From artefact to effect: the organising effects of artefacts on teams

Outcomes of Establishing an Urgent Care Centre in the Same Location as an Emergency Department

The emergency department (ED) is one of the busiest facilities in a hospital, and it is frequently described as a bottleneck that limits space and structures, jeopardising surge capacity during Major Incidents and Disasters (MIDs) and pandemics such as the COVID 19 outbreak. One remedy to facilitate surge capacity is to establish an Urgent Care Centre (UCC), i.e., a secondary ED, co-located and in close collaboration with an ED. This study investigates the outcome of treatment in an ED versus a UCC in terms of length of stay (LOS), time to physician (TTP) and use of medical services. If it was possible to make these parameters equal to or even less than the ED, UCCs could be used as supplementary units to the ED, improving sustainability. The results show reduced waiting times at the UCC, both in terms of TTP and LOS. In conclusion, creating a primary care-like facility in close proximity to the hospitals may not only relieve overcrowding of the hospital’s ED in peacetime, but it may also provide an opportunity for use during MIDs and pandemics to facilitate the victims of the incident and society as a whole.

Perinatal staff perceptions of safety and quality in their service

Background

Ensuring safe and appropriate service delivery is central to a high quality maternity service. With this in mind, over recent years much attention has been given to the development of evidence-based clinical guidelines, staff education and risk reporting systems. Less attention has been given to assessing staff perceptions of a service’s safety and quality and what factors may influence that. In this study we set out to assess staff perceptions of safety and quality of a maternity service and to explore potential influences on service safety.

Methods

The study was undertaken within a new low risk metropolitan maternity service in Victoria, Australia with a staffing profile comprising midwives (including students), neonatal nurses, specialist obstetricians, junior medical staff and clerical staff. In depth open-ended interviews using a semi-structured questionnaire were conducted with 23 staff involved in the delivery of perinatal care, including doctors, midwives, nurses, nursing and midwifery students, and clerical staff. Data were analyzed using naturalistic interpretive inquiry to identify emergent themes.

Results

Staff unanimously reported that there were robust systems and processes in place to maintain safety and quality. Three major themes were apparent: (1) clinical governance, (2) dominance of midwives, (3) inter-professional relationships. Overall, there was a strong sense that, at least in this midwifery-led service, midwives had the greatest opportunity to be an influence, both positively and negatively, on the safe delivery of perinatal care. The importance of understanding team dynamics, particularly mutual respect, trust and staff cohesion, were identified as key issues for potential future service improvement.

Conclusions

Senior staff, particularly midwives and neonatal nurses, play central roles in shaping team behaviors and attitudes that may affect the safety and quality of service delivery. We suggest that strategies targeting senior staff to enhance their performance in their roles, particularly in the training and teamwork role-modeling of the transitory junior workforce, are important for the development and maintenance of a high quality and safe maternity service.

The association between subcultures and resistance to change – in a Swedish hospital clinic

Purpose

– The purpose of this paper is to explore the different subcultures and the employees’ preparedness for change at an orthopaedic clinic in a university hospital in Sweden.

Design/methodology/approach

– Surveys were sent out to 179 nurses and physicians. The survey included the two instruments Organisational Values Questionnaire and resistance to change (RTC) Scale.

Findings

– The results suggest a dominance of a human relations culture, i.e. flexibility, cohesion and trust, in the orthopaedic clinic. These characteristics seemed to decrease RTC. Opposite to this, planning, routines and goal setting appeared to increase change-resistant behaviour.

Practical implications

– By predicting potential obstacles in a certain context prior to a change process, resources can be used in a more optimal way. An instrument that pinpoints the culture of a particular healthcare setting may be a useful tool in order to anticipate the possible outcome of change.

Originality/value

– The rational goal/internal processes dimension exerted a stronger association with RTC than in earlier studies. Deeply rooted standards and routinised care models, governed by work schedules, could be an obstacle to introducing a care model based on the individual needs of the patient. There was, however, a surprisingly low RTC. The results are contrary to the accepted understanding of public organisations known to be slow to change.

Trust tokens in team development

Purpose

– Computer-mediated communication systems (CMCSs) have become the standard for supporting virtual teamwork. However, interpersonal trust formation though CMCSs is impaired due to limited media richness of the communication channels. The aim of this paper is to identify trust forming cues that occur naturally in face-to-face environments and are suitable to include in CMCSs design, to facilitate greater trust in virtual teams.

Design/methodology/approach

– To select cues that had a strong effect on fostering trust behaviour, a non-participatory ethnographic study was conducted. Two student teams at the University of Waterloo were observed for 6-12 months. Researchers identified mechanisms used for building trust and bridging team developmental barriers.

Findings

– The paper identifies five trust tokens that were effective in developing trust and bridging team developmental barriers: expertise, recommendations, social capital, willingness to help/benevolence, and validation of information. These behavioural cues, or behavioural trust tokens, which are present in face-to-face collaborations, carry important trust supporting information that leads to increased trust, improved collaboration, and knowledge integration. These tokens have the potential to improve CMCSs by supplementing the cues necessary for trust formation in virtual environments.

Practical implications

– This study identifies important mechanisms used for fostering trust behaviour in face-to-face collaborations that have the potential to be included in the design of CMCSs (via interface design objects) and have implications for interface designers, team managers, and researchers in the field of teamwork.

Originality/value

– This work presents the first ethnographic study of trust between team members for the purpose of providing improved computer support for virtual collaboration via redesigned interface components.

Understanding the work done by NHS commissioning managers: an exploration of the microprocesses underlying day-to-day sensemaking in UK primary care organisations

PURPOSE

The purpose of this paper is to explore the practical daily work undertaken by middle-level managers in Primary Care Trusts (PCTs), focusing upon the micro-processes by which these managers enact sensemaking in their organisations.

DESIGN/METHODOLOGY/APPROACH

The research took a case study approach, undertaking detailed case studies in four PCTs in England. Data collection included shadowing managers, meeting observations and interviews.

FINDINGS

The research elucidated two categories of enactment behaviour exhibited by PCT managers: presence/absence; and the production of artefacts. Being "present" in or "absent" from meetings enacted sensemaking over and above any concrete contribution to the meeting made by the actors involved. This paper explores the factors affecting these processes, and describes the situations in which enactment of sense is most likely to occur. Producing artefacts such as meeting minutes or PowerPoint slides also enacted sense in the study sites in addition to the content of the artefact. The factors affecting this are explored.

PRACTICAL IMPLICATIONS

The study has practical implications for all managers seeking to maximise their influence in their organisations. It also provides specific evidence relevant to managers working in the new Clinical Commissioning Groups currently being formed in England.

ORIGINALITY/VALUE

The study expands the understanding of sensemaking in organisations in two important ways. Firstly, it moves beyond discourse to explore the ways in which behaviours can enact sense. Secondly, it explores the distinction between active and unconscious sensemaking.

Cultural camouflage--a critical study of how artefacts are camouflaged and mental health policy subverted

This study identifies hidden artefacts in a public organisation. In contrast to earlier studies, it focuses on artefacts as concealing rather than conveying meaning. Negligent behaviour caused by an unpopular culture was recognised in five psychiatric wards at a Swedish university hospital. Data comprising observations (87 h) and interviews (n = 60) were collected over a period of 48 months (2008-2011). Four different items used in everyday work representing a deeper meaning of the organisation were identified during the observations. The items selected were work attire, nametags, keys and restraint beds. These were considered particularly promising when it came to the aim of the study, namely, to find out how artefacts are camouflaged. The observations and the interviews revealed that these were controversial and contested artefacts in the organisation. The study uses the term 'cultural camouflage' for behaviour that ignores and consciously conceals symbols that have negative values. This concept contrasts with previous research that shows how artefacts are emphasised and how they contribute to the character of the activity in a transparent way. Conservative and backward-looking behaviour among staff provided one explanation as to why artefacts were concealed. Another was the need to establish harmonious internal interactions.

Organizational culture and the implementation of person centered care: results from a change process in Swedish hospital care

Sweden has one of the oldest, most coherent and stable healthcare systems in the world. The culture has been described as conservative, mechanistic and increasingly standardized. In order to provide a care adjusted to the patient, person centered care (PCC) has been developed and implemented into some parts of the health care industry. The model has proven to decrease patient uncertainty. However, the impact of PCC has been limited in some clinics and hospital wards. An assumption is that organizational culture has an impact on desired outcomes of PCC, such as patient uncertainty. Therefore, in this study we identify the impact of organizational culture on patient uncertainty in five hospital wards during the implementation of PCC. Data from 220 hospitalized patients who completed the uncertainty cardiovascular population scale (UCPS) and 117 nurses who completed the organizational values questionnaire (OVQ) were investigated with regression analysis. The results seemed to indicate that in hospitals where the culture promotes stability, control and goal setting, patient uncertainty is reduced. In contrast to previous studies suggesting that a culture of flexibility, cohesion and trust is positive, a culture of stability can better sustain a desired outcome of reform or implementation of new care models such as person centered care. It is essential for health managers to be aware of what characterizes their organizational culture before attempting to implement any sort of new healthcare model. The organizational values questionnaire has the potential to be used as a tool to aid health managers in reaching that understanding.

Organisational culture and change: implementing person-centred care

PURPOSE

The purpose of this paper is to explore the connection between organisational cultures and the employee's resistance to change at five hospital wards in Western Sweden. Staff had experienced extensive change during a research project implementing person-centred care (PCC) for patients with chronic heart failure.

DESIGN/METHODOLOGY/APPROACH

Surveys were sent out to 170 nurses. The survey included two instruments--the Organisational Values Questionnaire (OVQ) and the Resistance to Change Scale (RTC).

FINDINGS

The results indicate that a culture with a dominating focus on social competence decreases "routine seeking behaviour", i.e. tendencies to uphold stable routines and a reluctance to give up old habits. The results indicate that a culture of flexibility, cohesion and trust negatively covariate with the overall need for a stable and well-defined framework.

PRACTICAL IMPLICATIONS

An instrument that pinpoints the conditions of a particular healthcare setting can improve the results of a change project. Managers can use instruments such as the ones used in this study to investigate and plan for change processes.

ORIGINALITY/VALUE

Earlier studies of organisational culture and its impact on the performance of healthcare organisations have often investigated culture at the highest level of the organisation. In this study, the culture of the production units--i.e. the health workers in different hospital wards--was described. Hospital wards develop their own culture and the cultures of different wards are mirrored in the hospital.

Everyday practices at the medical ward: a 16-month ethnographic field study

BACKGROUND

Modern hospital care should ostensibly be multi-professional and person-centred, yet it still seems to be driven primarily by a hegemonic, positivistic, biomedical agenda. This study aimed to describe the everyday practices of professionals and patients in a coronary care unit, and analyse how the routines, structures and physical design of the care environment influenced their actions and relationships.

METHODS

Ethnographic fieldwork was conducted over a 16-month period (between 2009 and 2011) by two researchers working in parallel in a Swedish coronary care unit. Observations, informal talks and formal interviews took place with registered nurses, assistant nurses, physicians and patients in the coronary care unit. The formal interviews were conducted with six registered nurses (five female, one male) including the chief nurse manager, three assistant nurses (all female), two cardiologists and three patients (one female, two male).

RESULTS

We identified the structures that either promoted or counteracted the various actions and relationships of patients and healthcare professionals. The care environment, with its minimalistic design, strong focus on routines and modest capacity for dialogue, restricted the choices available to both patients and healthcare professionals. This resulted in feelings of guilt, predominantly on the part of the registered nurses.

CONCLUSIONS

The care environment restricted the choices available to both patients and healthcare professionals. This may result in increased moral stress among those in multi-professional teams who work in the grey area between biomedical and person-centred care.