provide an operational definition for nurse leaders. While resistance has been deemed a major barrier to the implementation of successful practice change in popular literature, specific evidence as to how it is a barrier within health care organizations is lacking. The Walker and Avant model of concept analysis was used to analyze the concept of resistance. Literature searches utilized the Cumulative Index for Nursing and Allied Health Literature (CINAHL), PsychARTICLES, and Google scholar. Resistance is defined as an individual's behavior in response to perceived or actual threat in an attempt to maintain baseline status. It may be preceded by and amplified through mistrust, fear, and communication barriers, ultimately influencing the implementation, quality, and sustainability of the change. Historically resistance has been viewed with negative conations due to its potential impact on organizational success. However, resistance is a normal response to a threat to baseline status. Nurse leaders prepared with knowledge of resistance, including the antecedents and attributes, can minimize the potential negative consequences of resistance and capitalize on a powerful impact of change adaptation.

Hospital length of stay among older people treated with flexible and integrative psychiatric service models in Germany

OBJECTIVE

Since 2012, a new law (§64b, Book V of the Social Security Code [SGB V]) regulates the implementation of flexible and integrative psychiatric treatment projects (FIT64b) in Germany. FIT64b allows rapid discharge of patients from inpatient to outpatient settings and cost reductions of hospital stays. Several psychiatric centres exclusively provide FIT64b; others provide FIT64b alongside with standard health care. The aim of the study was to assess the average hospital length of stay (AHLS) of older patients with mental illness included in FIT64b projects.

METHODS

A secondary data analysis was conducted using administrative data from eight German mental health centres providing FIT64b. The effects of gender, age, type of centre, and main diagnosis on AHLS were calculated for all older patients with age 65 years or older (n = 3495) treated in FIT64b in the year 2016. Data were analysed with descriptive statistics and robust multiway procedures.

RESULTS

The AHLS of older people with mental illness was 4.8 (SD = 11.5) days. The AHLS was shorter in centres exclusively providing FIT64b than in centres providing FIT64b alongside with standard health care: 3.2 (SD = 6.4) vs 8.4 (SD = 17.8) days, P = .001. This difference was particularly marked among patients with schizophrenia spectrum disorders, mood disorders, and neurotic, stress-related, and somatoform disorders.

CONCLUSIONS

FIT64b relates to very short AHLS even among older people. Centres using FIT64b alongside with standard health care usually provide standard care to most patients, which could lead to lower fidelity in the implementation of FIT64b.

Change Management in Health Care and Mental Health Nursing

Since Nightingale implied that progress was inherent in good nursing, change has slowly but surely accelerated to a frenetic pace in health care and to a degree in nursing. However, the healthy progress and implications associated with change in the nursing profession are not as readily embraced as this pace may imply. Rather, embracing change at the core of nursing and health care is a challenge as this is a group who it is suggested are not only resistant but also adept at reinforcing the status quo. Using mental health nursing as an example this position paper addresses the concept of change management, explores the facilitators and inhibitors to explain why change is not effectively managed at times. Further, case studies provided exemplify how change in mental health nursing has occurred and demonstrate how the concept of change management effectively has been achieved. Key strategies for change management are outlined in this article, noting the need to be sensitive to the culture and specifics of that organisation, because change takes place within people rather than within the organisation itself. Part of the challenges and strategies faced in the profession are related to the movement of information and knowledge from the point of research to implementation of evidence-based best practice. Leaders, therefore, should adopt change management principles and strategies, to further drive the developments which have changed mental health nursing over a relatively short period.

Nursing staff-led behavioural group intervention in psychiatric in-patient care: Patient and staff experiences

A promising intervention in mental health in-patient care is behavioural activation (BA). Interventions based on BA can be used by mental health nurses and other staff members. The aim of this study was to evaluate patients' and staff members' experiences of a nursing staff-led behavioural group intervention in mental health in-patient care. The intervention was implemented at three adult acute general mental health in-patient wards in a public hospital setting in Sweden. A self-administrated questionnaire, completed by 84 patients and 34 nurses and nurse assistants, was administered, and nonparametric data analysed using descriptive statistics. Our findings revealed that both patients and nursing staff ranked nursing care and care environment as important aspects in the recovery process. Patients and staff members reported overall positive experiences of the group sessions. Patients with higher frequencies of attendance and patients satisfied with overall care had a more positive attitude towards the intervention. A more positive experience of being a group leader was reported by staff members who had been leading groups more than ten times. The most common impeding factor during implementation, reported by staff members, was a negative attitude to change. Conducive factors were having support from a psychologist and the perception that patients were showing interest. These positive experiences reported by patients and nursing staff, combined with previous research in this field, are taking us one step further in evaluating group sessions based on BA as a meaningful nursing intervention in mental health in-patient care.

Developing an emotional coping skills workbook for inpatient psychiatric settings: a focus group investigation

BACKGROUND

Evidence suggests an unmet need for provision of psychological interventions in inpatient psychiatric settings. However, inpatient wards can present a challenging environment in which to implement interventions. The authors developed the Emotional Coping Skills workbook, a psychosocial intervention designed to overcome these challenges and provide inpatients with an opportunity for psychologically-informed therapeutic engagement. The workbook includes information and exercises to empower inpatients to understand their emotions and learn to cope with their distress.

METHODS

A qualitative study using thematic analysis was undertaken in two UK inpatient psychiatric hospitals to explore staff's views about whether and how the workbook could be implemented, and on barriers to its use. Thirty-five nursing and occupational therapy staff members participated in four focus groups, and a further two psychologists in semi-structured interviews.

RESULTS

Staff identified key barriers to successful implementation of the workbook. These were firstly, the difficulty in finding time and space for therapeutic work in the stressful ward environment. Secondly, staff identified a culture of emotional neglect whereby neither staff nor inpatients felt able to talk about emotions, and patients' physical needs and medication were prioritised. Thirdly, staff discussed how psychotic symptoms and emotional distress could limit patients' ability to engage with the workbook material. Staff suggested ways in which the feasibility of using the workbook could be enhanced. Firstly, they discussed the importance of encouraging staff to value psychological approaches and to view the workbook as a resource to help them manage their existing tasks. Secondly, they emphasised the value of staff drawing on their expertise to deliver the workbook flexibly in different formats and settings, depending on each patient's particular presentation. Thirdly, they advocated empowering staff to decide the timing of intervention delivery in the context of each inpatient's fluctuations in distress and progress towards recovery.

CONCLUSIONS

The study has highlighted key principles for flexible and well-integrated intervention delivery; these principles will be helpful for enhancing the feasibility of any nurse-delivered psychological intervention in inpatient settings.

Workplace culture in psychiatric nursing described by nurses

AIM

This study looks to describe the workplace culture from the viewpoints of stress, job satisfaction and practice environment.

METHODS

Data were collected from nurses (n = 109) using a web-based survey, The Person-Centred Nursing Index, from two purposefully selected hospital districts in Finland. Data were statistically analysed.

RESULTS

Nurses described their workplace culture in slightly positive terms. Nurses only occasionally experienced stress (mean = 2.56, SD = 0.55) and were fairly satisfied with their job (mean = 4.75, SD = 0.66) and their practice environment (mean = 4.42, SD = 0.81). Demographic variables such as the nurses' age, length of time in nursing, time at their present hospital, working shifts and their use of patient restriction were more frequently associated with their perceived workplace culture.

CONCLUSION

Older nurses and those with a longer work history in the nursing profession tended to be more satisfied with their workplace culture in psychiatric nursing. Young and/or newly graduated nurses felt more negatively on their workplace culture; this issue should be recognised and addressed with appropriate support and mentoring. Nurses who used restrictive measures were more often less satisfied with their workplace culture. Continuous efforts are needed to reduce the use of coercive measures, which challenge also the managers to support nursing practice to be more person-centred.

Generalist palliative care in hospital - Cultural and organisational interactions. Results of a mixed-methods study

BACKGROUND

It can be challenging to provide generalist palliative care in hospitals, owing to difficulties in integrating disease-oriented treatment with palliative care and the influences of cultural and organisational conditions. However, knowledge on the interactions that occur is sparse.

AIM

To investigate the interactions between organisation and culture as conditions for integrated palliative care in hospital and, if possible, to suggest workable solutions for the provision of generalist palliative care.

DESIGN

A convergent parallel mixed-methods design was chosen using two independent studies: a quantitative study, in which three independent datasets were triangulated to study the organisation and evaluation of generalist palliative care, and a qualitative, ethnographic study exploring the culture of generalist palliative nursing care in medical departments.

SETTING/PARTICIPANTS

A Danish regional hospital with 29 department managements and one hospital management.

RESULTS

Two overall themes emerged: (1) 'generalist palliative care as a priority at the hospital', suggesting contrasting issues regarding prioritisation of palliative care at different organisational levels, and (2) 'knowledge and use of generalist palliative care clinical guideline', suggesting that the guideline had not reached all levels of the organisation.

CONCLUSION

Contrasting issues in the hospital's provision of generalist palliative care at different organisational levels seem to hamper the interactions between organisation and culture - interactions that appear to be necessary for the provision of integrated palliative care in the hospital. The implementation of palliative care is also hindered by the main focus being on disease-oriented treatment, which is reflected at all the organisational levels.

Nurses' Time Use in Forensic Psychiatry: Core Interventions Outlined in the Finnish Clinical Practice Guideline on Schizophrenia

Forensic psychiatric nurses are key in implementing the core interventions outlined in the clinical practice guideline on schizophrenia. This study endeavors to ascertain how these were implemented in routine practice in forensic psychiatry by measuring how nurses use their time. Data were collected from registered nurses and practical mental nurses in all forensic psychiatric facilities in Finland using self-report diary forms for 1 week. In total, nurses used 20% of their weekly working hours on core interventions. The differences between the nurse groups were statistically significant (p ≤ 0.05) regarding the following core interventions: (a) care planning with physicians, (b) pharmacotherapy, and (c) basic clinical care. Nurses' qualifications, types of facilities and units, working experience, gender, and staffing levels explained the time used on core interventions. In summary, forensic psychiatric inpatients received insufficient appropriate nursing services according to the relevant guideline regarding schizophrenia. Furthermore, managerial recommendations need to restructure nurses' time use to increase the proportion of productive working hours spent with patients.

Doctors’ functional leadership in psychiatric healthcare teams – a reversible leadership logic

Purpose

– The purpose of this paper was to study how psychiatric doctors practise leadership in multidisciplinary healthcare teams. The paper seeks to answer the question: How do psychiatric doctors lead multidisciplinary teams during treatment conferences?

Design/methodology/approach

– Six psychiatric teams were studied at a university hospital. Each team was observed over a period of 18 months, and data were collected during four years (2008-2011). Data were collected through interviews with doctors (n = 19) and observations (n = 30) of doctors’ work in multidisciplinary psychiatric teams.

Findings

– Doctors in a multidisciplinary team use either self-imposed or involuntary leadership style. Oscillating between these two extremes was a strategy for handling the internal tensions of the team.

Research limitations/implications

– The study was a case study, performed during treatment conferences at psychiatric wards in a university hospital. This limitation means that there is cause for some caution in generalising the results.

Practical implications

– The results are useful for understanding leadership in multidisciplinary medical teams. By understanding the reversible logic of leadership, cooperation and knowledge sharing can be gained, which means that a situation of mere peaceful coexistence can be avoided. Understanding the importance of the informal contract makes it possible to switch leadership among team members. A reversible leadership with an informal contract makes the team less vulnerable. The team’s professionals can thus easily handle difficult situations and internal tensions, facilitating leadership and management of multidisciplinary teams.

Originality/value

– Doctors in multidisciplinary psychiatric teams use reversible leadership logic.

Organisational culture and post-merger integration in an academic health centre: a mixed-methods study

BACKGROUND

Around the world, the last two decades have been characterised by an increase in the numbers of mergers between healthcare providers, including some of the most prestigious university hospitals and academic health centres. However, many mergers fail to bring the anticipated benefits, and successful post-merger integration in university hospitals and academic health centres is even harder to achieve. An increasing body of literature suggests that organisational culture affects the success of post-merger integration and academic-clinical collaboration.

METHODS

This paper reports findings from a mixed-methods single-site study to examine 1) the perceptions of organisational culture in academic and clinical enterprises at one National Health Service (NHS) trust, and 2) the major cultural issues for its post-merger integration with another NHS trust and strategic partnership with a university. From the entire population of 72 clinician-scientists at one of the legacy NHS trusts, 38 (53%) completed a quantitative Competing Values Framework survey and 24 (33%) also provided qualitative responses. The survey was followed up by semi-structured interviews with six clinician-scientists and a group discussion including five senior managers.

RESULTS

The cultures of two legacy NHS trusts differed and were primarily distinct from the culture of the academic enterprise. Major cultural issues were related to the relative size, influence, and history of the legacy NHS trusts, and the implications of these for respective identities, clinical services, and finances. Strategic partnership with a university served as an important ameliorating consideration in reaching trust merger. However, some aspects of university entrepreneurial culture are difficult to reconcile with the NHS service delivery model and may create tension.

CONCLUSIONS

There are challenges in preserving a more desirable culture at one of the legacy NHS trusts, enhancing cultures in both legacy NHS trusts during their post-merger integration, and in aligning academic and clinical cultures following strategic partnership with a university. The seeds of success may be found in current best practice, good will, and a near identical ideal of the future preferred culture. Strong, fair leadership will be required both nationally and locally for the success of mergers and post-merger integration in university hospitals and academic health centres.

Psychiatric staff on the wards does not share attitudes on aggression

Background

The concept of ward culture has been proposed as a reason for the often reported differences in treatment decisions when managing inpatient aggression. We therefore studied whether staff on wards actually shares similar perceptions and attitudes about aggression and whether the specialty of the ward on which the staff members work influences these opinions.

Methods

The Attitudes Towards Aggression Scale was used to assess attitudes towards aggression in 31 closed psychiatric wards. Altogether 487 staff members working on the study wards were asked to fill in the scale. Respondent’s gender, age, educational level, working experience on the current ward, and specialty of this ward (acute, forensic, rehabilitation) served as background variables.

Results

Most of the variance found was due to differences between individuals. Belonging to the personnel of a particular ward did not explain much of the variance.

Conclusions

Psychiatric staff on the wards does not share attitudes on aggression. As each staff member has his/her own opinion about aggression, training for dealing with aggression or violent incidents should be done, at least partly, on an individual level. We also suggest caution in using the concept of ward culture as an explanation for the use of restrictive measures on psychiatric wards.