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AN EXPLORATION OF NURSING
STAFF ATTITUDES TOWARD THE
PROCESS OF CHANGE
by
Ronda S. Anderson
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Approved by:
7
Ju0 Schilling, CRNP, PhD
Committee Chairperson
Edinboro University of Pennsylvania
Date'
Mary Loy/Ke
Committee Member
Edinboro University of Pennsylvania
Date
P.
David P. Shaffer, R1 , MSN
Committee Member
Meadville Medical Center
Date
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AN EXPLORATION OF NURSING STAFF ATTITUDES TOWARD THE
PROCESS OF CHANGE
Abstract
The purpose of this study was to explore the relationship between nursing
staff members who have positive or negative attitudes towards the change process
and their support or nonsupport for the organizational strategic direction.
Differences in attitudes towards the change process and degree of organizational
support among nursing staff members with different licensure status were
evaluated. This study also identified patterns and trends in relation to nursing staff
members’ perceptions concerning factors that helped or hindered the successful
change process within their organization. With this information, nursing leaders
can better understand employees’ reactions to strategic change and implement
steps prior to the change process to gain a more successful outcome. A literature
review found little concerning nursing staff attitudes toward the process of
change. However, the literature documented the rapid change taking place in
healthcare institutions across the nation. The research participants in this study
were forty-two nursing staff members in two rural hospitals in northwestern
Pennsylvania. The research questionnaire utilized in this study consisted of a
demographic section, a seven-point Likert scale that measured attitude and
organizational support, one yes or no question with a comment section, and two
ii
descriptive questions with comment sections. The attitudinal and organizational
support tools used were developed by Dr. Karen Gaertner of Georgetown
University. The researcher designed descriptive questions were added to gain
further insight into nursing staff attitudes and perceptions about successful or
unsuccessful change efforts within their organization. This study concluded that
there was no significant correlation between attitude and organizational support.
The study did not reach a level of significance when looking at differences
between or within the groups. Further research is recommended to verify these
results in a larger sample, in more diverse healthcare organizations, and in other
geographic locations.
iii
Acknowledgment
The author wishes to express her sincere gratitude and appreciation to her
committee chairperson and advisor, Dr. Judith Schilling, to her other two
committee members Dr. Mary Lou Keller and David Shaffer, for their
professional guidance, support, and suggestions during the process of this thesis;
to Jeff Saintz for his computer wisdom; to Carolyn Masters for her statistical
assistance; to the nursing leaders and nursing staff members who participated in
the research; to my colleagues who have supported me; and finally and most
importantly, to my family, especially my husband and son for their patience, love,
and understanding throughout this research process.
R.S.A.
April 1998
iv
Dedication
This is dedicated to two very special persons, my husband, Mike and my
son, Steve, who gave me the irreplaceable gift of time and the immeasurable gift
of their love and support to complete this work.
v
Table of Contents
Title
Page
Abstract
ii
Acknowledgments
iv
Dedication
v
List of Tables
ix
Chapter I. Introduction
1
Background of the Problem
1
Theoretical Framework
3
Statement of Purpose
5
Statement of the Problem
5
Assumptions
6
Limitations
6
Definition of Terms
6
Summary
7
8
Chapter II. Review of Literature
Restructuring, Reengineering, and Work Redesign
8
Surviving and Coping During Change Efforts
9
Attitudes Toward the Change Process
12
Summary
15
vi
Chapter III. Methodology
17
Sample
17
Informed Consent
17
Instrumentation
18
Procedure for Data Collection
19
Data Analysis
20
Summary
21
23
Chapter IV. Results
Description of the Participants
25
Attitudinal and Organizational Support Scores
26
Successful Change Efforts
29
Factors Affecting Successful Change Process
31
Summary
33
Chapter V. Discussion and Recommendations
35
35
Discussion .
Relationship Between Attitude and Organizational Support
. 36
Licensure Status Comparison
36
Factors Identified that Helped or Hindered Organizational Success
37
Implications for Nurse Administrators ..
39
Recommendations for Further Research
39
vii
Summary
40
References
42
Appendixes
46
A. Letter to Vice Presidents
46
B. Participant Cover Letter
47
C. Research Questionnaire
48
D. List of Respondents Exact Comments Concerning Changes
51
in their Organization
E. List of Respondents Exact Comments Concerning Perceived
Factors that Helped the Successful Change Process
55
F. List of Respondents Exact Comments Concerning Perceived
Factors that Hindered the Successful Change Process
viii
59
List of Tables
Table
Page
1. Frequency Distribution of Descriptive Characteristics of the Sample
Population.
24
2. Attitudinal and Organizational Support Mean Scores by Group
26
3. Analysis of Variance for Attitudes and Organizational Support.
28
4. Correlations Between Attitude and Organizational Support
29
5. Perception of Successful Changes Within the Organization.
30
6. Respondents Comments Concerning Successful and Unsuccessful
31
Organizational Change
7. Respondents Comments Concerning Factors that Helped Successful
32
Change Process
8. Respondents Comments Concerning Factors that Hindered Successful
34
Change Process.
ix
1
Chapter I
Introduction
In healthcare today, nursing leaders are challenged with the need to
increase patient satisfaction, improve patient care outcomes, and decrease costs.
It is well documented that work redesign, reengineering, and restructuring efforts
have been ongoing over the past decade in an effort to accomplish these goals.
Clearly, nurse leaders have a critical role in these organizational change efforts.
The solution to successfully meeting the challenge of these change efforts is to
effectively manage the change process.
Background of the Problem
Susan Turner (1995) wrote that change is sweeping across the health care
industry, uprooting people, institutions, and professions in rapid order. Nurses
delivering patient care are seeing these changes and the pace of transformation in
their field is quickening. Turner observed that even with the fundamental shifts
taking place around the nursing staff, no other health care professionals have been
as surprised and unprepared for massive change as nurses. According to Turner,
many nurses are fighting change every step of the way. She posed the question,
“What’s behind this wave of nurse resistance?” (p. 20). Turner felt that the
biggest problem was the inability of many nurses to deal with transition and
change. Accepting change is mandatory for organization survival and is a
difficult concept for many.
2
According to Rizzo, Gilman, and Mersmann (1994), change is a dynamic
process in health care; the delivery of patient care is innovative and creative and
constantly evolving. This particular concept addresses the issue of flexibility as it
relates to change. Simms and Beckman (1992) referred to a flexible work group
as patient-centered and capable of changing when the make-up of its work
changes. Nurses must learn to keep pace with health care changes in order to
survive.
Frustrations with all the changes in the health care delivery system led one
hospital in Tucson, Arizona to rethink the design of nursing service delivery.
Nursing leaders decided that the process of change needed to be controlled from
the bedside. Expecting an external intervention to work in solving what was
clearly an internal problem violated the basics of organizational theory. It also
made good economic sense to carefully consider what work should be done and
who could best do it. “Initiating the change internally allowed those affected to
become active participants from the very beginning - a key strategy in the redesign
process” (Doerge & Hagenow, 1995, p. 29).
The stress of change can be immense. It is important to determine what is
needed to sell the idea to the staff. Much planning and many questions should
be raised prior to implementing any change. Few people like change, especially in
great amounts or when it happens frequently. Change is hard for employees to
accept if they did not initiate it, and do not understand it or approve of it. Once
management makes a decision to implement some restructuring or redesign
3
efforts, rarely does balking help. Employees need to modify their attitude and
accept the change. By accepting change and being a good team player, individuals
can boost their future within the organization (Parlay International, 1995).
Theoretical Framework
There are many theories on attitude and attitude change. G.W. Allport is
among the early theorists and one of the first to show that attitudes predict overt
behaviors. His research and definitions have consistently been referred to in the
literature about dealing with attitudes (McGuire, 1954). According to Allport
(1935), “An attitude is a mental and neutral state of readiness, organized through
experience, exerting a directive or dynamic influence upon the individual’s
response to all objects and situations with which it is related” (p. 810).
Attitudes are usually defined as a disposition or tendency to respond
positively or negatively towards an idea, object, person, or situation. They
encompass, or are closely related to, our opinions and beliefs and are based upon
our experiences. Since attitudes often relate in some way to interaction with
others, they represent an important link between cognitive and social psychology.
A great deal of learning involves acquiring or changing attitudes (Allport, 1935).
Hovland, Janis, and Kelley (1953) provided one of the first major theories
of attitude change. It was developed in the framework of Hull’s learning theory,
and oriented towards the effects of persuasive communication. According to the
Hovland, Janis and Kelley theory, changes in opinions can result in attitude
change depending upon the presence or absence of rewards. The learning of new
4
attitudes is no different in nature than any other verbal or motor skill, except that
attitudes relate to a single proposition whereas other skills involve a series of
propositions. The acceptance of a new opinion, and hence new attitude formation,
is dependent upon the incentives that are offered.
Festinger s (1957) theory of cognitive dissonance is one of the best known
and most researched frameworks pertaining to attitude change. According to this
theory, attitude change is caused by conflict among beliefs. A number of factors
determine the strength of the dissonance and therefore how much effort is
required to change attitudes. By manipulating these factors, attitude changes can
be facilitated or inhibited.
In an historical sense, the study of attitudes has undergone three distinct
phases. The first phase was in the 1920s and 1930s. There was a concentration
on fairly static issues of attitude measurement and how this related to behavior.
The second phase developed in the 1950s and 1960s. In this phase there was a
focus on the dynamics of change in an individual s attitudes. In the third phase
occurring in the 1980s and 1990s, there was a swing towards unraveling the
structure and function of systems of attitudes. All in all, attitudes are basic and
pervasive in all societies. Without attitude constructs, we would have difficulty
understanding and reacting to events, making decisions and conducting
meaningful social relationships (Robbins, 1994).
In summary, in this study, the researcher used Allport’s (1935) theory that
attitudes predict overt behaviors, Hovland, Janis, and Kelley’s (1953) theory of
5
attitude change as it relates to attitudinal changes that are dependent on the
presence or absence of rewards, and Festinger’s (1957) theory of cognitive
dissonance whereby factors are manipulated to facilitate or inhibit attitude change.
Statement of Purpose
The purpose of this study was to explore nursing staff attitudes toward the
process of change and their support for organizational strategy within two acute
care rural hospitals. Nursing staffs’ attitudes that either enhanced or inhibited
hospital redesign, restructuring, or reengineering efforts were examined. In doing
so, the results provided insight into possible contributing factors affecting the
attitudes and perceptions that enhance successful change efforts. If certain
attitudes are hindering or obstructing the success of the change process within
organizations, nursing leaders can modify their restructuring, work redesign, or
reengineering plans to include positive interventions that deal with employee
attitudes. Finally, attitudes toward the process of change and support for
organizational strategy among nurses in different staff positions were compared.
Statement of the Problem
For the purpose of this study, the following research questions were asked:
1. What is the relationship between nursing staff members who have
positive or negative attitudes towards the change process and their support or
nonsupport for the organization’s strategic direction?
6
2. Are there any differences in attitudes towards the change process and
degree of organizational support among nursing staff members with different
licensure status?
3. What are the perceived factors identified by nursing staff members that
helped or hindered the change process within their organization?
Assumptions
This study was based on the following assumptions:
1. Nursing staff attitudes toward the process of change and organizational
support can be measured.
2. The research instrument is reliable and valid.
3. The nursing staff participants responded honestly to the study
questions.
Limitations
The following study limitation was identified:
1. The sample population was limited to nursing staff members working
in two acute care, rural (classified by location) hospitals in northwestern
Pennsylvania.
Definition of Terms
The following terms were defined for this study:
1. Change process is any activity involving work redesign, restructuring
or reengineering.
7
2. Restructuring involves a change in the structure, physical lay out, or
work force of an organization. Generally, restructuring advocates prefer
managerially lean, decentralized, self-governing organizations that empower first
line caregivers to make decisions (Curtin, 1994).
3. Reengineering is revamping the processes by and through which things
are accomplished. “User friendliness,” efficiency, and economy are the
watchwords dealing with reengineering efforts (Curtin, 1994).
4. Work redesign deals with who should be doing what, where, how
much, and for how long. Flexibility, cross-training, and productivity are essential
(Curtin, 1994).
Summary
Healthcare organizations are going through a myriad of changes in rapid
order. Amidst these changes, nursing leaders are faced with the challenge of
increasing patient satisfaction, improving patient care outcomes, and decreasing
costs. Nursing leaders must be prepared to effectively deal with employees
experiencing these changes in order to facilitate a successful transition and
attainment of their goals to increase patient satisfaction, improve patient care
outcomes, and decrease costs. To assist nursing leaders in managing employee
acceptance of change, nursing staff attitudes in relation to successful change
efforts must be explored and understood.
8
Chapter II
Review of Literature
Every healthcare organization today, regardless of its’ size, faces a
marketplace of ever-increasing competition and complexity. Most organizations
have had to make significant changes on a continuing basis in order to
successfully compete in this difficult environment.
This research dealt with nursing staff attitudes toward this process of
change. It is the contention of the researcher that an individual’s attitudes toward
the process of change has a significant effect on the success or failure of the
organization’s change efforts. However, there is not much written in the
literature about nursing staff attitudes and perceptions toward this process of
change. For this study, the review of literature is presented under three main
categories: restructuring, reengineering, and work redesign; surviving and coping
during change efforts; and attitudes toward the change process.
Restructuring, Reengineering, and Work Redesign
According to Schweikhart (1996) the concept of restructuring, patient care
reengineering, and work redesign gained momentum in the late 1980s and early
1990s as healthcare organizations began to share their experiences in
implementing new patient care models. In looking at work redesign, many
hospitals have utilized unlicensed assistive personnel for years, while others have
just begun to add this skill level at their facility. As the state and federal
governments are pressuring hospitals and insurers to reduce the costs of care, they
9
are also scrutinizing the effects of redesign, restructuring or reengineering
processes (Staring & Taylor, 1997).
Restructuring, reengineering, and work redesign are all very common
terms in healthcare today. Managed care and capitation have had a significant
impact on available resources and nursing administrators are always exploring
ways to cut operational costs without diminishing quality outcomes. All of these
changes have an impact on nursing staff attitudes, perceptions, and behavior
which, in turn, affect the success or failure of the strategic plan (Schweikhart,
1996).
Aiken, Sochalski, and Anderson (1996) wrote that the hospital industry in
the United States is undergoing widespread reorganization that includes
restructuring of the work force. These authors concluded that in the quest to
reduce spending, hospital management could implement poorly conceived
reengineering plans that could undermine nursing’s best efforts to maintain the
quality and safety of patient care.
Surviving and Coping During Change Efforts
Acording to Staring and Taylor (1997), survivor symptoms may interfere
with effective change and team functioning. Along with the current change, many
nurses are dealing with their responses to surviving the reduction of the work
force. Staring and Taylor wrote that surviivor syndrome symptoms include
feelings of guilt, anxiety, distrust, fear, insecurity, and a sense of violation.
During the reorganization process, many health care managers announced the
10
change of integrating nursing assistants into the skill mix, with a significant
decrease in licensed practical nurses. This announcement triggered a range of
emotions from the nursing staff. It was believed that the energy from these
emotions could be channeled to achieve a variety of positive goals. After
employing strategies to help the staff develop their coping skills, the unit teams
began to feel more positive and supported the movement within the organization.
All members involved in the reorganization were given room to grow, to make
mistakes, and to learn from their mistakes. With these efforts, the nursing
management team lead the unit to internalized stability with a warm sense of
commitment to values.
According to Bernd and Reed (1994), reengineering requires a certain
resiliency to deal with disappointments, setbacks, and conflict. It requires
consistent support for a new mind set focusing on evidence that things are not
working, that encourages problem identification, and that welcomes truth.
One hospital in Denver, Colorado, (Wenzel, 1995) made some changes in
their delivery of patient care and differentiated practice in nursing.
Cross-functional teams redesigned the basic patient care delivery processes.
When asked to describe the 2 years it took to implement these changes, some
nursing members said, “It has been a worthy challenge of our leadership skills,
and, “It was like being on the bleeding edge!” (p. 60). Hindsight suggested that
distributing some of their programs across more departments might have reduced
the staff’s confusion and the impact on their time.
11
According to Wenzel (1995), the strategic objective of change was to
increase quality of service and efficiency, and to control costs in our managed care
environment. Problems encountered included obtaining a commitment of staff
time toward completion of the plan and a reluctance to change. In retrospect,
more simplicity and more planning would have enhanced their efforts. Having
human resource consultants and employee assistance personnel visible and
involved earlier in their process would have also helped to enhance their redesign
efforts.
Wenzel (1995) further explained that the chaos of change, with all the
range of emotions, was evident in the first months of implementation and was
reflected in the initial low staff satisfaction scores. Many course corrections were
made along the path of their redesign process toward a vision of quality and
excellence in service.
Trofino (1997) wrote that coping with change and helping to reshape
health care delivery requires adopting an open-minded attitude and a willingness
to try new ideas. These are considered effective ways to cope with change. The
driving forces to organizational success include: staying open to change, accepting
change, redefining the “business” of the organization as the environment changes,
putting a premium on high performing, flexible individuals at all levels, and
fostering a sense of community and team learning to help cope with chaos rather
than expecting a return to “normal.” Futurists predict that the ability to function
in continuous uncertainty and turbulence is essential.
12
Attitudes Toward the Change Process
Gaertner (1989) defined winners to be those employees who are in the
function, business, or expert group that becomes central to the success of the new
business strategy. Gaertner’s (1989) study found the following:
Being a “winner” means working with a group that is defined to be a
“winner.” While certainly there are employees in the “winning” function
who do not believe that they, personally, have “won,” they are in a
function or expert group that collectively has gained power and
opportunity. Losers are those in functions that have lost power, centrality,
or opportunity, relative to others, as a result of change (p. 531).
Being a winner or a loser is more than simply liking or not liking the
strategy. However, winners are expected to be more supportive of the new
strategy than losers. Winners are also expected to place more emphasis on the
personal outcomes associated with the change in their support for the strategy.
Gaertner found that winners support a new strategy because the personal
implications are straightforward. When an employee is among a group of winners
the future is bright. Those employees in the winning function are important to the
company or organization. Their collective opportunities for power and influence
are great.
Gaertner’s (1989) study found differences in the configuration of attitudes
that predicted support for the organization’s strategy, depending upon whether the
employees gained or lost power and opportunity as a result of the change. Among
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winners, the strongest predictors of support for the new strategy was positive
career expectations and current career satisfaction. Among “losers,” the strongest
predictor of support for the new strategy was belief that people had been treated
fairly during the change process.
In an effort to compete effectively in rapidly changing environments, many
organizations have adopted new or modified strategic plans. Middle managers
and professionals are the employees often charged with implementing the changes
in these strategies. Their support for (or resistance to) a new strategy can affect
the success of the plan. To the extent that these employees believe that the new
strategy is not in their self-interest, they can inhibit, delay, or even sabotage the
implementation process (Guth & MacMillan, 1986). Gaertner (1989) explained
the importance of avoiding negative consequences associated with changes in
organizational strategy by understanding why, and to what extent, employees
supported a new strategy.
Organizations are structured for stability, with interlocking and
interdependent parts, resulting in reinforcing systems and structural inertia
(Hannan & Freeman, 1984; Lorsch, 1986). Business strategy is an integral part of
an organization’s structure. When a change in strategy is made, it is more likely
to be accepted if it is consistent with the organization’s historically distinctive
competence (Ford & Baucus, 1987), with existing structures and processes
(Nadler, 1983), or with what managers believe to be true, based on past
experience (Ireland, Hitt, Bettis, & DePorras, 1987).
14
According to Gelinas and Manthey’s (1997) survey of more than 5000
nurse executives and managers, organizational redesign has impacted nursing
leadership roles. Nurse leaders have a critical role in redesign efforts. One
observational conclusion was that nurse leaders need to manage personal growth
by objectively challenging their own attitudes, behaviors and beliefs. This
concept was seen as a difficult but important component of successful change
efforts. The rapid pace of change has resulted in extensive challenges to
executives’ own beliefs and an unprecedented level of questioning of norms and
established principles. Effective change also occurs within individuals, and that is
where nurse leaders are experiencing the most dramatic change themselves. As
healthcare redesign continues, one of the major skills required for success is the
ability to tolerate uncertainty and maintain a positive attitude. Learning to
effectively handle these changes with a positive attitude seems to be a predictor of
success. Gelinas and Manthey (1997) wrote the following:
As healthcare redesign continues, one of the major skills required
for success is the ability to tolerate uncertainty. Ambivalence,
vagueness, and ambiguity with ideas and work have replaced
concepts that used to be clear and specific. What once was easy to
see and understand is now blurry - on both personal and
professional levels. The only certainty in the current system is that
change is constant and will continue (p. 42).
15
Gelinas and Manthey (1997) summarized by asserting that effective
leadership in the current environment requires high tolerance for continual
change. Many demands are placed on leaders in dealing with change. Effective
leadership requires greater patience in handling all of the entities feeling the
impact of the change, both people and the environment. Essential skills that must
be developed and continuously enhanced revolve around understanding, leading,
and dealing with the impact of the change process.
Change is more likely to be accepted to the extent that participation in
creating it is shared, and dissemination of information about it is adequate for
implementation (Nutt, 1987; Fidler & Johnson, 1984; Bourgeois & Brodwin,
1984). Additionally, to the extent that employees believe the organization can
actually execute the new strategy, they will be more likely to accept it (Guth &
MacMillan, 1986). Employees who have positive attitudes about the
organization’s abilities to perform are likely to be positive about the
organization’s ability to implement a new strategy successfully.
Summary
This literature review has shown that healthcare restructuring,
reengineering, and work redesign is widespread in the United States. These
changes have a significant impact on nursing staff attitudes, perceptions, and
behavior which, ultimately, can help or hinder the success of an organization s
change efforts. It is well documented that employees react and cope with change
16
in many different ways. Identifying and employing strategies that helped the staff
develop their coping skills resulted in a more positive, supportive environment.
Driving forces to organizational success include: staying open to change,
accepting change, being flexible, and fostering team function. Learning to tolerate
uncertainty, maintaining a positive attitude, and effectively handling change, all
seem to be predictors of a successful change process.
17
Chapter III
Methodology
The purpose of this study was to explore nursing staff attitudes toward the
process of change experienced within their healthcare organization. This study
took place in two rural community hospitals in northwestern Pennsylvania.
Sample
Participants in this study consisted of a random selection of nursing staff
members delivering direct patient care in two rural hospitals located in
northwestern Pennsylvania. The Chief Nurse Executive at each facility randomly
distributed the questionnaires to registered nurses, licensed practical nurses, and
unlicensed assistive personnel on various units and shifts. Each facility utilized in
this study had experienced some type of organizational restructuring, work
redesign, or reengineering within the past 3 years.
Informed Consent
Permission to implement this study at the two rural community hospitals
was verbally obtained from the Chief Nursing Executive at each institution. The
letter that was sent to each vice president confirming participation can be found in
Appendix A. Survey participants were informed via cover letter (Appendix B)
that their participation was completely voluntary. All participants were assured of
complete anonymity and confidentiality. Participants and the nursing executives
were informed that only grouped data would be reported.
18
Instrumentation
The survey tool utilized to evaluate nursing staff attitudes toward the
process of change was the questionnaire developed by Dr. Karen N. Gaertner for
her study of understanding managers’ reactions to strategic change. Gaertner used
the Delphi technique to develop the survey questions. Gaertner’s 1984 and 1986
data had a reliability co-efficient alpha of .80 (1989). This research study utilized
all four questions from her survey tool entitled “Attitudes Toward the Process of
Change” and three of four questions from Gaertner’s survey tool entitled “Support
for the Current Business Strategy”.
The items comprising this self-report instrument evaluated respondents’
attitude toward the process of change and their support for the current
organization strategy. The questions were posed in a Likert-type format with
response categories ranging from (1) strongly agree to (7) strongly disagree
(Gaertner, 1989). For the purposes of this study, Gaertner’s survey tool was
modified only in that wherever the term “business” or “company” appeared, it was
changed to read “organization”. Permission to use and modify Dr. Gaertner s tool
was granted via telephone from her office at Georgetown University (K. N.
Gaertner, personal communication, August 21, 1997). Neither Dr. Gaertner nor
the researcher felt that this modification changed the overall usefulness of the
survey questions.
There were three parts to the research questionnaire (Appendix C). In the
first part, there were four demographic questions: sex, age, current licensed or
19
unlicensed status, and time of the most recent organizational change. The next
section included the seven Likert statements that described participants’ attitudes
and perceptions of the effectiveness of organizational change and their support for
the current organizational strategy. Respondents were asked to circle the number
that best described their feelings toward the effectiveness of organizational change
and their perception of the organization’s commitment to address employees’
needs during a change. The numbers range from a “1”, strongly agree to a “7”,
strongly disagree. The attitudinal scale scores on the lower end were indicative of
positive attitudes, scores on the higher end of the scale indicated a negative
attitude. On the organizational support scale, lower scores indicated support for
the organization’s strategic direction, higher scores indicated nonsupport for the
organization’s strategic direction. The third and last page covered three
researcher-designed descriptive questions. Question number 12 stated, “Overall,
do you feel that the changes that have taken place in your organization have been
successful?” Respondents were asked to check “yes” or “no.” Several blank lines
were left for comments. Questions number 13 and 14 were open-ended questions
requesting the respondents to write what they felt helped (question 13) or hindered
(question 14) the success of the changes in their organization.
Procedure for Data Collection
The cover letters, questionnaires, and self-addressed stamped envelopes
were sorted and placed into individual packets and then mailed to the Chief Nurse
Executive at each hospital. The cover letter indicated that the purpose of the
20
questionnaire was a research project, that participation was voluntary, and that
anonymity would be maintained. A copy of the cover letter can be found in
Appendix B. A total of 100 questionnaires and cover letters (50 to each
participating facility) were delivered to the designated nursing executive at each
of the two hospitals. The nursing executives then randomly distributed the
questionnaire to registered nurses, licensed practical nurses, and unlicensed
assistive personnel on each shift and unit. Participants were asked to complete the
questionnaire, place it in the self-addressed stamped envelope, and mail before
March 15, 1998. All data was collected via mail. A total of 43 returned
questionnaires were postmarked by the specified March 15, 1998 deadline. One
questionnaire was returned blank and could not be used in the study. There were
42 usable questionnaires. Questionnaires returned after the deadline date were
excluded from the data analysis.
Data Analysis
Analysis of the data was performed using a 1997 edition of the Lotus
Smart Suite Computer Software Program. The four questions related to the
demographics of the group were analyzed using frequency distribution and
percentages. These data were gathered in order to describe the sample population.
AU data from Gaertner’s survey tool were scored. The instrument scales
and scoring information were obtained from the author. Two scores were
obtained for each participant. The first score measured the respondent’s attitude
toward changes within their organization. The second score measured the
21
respondent s support for the organization’s strategic direction. The scores could
range from one to seven. The lower scores represent a more positive attitude
toward change and positive support for organization strategy. The higher scores
represent a more negative attitude towards change and less support or nonsupport
for organization strategy. Mean scores were computed for the attitudinal factor
and organization support factor in each of the nursing staff groups of registered
nurses, licensed practical nurses, and unlicensed assistive personnel. The mean
scores and standard deviations were computed and summarized in table form.
Analysis of Variance (ANOVA) was done to determine significance of difference
within and between the groups. Pearson’s r was then computed to determine the
degree of relationship between the variables.
Question number 12 yielded “yes” or “no” responses which were tallied
and presented as frequency distributions and percentages in table form. The
respondents’ comments were reviewed and analyzed with frequency distributions,
and percentages. The res:ponses to the remaining two open-ended questions were
analyzed and described in descriptive format. Identified patterns and trends were
described and noted in a frequency table.
Summary
This chapter described a study that evaluated nursing staff attitudes and
perceptions toward changes within their organization and their support for the
organization’s strategic direction. Questionnaires were randomly distributed to
100 participants in two rural hospitals. Forty-two usable questionnaires were
22
returned. The research sample was described. Variables measured in the study
included attitudes toward change, support for the current organizational strategy,
and the perception of successful change efforts. Responses were analyzed and
described using frequency distributions, percentages, mean scores, standard
deviations, ANOVA, and Pearson’s r correlation analysis.
23
Chapter IV
Results
This descriptive survey study was undertaken to explore nursing staff
attitudes toward the process of change. The researcher planned to determine
whether a positive attitude toward change resulted in support for the current
organizational strategy, and whether there was a difference in attitudes and
organizational support among the licensed and unlicensed staff.
A total of 43 questionnaires (43%) out of 100 distributed were returned by
the deadline date set for initiation of data analysis. Forty-two (42%)
questionnaires were deemed usable because they had the demographic
information of sex, age, current licensed or unlicensed status, the time period of
most recent change within their organization, and the attitudinal Likert scale
portions completed. One questionnaire was returned blank, and therefore, could
not be used in the study.
Information obtained from the demographic section of the three-part
questionnaire is contained in Table 1. The information included sex, age, licensed
or unlicensed status, and the most recent time the respondents experienced change
within their organization. These data were collected to describe the composition
of the sample population.
24
Table 1
Frequency Distribution of Descriptive Characteristics of the Sample Population
Factor
f
Percent
(n = 42)
Sex
Female
Male
Age
29 or under
30 to 39
40 to 49
50 to 64
65 or over
Status
RN
LPN
UAP
Time of change
0-6 Months
7-12 Months
1-3 Years
No Change
41
1
1
9
25
7
0
27
12
98
2
2
21
60
17
0
64
29
3
7
23
9
55
10
0
21
24
0
25
Description of the Research Participants
Forty-one of the forty-two (98%) study respondents were female. One
male registered nurse participated in the survey, representing 2% of the sample
population.
The population surveyed included unlicensed assistive personnel, licensed
practical nurses, and registered nurses. The majority of nursing staff members in
this sample were registered nurses. Twenty-seven (64%) of the forty-two
respondents were identified as registered nurses. Twelve (29%) were identified as
licensed practical nurses and the remaining three (7%) respondents were classified
as unlicensed assistive personnel. The majority of the participants (25) were in
the 40 to 49 age range, representing 60% of the sample population. Nine
participants (21%) were in the 30 to 39 age group and seven nursing staff
members (17%) were in the 50 to 64 age group range. One participant (2%) fell
in the youngest category of 29 years or under. There were no participants in the
65 or over age range. This sample population represented a fairly broad age span
for nursing staff members.
The majority, twenty-three (55%), of the respondents had experienced
change within their organization during the last 6 months. Nine (21%) had
experienced change 7 to 12 months ago. Ten (24%) had experienced change 1 to
3 years ago. Everyone in the sample population had experienced some type of
change within their organization within the past 3 years which met the
researcher’s criteria for participating in this study.
26
Attitudinal and Organizational Support Scores
The attitudinal scores and the organizational support scores are presented
in Table 2 with the mean scores and standard deviations for each nursing group.
Registered nurses had the highest mean score (4.69) out of a possible 7 points on
the attitudinal scale, and the unlicensed assistive personnel had the lowest mean
score (4.00). On the organizational support scale, the licensed practical nurse
group had the highest mean score (4.64) out of a possible 7 points, and the
unlicensed assistive personnel had the lowest mean score (3.20).
Table 2
Attitudinal and Organizational Support Mean Scores by Group
Organizational Support
Attitudinal
SD
M
SD
n
M
RN
4.69
1.12
27
4.19
.99
27
LPN
4.17
1.45
12
4.64
1.94
12
UAP
4.00
2.61
3.20
2.15
3
Total
4.65
1.31
4.25
1.41
42
Group
42
n
The scores of the registered nurses, the licensed practical nurses, and the
unlicensed assistive personnel were evaluated by individual groups and then the
totals of all groups were evaluated. The registered nurses were evaluated within
27
the licensed practical nurse group and the unlicensed assistive personnel group.
Each of the other groups were then evaluated within each other. A 2x3 ANOVA
was performed. In each of the groups, the ANOVA was greater than the .05 level
of significance, therefore there was no significant difference between the groups’
attitudinal and organizational support scores (Table 3).
The individual group scores were analyzed using Pearson’s r correlation
coefficient (Table 4) to determine the strength of the relationship between
attitudinal scores and organizational support scores. The sample population of
registered nurses revealed a moderate correlation (r=.537) between attitudinal
scores and organizational support scores. The r value indicates the degree of
relationship between the two scores. In a positive relationship, a high score on
one variable is related to a high score on another variable. A positive correlation
also exists when a low score on one variable is related to a low score on another
variable. In this study, registered nurses with positive attitudinal scores tended to
have positive organizational support scores. Those with negative attitudinal
scores tended to show less support for the organization s strategic direction.
The licensed practical nurse group revealed a strong correlation (r=.679)
between attitudinal scores and organizational support scores. Those showing
positive attitudes were more likely to show support for organizational strategy.
Those with negative attitudinal scores were more likely to have scores indicating
less support for the organization’s strategic direction.
28
Table 3
Analysis of Variance for Attitude and Organizational Support
F
Source
df
Attitudinal
Organizational Support
Between Subjects
RN/LPN
38
1.468
1.805
RN/UAP
29
1.645
1.294
LPN/UAP
14
2.701
3.968
Within Subjects
RN
26
1.261
0.985
LPN
11
2.089
3.755
UAP
2
4.542
4.630
The small sample of unlicensed assistive personnel group revealed a very
strong correlation (r=.836) between attitudinal scores and organizational support
scores. The unlicensed assistive personnel with the strongly positive attitudinal
score had a score showing strong support for the organization’s strategic direction.
Those with negative attitudinal scores had scores indicating less support for the
organization’s strategic direction.
29
Table 4
Correlations Between Attitude and Organizational Support
Group
n
Pearson’s r correlation
coefficient
RN
27
0.5372
LPN
12
0.6790
UAP
3
0.8369
Total
42
0.6344
Successful Change Efforts
Answers to the “yes” or C4.
“no” question of the survey (#12), regarding the
respondent’s perception of successful change efforts within their organization,
were tabulated. Table 5 displays frequency distribution and percent of the “yes”
and “no” responses for registered nurses, licensed practical nurses, and unlicensed
assistive personnel.
The majority of the sample population (59%) did not perceive successful
changes within their organizations. The highest group of respondents that
perceived successful changes (67%) within their organization was the unlicensed
assistive personnel group. However, the small sample size of this group made it
30
Table 5
Perception of Successful Changes Within the Organization
Yes
Percent
No
Percent
RN
n=26
10
39
16
61
LPN
n=12
5
42
7
58
UAP
n=3
2
67
1
33
Total
n=41
17
41
24
59
Group
difficult to analyze or trend the findings. In the licensed practical nurse group,
42% perceived successful changes within their organization. A total of 39% of
the registered nurse group perceived successful changes within their organization.
Table 6 displays frequency distribution and percent of comments grouped
in one of three main categories from the comment section of the yes or no
question regarding successful or unsuccessful changes. This section yielded
thirty-one comments from twenty-seven respondents. Issues pertaining to safety,
quality patient care and staffing accounted for 21 (68%) of the responses.
Comments that related to decision making, planning, and communication
31
accounted for 6 (19%) of the responses. The third category of comments related
to employee attitude and hard work, which accounted for 8 (13%) of the total
comments in this section. A list of the respondents’ exact comments can be found
in Appendix D.
Table 6
Respondents Comments Concerning Successful and Unsuccessful Organizational
Change
f
%
21
68
2. Decision making, planning, communication
6
19
3. Employee attitude, hard work
4
13
Category
1. Safety, quality patient care concerns, staffing
Note. Twenty-seven of the 42 respondents (64%) wrote 31 comments following
the uyes” or uno” question of the questionnaire. Fifteen (36%) respondents left
this comment section blank.
Factors Affecting Successful Change Process
The final two open-ended questions were analyzed and described in
descriptive formats. Table 7 and Table 8 contain summarized lists and frequency
of comments that nursing staff members believed helped (Table 7) or hindered
(Table 8) the change process within their organizations.
32
After reviewing and analyzing the data in Table 7, trending was identified
in the sample population’s comments (Appendix E) about factors that helped
make the changes in their organizations successful. Positive attitudes, employee
cooperation, and open-mindedness were the most frequently (14) noted responses.
Patient safety, quality of care, and hard working employees that maintain patient
care standards were the next most frequently (12) noted responses. Responses
related to supportive management attitudes accounted for seven of the total
responses read.
Table 7
Respondents Comments Concerning Factors that Helped Successful Change
Process
f
%
1. Positive employee attitude, cooperation, open-mindedness
14
35
2. Patient safety, quality of care, hard work of employees
12
30
Category
3. Supportive management attitudes
7
17.5
4. Supportive management attitudes
5
12.5
5. Inservice, education, available resources
2
5
Note. Thirty-five of the 42 respondents (83%) yielded 40 comments and seven
respondents (17%) left the comment section blank.
33
In the category of effective communication and follow through, five responses
were written that pertained to these factors. The two least mentioned factors were
those that pertained to inservice, education, and availability of resources. Seven
respondents left this comment section blank.
Trends were also noted in the factors that the nursing staff members felt
hindered the successful implementation of the change process. The sample
population comments (Appendix F) were summarized and grouped under five
categories as displayed in Table 8. The most prevalent (17) comments noted were
those that pertained to lack of patient safety, poor quality of care and staffing
issues. Fifteen comments pertained to poor communication, lack of employee
input, and poor planning. Comments relating to a mistrust of upper management
and negative administrative attitudes accounted for ten of the total responses.
Eight responses related to negative employee attitudes and two responses
pertained to lack of inservice and education programs prior to implementation of
change. Two respondents left this comment section blank.
Summary
In summary, more nursing staff participants believed changes within their
organization were not successful. The participants’ comments were analyzed and
summarized revealing that the majority of participants from all of the groups
believed patient care, safety, quality of care, attitude, staffing, planning, and
communication were among the most important factors affecting the change
process. Correlational trending was identified with attitudinal and organizational
34
Table 8
Respondents Comments Concerning Factors that Hindered Successful Change
Process
Category
f
%
1. Lack of patient safety, poor quality of care, and staffing issues
17
33
2. Poor communication, lack of employee input, poor planning
15
29
3. Negative administrative attitudes, mistrust of upper management
10
19
4. Negative employee attitudes
8
15
5. Lack of inservice, and education programs prior to change
2
4
Note. Forty of 42 respondents (95%) wrote 52 comments and two respondents
(5%) left the comment section blank.
support scores, however, a level of significance was not obtained. Additionally,
there was no significant difference between or within the groups’ attitudinal and
organizational support scores.
35
Chapter V
Discussion and Recommendations
Few references were found in the literature that addressed nursing staff
attitudes toward the process of change. This study was undertaken to explore
nursing staff attitudes towards the process of change and determine the
relationship between attitude and organizational support. A survey questionnaire
was used to examine and measure nursing staff attitudes and support for the
organization’s strategic direction. The participants were asked about their
perceptions of the effectiveness of organizational change and their perception of
the organization’s commitment to address employees’ needs during change.
Nursing staff participants were asked: Overall, do you feel that the changes that
have taken place in your organization have been successful? Two additional
questions requested nursing staff participants to document what they felt had
helped or hindered the success of the changes within their organization.
Discussion
The research questions addressed by this study were: a) What is the
relationship between nursing staff members who have positive or negative
attitudes towards the change process and their support or nonsupport for the
organization’s strategic direction? b) Are there any differences in attitudes
towards the change process and degree of organizational support among nursing
staff members with different licensure status? c) What are the perceived factors
identified by nursing staff members that helped or hindered the successful change
36
process within the organization? The sample group for this study consisted of
forty-two nursing staff members employed as registered nurses, licensed practical
nurses, or unlicensed assistive personnel in two acute care rural hospitals in
northwestern Pennsylvania.
Relationship Between Attitudes and Organizational Support
The attitudinal mean scores in each nursing group were compared to the
organizational support scores and a 2x3 ANOVA was performed between and
within the groups. The ANOVA was greater than the .05 level of significance,
therefore, there was no significant difference between the groups’ attitudinal and
organizational support scores. However, the results showed a high level of
agreement existed with each group’s attitudinal and organizational support
responses.
Relationship trending was identified in that in each of the three nursing
staff groups, those participants with positive attitudes tended to show favorable
support for the organization’s strategic direction, while those with negative
attitudes tended to show less favorable organizational support. However, this
trending did not reach a level of significance in this research study.
Licensure Status Comparison
In answering the second research question, the analysis of the Pearson’s r
revealed that the registered nurses, licensed practical nurses, and the unlicensed
assistive personnel groups tended to have scores that correlated positive attitudes
with organizational support as well as negative attitudes that correlated with less
37
support or nonsupport of the organization’s strategic direction. Therefore, there
was congruity within the groups. However, the results of the analysis of variance
showed that there were no significant differences between the attitudinal scores
and the organizational support scores between or within the groups.
Factors Identified that Helped or Hindered Organizational Success
After reviewing and summarizing the sample population comments, many
remarks were noted to be consistent with Allport’s (1935) theory on attitude and
change. Allport wrote that an attitude is a mental and neural state of readiness,
just as several employees wrote that it was difficult to accept change if they were
not aware that change was coming and did not feel ready to accept the change.
Many respondents wrote about the importance of communication from
administration. Many nursing staff members indicated they would have been
more willing to accept change and to be more supportive if they had been
informed and given time to be ready for the change. Respondents also wrote that
more inservice and education programs would have helped prepare them for the
change process. They perceived that an educational component would have
helped increase their awareness and knowledge about the changes, which in turn,
would have helped to ensure safe, quality care for patients. Patient safety, quality
of care and staffing were the most prevalent factors mentioned by the respondents.
Nursing staff respondents felt change in their organization would have
been more successful if they had been recognized and appreciated for the good job
they were doing. Hovland, Janis, and Kelley (1953) wrote about a theory on
38
attitude change. The theory is oriented towards the effect of persuasive
communication and the importance of changing attitudes with the presence or
absence of rewards. While the rewards of being appreciated and being recognized
may not be tangible, they seemed to be an important factor that the sample
population believed would have led to more positive outcomes.
This study, like Gaertner’s (1989), found that overcoming resistance to
change includes things such as employee participation, communication, and
education. These efforts are useful for helping employees understand the meaning
of change and for gaining acceptance of the change. A few final points are
noteworthy. The strongest correlates of successful change efforts within the
organization were perceived by this study sample to be commitment to quality
patient care, patient safety, communication adequacy, and concern for people.
This study represents only a beginning in our understanding of the ways in
which attitudes toward the process of change are interpreted, and organizational
support given, by nursing staff members. The researcher’s sample was relatively
small and only from two hospitals, so it cannot be presumed that the results are
generalizable. Moreover, this study showed only attitudinal evidence of support
for the strategy, not behavioral evidence. The results, however, are indicative of
the need to further explore the effects of attitudes during periods of substantial
organizational change.
39
Implications for Nurse Administrators
Based on the results of this study, the following recommendations are
made to nurse administrators and nurse leaders that will be going through a
change process.
1. Nurse administrators should create an atmosphere that conveys quality
patient care and positive patient outcomes as priorities.
2. Administration and nursing leaders should conduct regular staff
meetings to communicate the proposed changes, then follow up with regular
progress reports. Provide as much positive feedback as possible.
3. Nursing staff members should be included in the planning and
implementation of the proposed change process to create a “buy-in” by
employees.
4. Inservice education programs, designed to meet the needs of the staff in
relation to the particular type of change they will be encountering, should be
developed and presented.
Recommendations for Further Research
Further research is needed to investigate the most appropriate, effective
way to manage nursing staff attitudes towards the process of change. Based on
the results of this study, the following recommendations are made.
1. The study should be replicated using a larger sample size and more
hospitals in other geographic locations.
40
2. Comparison studies are recommended to examine attitudes and
organizational support before and after implementation of any change process.
3. The questionnaire should be revised to replace the three separate
comment sections with one comment section available at the end of the
questionnaire. This revision would eliminate the redundant remarks written under
each of the comment sections yet still provide an opportunity for the participants
to further respond. The comment section provides valuable information to the
researcher and gains further insight from the participant’s perspective regarding
the change process.
4. Utilizing results from this study, develop a check list of predetermined
categories that identify factors that helped and factors that hindered the change
process. Participants should be instructed to prioritize the importance of each
factor. Additional comments could be written in the comment section for further
analysis on the successful change process.
Summary
This study suggests that nursing staff members experiencing change within
their organization have a need to be informed and to be kept informed of the
process. An important aspect in a successful change process is keeping the focus
on the patient. Much planning and organization should be in place prior to
implementing any change. The study determined that employees with positive
attitudes were more likely to accept change and support the organization s
strategic direction. Conversely, negative attitudes resulted in less support or
41
nonsupport of the organization’s strategic plan. However, these findings did not
reach a level of significance.
The study population and the literature agree: maintaining quality patient
care as the focus throughout the change process is an important factor if nursing
staff employees are to perceive changes as being successful within their
organizations. Another key strategy that these research findings support is
allowing those affected to be active participants from the very beginning (Doerge
& Hagenow, 1995). Administrators and nurse managers need to ensure effective
two-way communications while fostering positive attitudes to guide and support
nursing staff employees through the dynamics of the change process. Finally,
administrators and nurse managers must keep positive interventions in mind when
planning any change process. Successful outcomes are dependent on these highly
meaningful points.
42
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46
Appendix A
Letter to Vice Presidents
3/2/98
Vice President Patient Care Services
Dear
Thank you for volunteering to spend a few minutes of your time distributing the enclosed
questionnaires. Please distribute the questionnaires randomly among your Registered Nurses,
Licensed Practical Nurses and unlicensed assistive personnel on each shift. The questionnaire is part
of a research study, titled “Evaluating Nursing Staff Attitudes Toward the Process of Change” being
supervised by Dr. Judith Schilling, at Edinboro University of Pennsylvania. The study is in partial
fulfillment of the requirements for my Master’s degree in nursing.
The purpose of the research project is to evaluate nursing staff attitudes to determine what
factors enhance or inhibit hospital redesign, reengineering, or restructuring efforts.
This survey is not an evaluation of your hospital nor of your orientation or communication
programs, and will only be used for research purposes. All responses will remain confidential and
only grouped data will be reported. My target population for the study is nursing staff members that
provide direct patient care. Participants are being instructed to complete the questionnaire, place it in
the attached self-addressed stamped envelope and mail directly to me before March 15, 1998. If you
are interested in the results of the study, please contact me.
Again, thank you for your time and assistance. I truly appreciate your help in this
undertaking. If you have any questions, I can be reached at either (814) 589-5138 (home) or (814)
827-1851 (work).
Sincerely,
Ronda Anderson, RN, BSN, CNA
RD # 2 Box 154 A
Titusville, PA 16354
47
Appendix B
Participant Cover letter
March 2,1998
Dear Participant,
I would greatly appreciate your assistance in completing the attached questionnaire. This
survey is being conducted in partial fulfillment of the requirements to complete the Master of Science
in Nursing degree at Edinboro University.
The purpose of the research study is to evaluate nursing staff attitudes toward the process of
change in order to determine what factors enhance or inhibit a hospital’s restructuring, redesign, or
reorganizational efforts. Your name has been randomly selected to participate, and your participation
is completely voluntary. Please be assured that all individual responses are anonymous and will be
kept completely confidential. Only grouped data will be reported.
Please answer all the questions and place the completed questionnaire in the attached self
addressed stamped envelope. Seal it and mail before March 15,1998.
Your responses and interest are appreciated; be assured that your contribution will add value
to this study. Thank you.
Sincerely,
Ronda Anderson, RN, BSN, CNA
RD # 2 Box 154 A
Titusville, PA 16354
48
Appendix C
Research Questionnaire
DEMOGRAPHIC INFORMATION
Please complete the following information. Do not write your name on this
questionnaire. Your responses will remain confidential.
1.
Please indicate your sex:
Male
Female
2.
Your present age is:
29 or under
30 to 39
40 to 49
50 to 64
65 or over
3.
What is your current licensed or unlicensed status?
Unlicensed Assistive Personnel
L.P.N.
R.N.
Other (Describe):
4.
Which best describes the most recent time your organization
or unit experienced change (work redesign, restructuring, reengineering,
layoffs, increased patient assignment, or decreased staffing)?
Experiencing changes now or wit
Experienced change 7-12 months ago
~ Experienced change 1 - 3 years ago
Experienced no change
Please turn to next page
49
page 2 of 3
°F THE
ORGANIZATION'S COMMITMENT TO ADDRESS
CHANGE. PLEASE CIRCLE THE pSSE?™™8 DUWNG A
FEELINGS TOWARD ORGANIZATIONAL CHANGR ™AT MST DESCRIBES YOUR OWN
* For the purposes of this survey, “change” is used to denote any type of restructuring,
reorganization, reengineering, layoffs, increased patient assignment, or decreased staffing
within your organization. (1) INDICATES THAT YOU STRONGLY AGREE WITH
THE STATEMENT AND (7) INDICATES THAT YOU STRONGLY DISAGREE
WITH THE STATEMENT.
5.
The changes necessary to keep this organization competitive have been
implemented with enough consideration given to employees.
1
Strongly
Agree
6.
3
2
4
5
6
7
Strongly
Disagree
When changes are made in this organization, the employees usually lose
out in the end.
1
Strongly
Agree
3
2
4
5
6
7
Strongly
Disagree
I think that changes in this organization tend to work well.
7.
1
Strongly
Agree
2
3
4
5
6
7
Strongly
Disagree
Changes in this organization always seem to create more problems than
they solve.
8.
1
Strongly
Agree
9.
I am
1
Strongly
Agree
10.
3
4
5
6
7
Strongly
Disagree
encouraged by the direction I see this organization taking today.
2
This organization
1
Strongly
Agree
11.
2
2
3
4
5
6
7
Strongly
Disagree
has chosen a strategic direction that is going to be a winner.
3
4
5
6
7
Strongly
Disagree
6
7
Strongly
Disagree
This organization’s future does not look bright.
1
Strongly
Agree
2
3
4
5
50
page 3 of 3
PLEASE ANSWER THE REMAINING THREE QUESTIONS.
12.
Overall, do you feel that the changes that have taken place in your
organization
successful?
As
changes inhave
yourbeen
organization
have taken place, what do you feel
helped make these changes successful?
Yes
No
Comments:
13.
14.
As changes in your organization have taken place, what do you feel
hindered the success of these changes?
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS
SURVEY. PLEASE PLACE YOUR COMPLETED SURVEY IN
THE ATTACHED SELF-ADDRESSED STAMPED ENVELOPE
AND MAIL DIRECTLY TO ME BY MARCH 15,1998-
51
Appendix D
List of Respondents Exact Comments Concerning Changes in their Organization:
1. Pt care seems to be the least concern, decreased staffing = increased stress
2. I answer yes to the major changes but the smaller changes that are made
interdepartmentally do not seem to go smooth or even work at the end. Not
enough though process before implementing.
3. The unit I work on is comprised of highly skilled nurses but since we are well
organized and work as a team, we are the last to get any assistance. As for the
majority of the organization - too management heavy.
4. Due to excellent staff participation and desire to help the organization survive.
5. Changes in middle managers have given both middle and upper management a
more overall perspective. However, changes on a staff level have been
sporadic & appear unorganized & not thoroughly thought through.
6. Its hard work because nobody wants to change even though everyone thinks
things should change.
7. For hospitals to survive - changes are a necessity, it has caused heavier work
load, less help.
8. However, question the changes due to quality patient care.
9. Changes have been successful but have taken much time for employees to
adjust to the changes.
io. Lack of two way communication has hindered any progress.
52
11. It’s the people who never have pt contact making the staffing decisions,
sometimes even accounting decides the ratio or whether we need a secretary or
not.
12. We went to a new computer system a couple of years ago- not user friendly-
caused nothing but gnef. Also when they downsized a couple of yrs ago
didn’t feel they gave enough notice and didn’t ask for input from staff.
13. Not enough staff, make cuts which don’t directly involve pt care!
14. 80% of the changes seem to take place to the nursing staffs being cut and the
patient load higher. Therefore the quality of care suffers and the patients
aren’t satisfied with their care.
15. Pts wonder if they have a nurse! Excessively high stress levels for staff leads
to less efficiency, greater job dissatisfaction, less loyalty to hospital
organization, less willingness to participate in implementation of new
programs.
16. Example - the closing of expresscare (where minor pts are seen) was done
without adding the appropriate physical space or staff. Prior to expresscare
closing our ER census increased from 16,000 to 21,000 without any
readjustment in staffing or space. Then attempting to see an increase in
volume with 1 physician & 1 nurse practicionier.
17. Changes have resulted in fewer direct care givers, poorer quality care & an
inability to flex up to meet increased census or acuity penods.
53
18. Decreased staff lead to poor pt care - as evidenced by what the community is
saying.
19. They have lost good work that go elsewhere - people have lost jobs.
20.1 think pt. care has decreased, less staff with the same amt. of pts., then with
computer charting, the problems were compounded.
21. The decrease in staff has not benefited the patient care, many patients and
family are dissatisfied and angry.
22. Low morale throughout work place, numerous injuries due to decreased staff,
increased stress, increased workload, pt safety has become a big issue due to
decreased staff, decreased restraint useage, unable to monitor pt due to
workload increases.
23. Valued LPNs have lost their jobs - then management saw it did not work &
had to hire inexperienced LPNs.
24.1 don’t know if you can call them successful or not. They cut nursing bad and
its the patients that suffer with poor care and tired nurses. I think cuts can be
done elsewhere in the organization that don’t affect pt care so badly. Overall
yes this organization will make $, but at what expense.
25. It has caused a lot of hard feelings with staff towards adm. which effects the
pts in the long run.
26. We work a lot of days under our recommended no. of nurses. Our LPNs were
decreased when we still need them. Their jobs were put up for bid.
54
27. Recently closed xpress care & placed all xpress/er pts in same unit but added
no extra space or beds to accomadate additional pts. Added LPN instead of
RN & a Nurse Practioner instead of MD to help with increased volume.
55
Appendix E
List of Respondents Exact Comments Concerning Perceived Factors that Helped
the Successful Change Process:
1. The employee attitude
2. people working together
3. Attitude of employees/considerate attitude of administration
4. Staff cooperation
5. We’re threatened: “Be thankful you have a job...” Economics force me to stay.
6. Cooperation, willingness to be able to change
7. Managers informing staff. & Senior management having meetings with staff,
8. On my department level - it has been my immediate supervisor. As an
organization as a whole, the help has been sparse.
9. Staff willingness to work together toward common goal. Staff willing and
able to maintain positive attitudes.
10. Individual sacrifice
11. Administrative - manager - employee meetings (informative), Seeing the
positive growth.
12. Understanding administrative decisions.
13. The positive attitudes of the staff.
56
14. Staffs’ positive attitudes toward quality care. Hospital has tried to spread the
“bad news” re: lay-off or less work time over more staff to minimize impact
on a few people.
15. The hard work of the employees
16. The staff has helped each other out - We had to overlook a lot of our faults,
work together even more, maintain good attitudes.
17. The changes just took place and you either adapted or not. They really didn’t
care. They were out to do what they thought needed done. Again, its the
patients that suffer and overworked nurses working doubles, OT, Bonus. So
they decrease staff to save $ But staff is burning out. Can we consider
ourselves successful with increased pts complaints and the public feeling
unsafe here!
18. Many RNs and LPNs worked overtime, on their days off etc. Rns working
“bonus” weekends. If no one would have been willing to work extra - it would
have been unsafe!
19. Our changes haven’t been successful, should be able to change in other areas
without decreasing safety and quality of patient care. Too many adm.
personnel, too little staff to provide pt. care.
20. Staff willing to work very hard with less and to give up days off including
weekends and holidays to make sure pts get safe quality care.
57
21. The ability of the staff to pick up the slack, to work overtime to help maintain
pt. care standards.
22. Mgmt, asking for employees’ buy-in, opinions.
23. Employees extend themselves (especially nursing) to make things go well for
the patients. Some are fearful of speaking out.
24. Nurses working 12 hour shifts without lunch or supper, overtime, increased pt
census leading to poor pt care, unsafe conditions regarding the ratio of acute
care pts to nursing staff.
25. The do it or else attitude of the supervisors, etc...
26. When there is more staff involvement. Honesty from management.
27. Nothing since it seems as if it is a catch up situation.
28. Helped by determination of employees to make it work. The positive attitudes
had to “carry” the negative reactions. Many times it seemed the negatives
were winning.
29. Cooperation of the employees to maintain quality of care.
30. Supportive management attitudes
31. Inservice, follow thru with plans and communication of changes
32. Instituted inservices on new policy changes in restraint care to aide staff on
proper use and proper procedure.
33. Maintaining a positive attitude.
34. Cooperation and open-mindedness of employees and management.
58
35. Good attitudes and being open minded.
59
Appendix F
List of Respondents Exact Comments Concerning Perceived Factors That
Hindered the Successful Change Process:
1. A larger workload on fewer workers.
2. Lack of follow thru, (no note usual progress), lack of contact with updates of
progress.
3. Always the nursing department, more work, less money!
4. Expectations greater than humanly possible; not putting patients need first;
lack of staff involvement in decisions prior to implementing.
5. To much management people not enough workers to take care of patients.
6. Negative attitudes of employees
7. Negative attitudes always are the biggest hinderance to any change. An
unwillingness to try change is also a hinderance. Patients are no longer people
with feelings & problems but are now seen as “money” - & blame most of this
on the HMO’s & regulations. Without reimbursement for the care provided it
is very difficult for any organization to provide quality care.
8. Lack of communication to inform reasons for change and obtaining input from
all that it effects - Poor time frame of implementation.
9. Not really caring for pt care; only the bottom line. Administration making
decisions, we aren’t listened to, they don’t worry about liability and safety,
only money.
60
10. A sense of mistrust and betrayal by the management.
11. Not taking in the consideration once again on pt. care! and staffing!
12. Stress of change, being overworked, feeling guilty about the poor quality of
patient care.
13. Poor planning without any insight, no consulting of experienced nursing staff
regarding their input, ideas.
14. Resistance to change, special interest groups, lack of skills, haste, poor
planning.
15. Not including the workers in the decision-making, those who actually do the
work!
16. They have used number systems to rate the amt of staff needed; whether your
census calls for 2 RNs or 5 RNs - you only get 2 RNs (Rarely get what’s
called for).
17. There seems to be far too many administrative persons that really do not
realize the work load of the staff. They have week-end and all holidays off,
and never need to do shift work. They also get a yearly bonus. This really
doesn’t seem fair. (Poor administrative attitudes).
18. Total disregard for fairness and respect to employees, looking at financial gain
only, poor adm management.
61
19. Too much change all at 1 time - loss of employees - switch to computerized
charting, you get overwhelmed. Not enough staff to cover all shifts, working
too many hours.
20. Rarely looking at the bottom line. Management just tells us what we are doing
wrong. To answer this question honestly: Mistrust of upper management.
21. Administration being self centered & not looking out for lower positions!
22. Not being truthful with us or involving us in the change before it happened -
we prepared for one way of change and a totally different way was thrown at
us.
23. Adm. worries about cost and not quality of care - Nurses have a freeze on all
education except mandatories (ACLS) & step raises for seniority were done
away with. Organization can’t be successful when they don’t view
experienced RN’s as a valuable comodity.
24. Management made the decisions without involving the actual personnel
involved for input so could be workable and employees feel better about
decisions.
25. Could have used a more participatory management approach/more actively
involve staff.
26. The negative attitudes.
62
27. Negative attitudes, the cut & dry coldness of mandatory job position changes.
Statements such as : “This is the way it has to be either take the job that’s
offered to you or you don’t have a job”
28. Changes are made in a fragmented way with little planning and management
acting as if they really don’t know what is really going on - when they really
do!
29. Not enough administration change with staff changes, not enough staff. Lack
of open communication within the organization.
30. The lack of communication & explanation of changes to be made or
implemented is staggering. Staff is told days before changes are made. There
is little follow up done after changes are made. There needs to be more
advanced education re: changes. There was also no acknowledgement of staff
concerns re: changes. Staff was told only of changes specific to them & not
institution-wide changes.
31. Staff negative attitudes. Everyone thinks change should be perfect with no
disruption but its not possible. Thanks.
32. Failure of employees to realize change will occur, we need to try to understand
them to adjust to changes.
33. No input from those affected
34. Nurses were only told that they were going to happen, their opinions were not
sought
63
35. The changes themselves (itself) if they compromised pt care or staff
perceptions of decreased care.
36. Resources available when changes made
37. Peoples unwillingness to change.
38. Management not knowing or caring to listen to the workers
39. Lack of pt safety concerns, less staff - more work!
40. Increased workload for staff, increased week-end work and on-call
assignments.
A549e
c.2
Anderson, Honda s.
An r*
- '
exploration
nursing ■staff i, of
u 1111udes
1998.
/<
AN EXPLORATION OF NURSING
STAFF ATTITUDES TOWARD THE
PROCESS OF CHANGE
by
Ronda S. Anderson
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Approved by:
7
Ju0 Schilling, CRNP, PhD
Committee Chairperson
Edinboro University of Pennsylvania
Date'
Mary Loy/Ke
Committee Member
Edinboro University of Pennsylvania
Date
P.
David P. Shaffer, R1 , MSN
Committee Member
Meadville Medical Center
Date
r
\(V"
AN EXPLORATION OF NURSING STAFF ATTITUDES TOWARD THE
PROCESS OF CHANGE
Abstract
The purpose of this study was to explore the relationship between nursing
staff members who have positive or negative attitudes towards the change process
and their support or nonsupport for the organizational strategic direction.
Differences in attitudes towards the change process and degree of organizational
support among nursing staff members with different licensure status were
evaluated. This study also identified patterns and trends in relation to nursing staff
members’ perceptions concerning factors that helped or hindered the successful
change process within their organization. With this information, nursing leaders
can better understand employees’ reactions to strategic change and implement
steps prior to the change process to gain a more successful outcome. A literature
review found little concerning nursing staff attitudes toward the process of
change. However, the literature documented the rapid change taking place in
healthcare institutions across the nation. The research participants in this study
were forty-two nursing staff members in two rural hospitals in northwestern
Pennsylvania. The research questionnaire utilized in this study consisted of a
demographic section, a seven-point Likert scale that measured attitude and
organizational support, one yes or no question with a comment section, and two
ii
descriptive questions with comment sections. The attitudinal and organizational
support tools used were developed by Dr. Karen Gaertner of Georgetown
University. The researcher designed descriptive questions were added to gain
further insight into nursing staff attitudes and perceptions about successful or
unsuccessful change efforts within their organization. This study concluded that
there was no significant correlation between attitude and organizational support.
The study did not reach a level of significance when looking at differences
between or within the groups. Further research is recommended to verify these
results in a larger sample, in more diverse healthcare organizations, and in other
geographic locations.
iii
Acknowledgment
The author wishes to express her sincere gratitude and appreciation to her
committee chairperson and advisor, Dr. Judith Schilling, to her other two
committee members Dr. Mary Lou Keller and David Shaffer, for their
professional guidance, support, and suggestions during the process of this thesis;
to Jeff Saintz for his computer wisdom; to Carolyn Masters for her statistical
assistance; to the nursing leaders and nursing staff members who participated in
the research; to my colleagues who have supported me; and finally and most
importantly, to my family, especially my husband and son for their patience, love,
and understanding throughout this research process.
R.S.A.
April 1998
iv
Dedication
This is dedicated to two very special persons, my husband, Mike and my
son, Steve, who gave me the irreplaceable gift of time and the immeasurable gift
of their love and support to complete this work.
v
Table of Contents
Title
Page
Abstract
ii
Acknowledgments
iv
Dedication
v
List of Tables
ix
Chapter I. Introduction
1
Background of the Problem
1
Theoretical Framework
3
Statement of Purpose
5
Statement of the Problem
5
Assumptions
6
Limitations
6
Definition of Terms
6
Summary
7
8
Chapter II. Review of Literature
Restructuring, Reengineering, and Work Redesign
8
Surviving and Coping During Change Efforts
9
Attitudes Toward the Change Process
12
Summary
15
vi
Chapter III. Methodology
17
Sample
17
Informed Consent
17
Instrumentation
18
Procedure for Data Collection
19
Data Analysis
20
Summary
21
23
Chapter IV. Results
Description of the Participants
25
Attitudinal and Organizational Support Scores
26
Successful Change Efforts
29
Factors Affecting Successful Change Process
31
Summary
33
Chapter V. Discussion and Recommendations
35
35
Discussion .
Relationship Between Attitude and Organizational Support
. 36
Licensure Status Comparison
36
Factors Identified that Helped or Hindered Organizational Success
37
Implications for Nurse Administrators ..
39
Recommendations for Further Research
39
vii
Summary
40
References
42
Appendixes
46
A. Letter to Vice Presidents
46
B. Participant Cover Letter
47
C. Research Questionnaire
48
D. List of Respondents Exact Comments Concerning Changes
51
in their Organization
E. List of Respondents Exact Comments Concerning Perceived
Factors that Helped the Successful Change Process
55
F. List of Respondents Exact Comments Concerning Perceived
Factors that Hindered the Successful Change Process
viii
59
List of Tables
Table
Page
1. Frequency Distribution of Descriptive Characteristics of the Sample
Population.
24
2. Attitudinal and Organizational Support Mean Scores by Group
26
3. Analysis of Variance for Attitudes and Organizational Support.
28
4. Correlations Between Attitude and Organizational Support
29
5. Perception of Successful Changes Within the Organization.
30
6. Respondents Comments Concerning Successful and Unsuccessful
31
Organizational Change
7. Respondents Comments Concerning Factors that Helped Successful
32
Change Process
8. Respondents Comments Concerning Factors that Hindered Successful
34
Change Process.
ix
1
Chapter I
Introduction
In healthcare today, nursing leaders are challenged with the need to
increase patient satisfaction, improve patient care outcomes, and decrease costs.
It is well documented that work redesign, reengineering, and restructuring efforts
have been ongoing over the past decade in an effort to accomplish these goals.
Clearly, nurse leaders have a critical role in these organizational change efforts.
The solution to successfully meeting the challenge of these change efforts is to
effectively manage the change process.
Background of the Problem
Susan Turner (1995) wrote that change is sweeping across the health care
industry, uprooting people, institutions, and professions in rapid order. Nurses
delivering patient care are seeing these changes and the pace of transformation in
their field is quickening. Turner observed that even with the fundamental shifts
taking place around the nursing staff, no other health care professionals have been
as surprised and unprepared for massive change as nurses. According to Turner,
many nurses are fighting change every step of the way. She posed the question,
“What’s behind this wave of nurse resistance?” (p. 20). Turner felt that the
biggest problem was the inability of many nurses to deal with transition and
change. Accepting change is mandatory for organization survival and is a
difficult concept for many.
2
According to Rizzo, Gilman, and Mersmann (1994), change is a dynamic
process in health care; the delivery of patient care is innovative and creative and
constantly evolving. This particular concept addresses the issue of flexibility as it
relates to change. Simms and Beckman (1992) referred to a flexible work group
as patient-centered and capable of changing when the make-up of its work
changes. Nurses must learn to keep pace with health care changes in order to
survive.
Frustrations with all the changes in the health care delivery system led one
hospital in Tucson, Arizona to rethink the design of nursing service delivery.
Nursing leaders decided that the process of change needed to be controlled from
the bedside. Expecting an external intervention to work in solving what was
clearly an internal problem violated the basics of organizational theory. It also
made good economic sense to carefully consider what work should be done and
who could best do it. “Initiating the change internally allowed those affected to
become active participants from the very beginning - a key strategy in the redesign
process” (Doerge & Hagenow, 1995, p. 29).
The stress of change can be immense. It is important to determine what is
needed to sell the idea to the staff. Much planning and many questions should
be raised prior to implementing any change. Few people like change, especially in
great amounts or when it happens frequently. Change is hard for employees to
accept if they did not initiate it, and do not understand it or approve of it. Once
management makes a decision to implement some restructuring or redesign
3
efforts, rarely does balking help. Employees need to modify their attitude and
accept the change. By accepting change and being a good team player, individuals
can boost their future within the organization (Parlay International, 1995).
Theoretical Framework
There are many theories on attitude and attitude change. G.W. Allport is
among the early theorists and one of the first to show that attitudes predict overt
behaviors. His research and definitions have consistently been referred to in the
literature about dealing with attitudes (McGuire, 1954). According to Allport
(1935), “An attitude is a mental and neutral state of readiness, organized through
experience, exerting a directive or dynamic influence upon the individual’s
response to all objects and situations with which it is related” (p. 810).
Attitudes are usually defined as a disposition or tendency to respond
positively or negatively towards an idea, object, person, or situation. They
encompass, or are closely related to, our opinions and beliefs and are based upon
our experiences. Since attitudes often relate in some way to interaction with
others, they represent an important link between cognitive and social psychology.
A great deal of learning involves acquiring or changing attitudes (Allport, 1935).
Hovland, Janis, and Kelley (1953) provided one of the first major theories
of attitude change. It was developed in the framework of Hull’s learning theory,
and oriented towards the effects of persuasive communication. According to the
Hovland, Janis and Kelley theory, changes in opinions can result in attitude
change depending upon the presence or absence of rewards. The learning of new
4
attitudes is no different in nature than any other verbal or motor skill, except that
attitudes relate to a single proposition whereas other skills involve a series of
propositions. The acceptance of a new opinion, and hence new attitude formation,
is dependent upon the incentives that are offered.
Festinger s (1957) theory of cognitive dissonance is one of the best known
and most researched frameworks pertaining to attitude change. According to this
theory, attitude change is caused by conflict among beliefs. A number of factors
determine the strength of the dissonance and therefore how much effort is
required to change attitudes. By manipulating these factors, attitude changes can
be facilitated or inhibited.
In an historical sense, the study of attitudes has undergone three distinct
phases. The first phase was in the 1920s and 1930s. There was a concentration
on fairly static issues of attitude measurement and how this related to behavior.
The second phase developed in the 1950s and 1960s. In this phase there was a
focus on the dynamics of change in an individual s attitudes. In the third phase
occurring in the 1980s and 1990s, there was a swing towards unraveling the
structure and function of systems of attitudes. All in all, attitudes are basic and
pervasive in all societies. Without attitude constructs, we would have difficulty
understanding and reacting to events, making decisions and conducting
meaningful social relationships (Robbins, 1994).
In summary, in this study, the researcher used Allport’s (1935) theory that
attitudes predict overt behaviors, Hovland, Janis, and Kelley’s (1953) theory of
5
attitude change as it relates to attitudinal changes that are dependent on the
presence or absence of rewards, and Festinger’s (1957) theory of cognitive
dissonance whereby factors are manipulated to facilitate or inhibit attitude change.
Statement of Purpose
The purpose of this study was to explore nursing staff attitudes toward the
process of change and their support for organizational strategy within two acute
care rural hospitals. Nursing staffs’ attitudes that either enhanced or inhibited
hospital redesign, restructuring, or reengineering efforts were examined. In doing
so, the results provided insight into possible contributing factors affecting the
attitudes and perceptions that enhance successful change efforts. If certain
attitudes are hindering or obstructing the success of the change process within
organizations, nursing leaders can modify their restructuring, work redesign, or
reengineering plans to include positive interventions that deal with employee
attitudes. Finally, attitudes toward the process of change and support for
organizational strategy among nurses in different staff positions were compared.
Statement of the Problem
For the purpose of this study, the following research questions were asked:
1. What is the relationship between nursing staff members who have
positive or negative attitudes towards the change process and their support or
nonsupport for the organization’s strategic direction?
6
2. Are there any differences in attitudes towards the change process and
degree of organizational support among nursing staff members with different
licensure status?
3. What are the perceived factors identified by nursing staff members that
helped or hindered the change process within their organization?
Assumptions
This study was based on the following assumptions:
1. Nursing staff attitudes toward the process of change and organizational
support can be measured.
2. The research instrument is reliable and valid.
3. The nursing staff participants responded honestly to the study
questions.
Limitations
The following study limitation was identified:
1. The sample population was limited to nursing staff members working
in two acute care, rural (classified by location) hospitals in northwestern
Pennsylvania.
Definition of Terms
The following terms were defined for this study:
1. Change process is any activity involving work redesign, restructuring
or reengineering.
7
2. Restructuring involves a change in the structure, physical lay out, or
work force of an organization. Generally, restructuring advocates prefer
managerially lean, decentralized, self-governing organizations that empower first
line caregivers to make decisions (Curtin, 1994).
3. Reengineering is revamping the processes by and through which things
are accomplished. “User friendliness,” efficiency, and economy are the
watchwords dealing with reengineering efforts (Curtin, 1994).
4. Work redesign deals with who should be doing what, where, how
much, and for how long. Flexibility, cross-training, and productivity are essential
(Curtin, 1994).
Summary
Healthcare organizations are going through a myriad of changes in rapid
order. Amidst these changes, nursing leaders are faced with the challenge of
increasing patient satisfaction, improving patient care outcomes, and decreasing
costs. Nursing leaders must be prepared to effectively deal with employees
experiencing these changes in order to facilitate a successful transition and
attainment of their goals to increase patient satisfaction, improve patient care
outcomes, and decrease costs. To assist nursing leaders in managing employee
acceptance of change, nursing staff attitudes in relation to successful change
efforts must be explored and understood.
8
Chapter II
Review of Literature
Every healthcare organization today, regardless of its’ size, faces a
marketplace of ever-increasing competition and complexity. Most organizations
have had to make significant changes on a continuing basis in order to
successfully compete in this difficult environment.
This research dealt with nursing staff attitudes toward this process of
change. It is the contention of the researcher that an individual’s attitudes toward
the process of change has a significant effect on the success or failure of the
organization’s change efforts. However, there is not much written in the
literature about nursing staff attitudes and perceptions toward this process of
change. For this study, the review of literature is presented under three main
categories: restructuring, reengineering, and work redesign; surviving and coping
during change efforts; and attitudes toward the change process.
Restructuring, Reengineering, and Work Redesign
According to Schweikhart (1996) the concept of restructuring, patient care
reengineering, and work redesign gained momentum in the late 1980s and early
1990s as healthcare organizations began to share their experiences in
implementing new patient care models. In looking at work redesign, many
hospitals have utilized unlicensed assistive personnel for years, while others have
just begun to add this skill level at their facility. As the state and federal
governments are pressuring hospitals and insurers to reduce the costs of care, they
9
are also scrutinizing the effects of redesign, restructuring or reengineering
processes (Staring & Taylor, 1997).
Restructuring, reengineering, and work redesign are all very common
terms in healthcare today. Managed care and capitation have had a significant
impact on available resources and nursing administrators are always exploring
ways to cut operational costs without diminishing quality outcomes. All of these
changes have an impact on nursing staff attitudes, perceptions, and behavior
which, in turn, affect the success or failure of the strategic plan (Schweikhart,
1996).
Aiken, Sochalski, and Anderson (1996) wrote that the hospital industry in
the United States is undergoing widespread reorganization that includes
restructuring of the work force. These authors concluded that in the quest to
reduce spending, hospital management could implement poorly conceived
reengineering plans that could undermine nursing’s best efforts to maintain the
quality and safety of patient care.
Surviving and Coping During Change Efforts
Acording to Staring and Taylor (1997), survivor symptoms may interfere
with effective change and team functioning. Along with the current change, many
nurses are dealing with their responses to surviving the reduction of the work
force. Staring and Taylor wrote that surviivor syndrome symptoms include
feelings of guilt, anxiety, distrust, fear, insecurity, and a sense of violation.
During the reorganization process, many health care managers announced the
10
change of integrating nursing assistants into the skill mix, with a significant
decrease in licensed practical nurses. This announcement triggered a range of
emotions from the nursing staff. It was believed that the energy from these
emotions could be channeled to achieve a variety of positive goals. After
employing strategies to help the staff develop their coping skills, the unit teams
began to feel more positive and supported the movement within the organization.
All members involved in the reorganization were given room to grow, to make
mistakes, and to learn from their mistakes. With these efforts, the nursing
management team lead the unit to internalized stability with a warm sense of
commitment to values.
According to Bernd and Reed (1994), reengineering requires a certain
resiliency to deal with disappointments, setbacks, and conflict. It requires
consistent support for a new mind set focusing on evidence that things are not
working, that encourages problem identification, and that welcomes truth.
One hospital in Denver, Colorado, (Wenzel, 1995) made some changes in
their delivery of patient care and differentiated practice in nursing.
Cross-functional teams redesigned the basic patient care delivery processes.
When asked to describe the 2 years it took to implement these changes, some
nursing members said, “It has been a worthy challenge of our leadership skills,
and, “It was like being on the bleeding edge!” (p. 60). Hindsight suggested that
distributing some of their programs across more departments might have reduced
the staff’s confusion and the impact on their time.
11
According to Wenzel (1995), the strategic objective of change was to
increase quality of service and efficiency, and to control costs in our managed care
environment. Problems encountered included obtaining a commitment of staff
time toward completion of the plan and a reluctance to change. In retrospect,
more simplicity and more planning would have enhanced their efforts. Having
human resource consultants and employee assistance personnel visible and
involved earlier in their process would have also helped to enhance their redesign
efforts.
Wenzel (1995) further explained that the chaos of change, with all the
range of emotions, was evident in the first months of implementation and was
reflected in the initial low staff satisfaction scores. Many course corrections were
made along the path of their redesign process toward a vision of quality and
excellence in service.
Trofino (1997) wrote that coping with change and helping to reshape
health care delivery requires adopting an open-minded attitude and a willingness
to try new ideas. These are considered effective ways to cope with change. The
driving forces to organizational success include: staying open to change, accepting
change, redefining the “business” of the organization as the environment changes,
putting a premium on high performing, flexible individuals at all levels, and
fostering a sense of community and team learning to help cope with chaos rather
than expecting a return to “normal.” Futurists predict that the ability to function
in continuous uncertainty and turbulence is essential.
12
Attitudes Toward the Change Process
Gaertner (1989) defined winners to be those employees who are in the
function, business, or expert group that becomes central to the success of the new
business strategy. Gaertner’s (1989) study found the following:
Being a “winner” means working with a group that is defined to be a
“winner.” While certainly there are employees in the “winning” function
who do not believe that they, personally, have “won,” they are in a
function or expert group that collectively has gained power and
opportunity. Losers are those in functions that have lost power, centrality,
or opportunity, relative to others, as a result of change (p. 531).
Being a winner or a loser is more than simply liking or not liking the
strategy. However, winners are expected to be more supportive of the new
strategy than losers. Winners are also expected to place more emphasis on the
personal outcomes associated with the change in their support for the strategy.
Gaertner found that winners support a new strategy because the personal
implications are straightforward. When an employee is among a group of winners
the future is bright. Those employees in the winning function are important to the
company or organization. Their collective opportunities for power and influence
are great.
Gaertner’s (1989) study found differences in the configuration of attitudes
that predicted support for the organization’s strategy, depending upon whether the
employees gained or lost power and opportunity as a result of the change. Among
13
winners, the strongest predictors of support for the new strategy was positive
career expectations and current career satisfaction. Among “losers,” the strongest
predictor of support for the new strategy was belief that people had been treated
fairly during the change process.
In an effort to compete effectively in rapidly changing environments, many
organizations have adopted new or modified strategic plans. Middle managers
and professionals are the employees often charged with implementing the changes
in these strategies. Their support for (or resistance to) a new strategy can affect
the success of the plan. To the extent that these employees believe that the new
strategy is not in their self-interest, they can inhibit, delay, or even sabotage the
implementation process (Guth & MacMillan, 1986). Gaertner (1989) explained
the importance of avoiding negative consequences associated with changes in
organizational strategy by understanding why, and to what extent, employees
supported a new strategy.
Organizations are structured for stability, with interlocking and
interdependent parts, resulting in reinforcing systems and structural inertia
(Hannan & Freeman, 1984; Lorsch, 1986). Business strategy is an integral part of
an organization’s structure. When a change in strategy is made, it is more likely
to be accepted if it is consistent with the organization’s historically distinctive
competence (Ford & Baucus, 1987), with existing structures and processes
(Nadler, 1983), or with what managers believe to be true, based on past
experience (Ireland, Hitt, Bettis, & DePorras, 1987).
14
According to Gelinas and Manthey’s (1997) survey of more than 5000
nurse executives and managers, organizational redesign has impacted nursing
leadership roles. Nurse leaders have a critical role in redesign efforts. One
observational conclusion was that nurse leaders need to manage personal growth
by objectively challenging their own attitudes, behaviors and beliefs. This
concept was seen as a difficult but important component of successful change
efforts. The rapid pace of change has resulted in extensive challenges to
executives’ own beliefs and an unprecedented level of questioning of norms and
established principles. Effective change also occurs within individuals, and that is
where nurse leaders are experiencing the most dramatic change themselves. As
healthcare redesign continues, one of the major skills required for success is the
ability to tolerate uncertainty and maintain a positive attitude. Learning to
effectively handle these changes with a positive attitude seems to be a predictor of
success. Gelinas and Manthey (1997) wrote the following:
As healthcare redesign continues, one of the major skills required
for success is the ability to tolerate uncertainty. Ambivalence,
vagueness, and ambiguity with ideas and work have replaced
concepts that used to be clear and specific. What once was easy to
see and understand is now blurry - on both personal and
professional levels. The only certainty in the current system is that
change is constant and will continue (p. 42).
15
Gelinas and Manthey (1997) summarized by asserting that effective
leadership in the current environment requires high tolerance for continual
change. Many demands are placed on leaders in dealing with change. Effective
leadership requires greater patience in handling all of the entities feeling the
impact of the change, both people and the environment. Essential skills that must
be developed and continuously enhanced revolve around understanding, leading,
and dealing with the impact of the change process.
Change is more likely to be accepted to the extent that participation in
creating it is shared, and dissemination of information about it is adequate for
implementation (Nutt, 1987; Fidler & Johnson, 1984; Bourgeois & Brodwin,
1984). Additionally, to the extent that employees believe the organization can
actually execute the new strategy, they will be more likely to accept it (Guth &
MacMillan, 1986). Employees who have positive attitudes about the
organization’s abilities to perform are likely to be positive about the
organization’s ability to implement a new strategy successfully.
Summary
This literature review has shown that healthcare restructuring,
reengineering, and work redesign is widespread in the United States. These
changes have a significant impact on nursing staff attitudes, perceptions, and
behavior which, ultimately, can help or hinder the success of an organization s
change efforts. It is well documented that employees react and cope with change
16
in many different ways. Identifying and employing strategies that helped the staff
develop their coping skills resulted in a more positive, supportive environment.
Driving forces to organizational success include: staying open to change,
accepting change, being flexible, and fostering team function. Learning to tolerate
uncertainty, maintaining a positive attitude, and effectively handling change, all
seem to be predictors of a successful change process.
17
Chapter III
Methodology
The purpose of this study was to explore nursing staff attitudes toward the
process of change experienced within their healthcare organization. This study
took place in two rural community hospitals in northwestern Pennsylvania.
Sample
Participants in this study consisted of a random selection of nursing staff
members delivering direct patient care in two rural hospitals located in
northwestern Pennsylvania. The Chief Nurse Executive at each facility randomly
distributed the questionnaires to registered nurses, licensed practical nurses, and
unlicensed assistive personnel on various units and shifts. Each facility utilized in
this study had experienced some type of organizational restructuring, work
redesign, or reengineering within the past 3 years.
Informed Consent
Permission to implement this study at the two rural community hospitals
was verbally obtained from the Chief Nursing Executive at each institution. The
letter that was sent to each vice president confirming participation can be found in
Appendix A. Survey participants were informed via cover letter (Appendix B)
that their participation was completely voluntary. All participants were assured of
complete anonymity and confidentiality. Participants and the nursing executives
were informed that only grouped data would be reported.
18
Instrumentation
The survey tool utilized to evaluate nursing staff attitudes toward the
process of change was the questionnaire developed by Dr. Karen N. Gaertner for
her study of understanding managers’ reactions to strategic change. Gaertner used
the Delphi technique to develop the survey questions. Gaertner’s 1984 and 1986
data had a reliability co-efficient alpha of .80 (1989). This research study utilized
all four questions from her survey tool entitled “Attitudes Toward the Process of
Change” and three of four questions from Gaertner’s survey tool entitled “Support
for the Current Business Strategy”.
The items comprising this self-report instrument evaluated respondents’
attitude toward the process of change and their support for the current
organization strategy. The questions were posed in a Likert-type format with
response categories ranging from (1) strongly agree to (7) strongly disagree
(Gaertner, 1989). For the purposes of this study, Gaertner’s survey tool was
modified only in that wherever the term “business” or “company” appeared, it was
changed to read “organization”. Permission to use and modify Dr. Gaertner s tool
was granted via telephone from her office at Georgetown University (K. N.
Gaertner, personal communication, August 21, 1997). Neither Dr. Gaertner nor
the researcher felt that this modification changed the overall usefulness of the
survey questions.
There were three parts to the research questionnaire (Appendix C). In the
first part, there were four demographic questions: sex, age, current licensed or
19
unlicensed status, and time of the most recent organizational change. The next
section included the seven Likert statements that described participants’ attitudes
and perceptions of the effectiveness of organizational change and their support for
the current organizational strategy. Respondents were asked to circle the number
that best described their feelings toward the effectiveness of organizational change
and their perception of the organization’s commitment to address employees’
needs during a change. The numbers range from a “1”, strongly agree to a “7”,
strongly disagree. The attitudinal scale scores on the lower end were indicative of
positive attitudes, scores on the higher end of the scale indicated a negative
attitude. On the organizational support scale, lower scores indicated support for
the organization’s strategic direction, higher scores indicated nonsupport for the
organization’s strategic direction. The third and last page covered three
researcher-designed descriptive questions. Question number 12 stated, “Overall,
do you feel that the changes that have taken place in your organization have been
successful?” Respondents were asked to check “yes” or “no.” Several blank lines
were left for comments. Questions number 13 and 14 were open-ended questions
requesting the respondents to write what they felt helped (question 13) or hindered
(question 14) the success of the changes in their organization.
Procedure for Data Collection
The cover letters, questionnaires, and self-addressed stamped envelopes
were sorted and placed into individual packets and then mailed to the Chief Nurse
Executive at each hospital. The cover letter indicated that the purpose of the
20
questionnaire was a research project, that participation was voluntary, and that
anonymity would be maintained. A copy of the cover letter can be found in
Appendix B. A total of 100 questionnaires and cover letters (50 to each
participating facility) were delivered to the designated nursing executive at each
of the two hospitals. The nursing executives then randomly distributed the
questionnaire to registered nurses, licensed practical nurses, and unlicensed
assistive personnel on each shift and unit. Participants were asked to complete the
questionnaire, place it in the self-addressed stamped envelope, and mail before
March 15, 1998. All data was collected via mail. A total of 43 returned
questionnaires were postmarked by the specified March 15, 1998 deadline. One
questionnaire was returned blank and could not be used in the study. There were
42 usable questionnaires. Questionnaires returned after the deadline date were
excluded from the data analysis.
Data Analysis
Analysis of the data was performed using a 1997 edition of the Lotus
Smart Suite Computer Software Program. The four questions related to the
demographics of the group were analyzed using frequency distribution and
percentages. These data were gathered in order to describe the sample population.
AU data from Gaertner’s survey tool were scored. The instrument scales
and scoring information were obtained from the author. Two scores were
obtained for each participant. The first score measured the respondent’s attitude
toward changes within their organization. The second score measured the
21
respondent s support for the organization’s strategic direction. The scores could
range from one to seven. The lower scores represent a more positive attitude
toward change and positive support for organization strategy. The higher scores
represent a more negative attitude towards change and less support or nonsupport
for organization strategy. Mean scores were computed for the attitudinal factor
and organization support factor in each of the nursing staff groups of registered
nurses, licensed practical nurses, and unlicensed assistive personnel. The mean
scores and standard deviations were computed and summarized in table form.
Analysis of Variance (ANOVA) was done to determine significance of difference
within and between the groups. Pearson’s r was then computed to determine the
degree of relationship between the variables.
Question number 12 yielded “yes” or “no” responses which were tallied
and presented as frequency distributions and percentages in table form. The
respondents’ comments were reviewed and analyzed with frequency distributions,
and percentages. The res:ponses to the remaining two open-ended questions were
analyzed and described in descriptive format. Identified patterns and trends were
described and noted in a frequency table.
Summary
This chapter described a study that evaluated nursing staff attitudes and
perceptions toward changes within their organization and their support for the
organization’s strategic direction. Questionnaires were randomly distributed to
100 participants in two rural hospitals. Forty-two usable questionnaires were
22
returned. The research sample was described. Variables measured in the study
included attitudes toward change, support for the current organizational strategy,
and the perception of successful change efforts. Responses were analyzed and
described using frequency distributions, percentages, mean scores, standard
deviations, ANOVA, and Pearson’s r correlation analysis.
23
Chapter IV
Results
This descriptive survey study was undertaken to explore nursing staff
attitudes toward the process of change. The researcher planned to determine
whether a positive attitude toward change resulted in support for the current
organizational strategy, and whether there was a difference in attitudes and
organizational support among the licensed and unlicensed staff.
A total of 43 questionnaires (43%) out of 100 distributed were returned by
the deadline date set for initiation of data analysis. Forty-two (42%)
questionnaires were deemed usable because they had the demographic
information of sex, age, current licensed or unlicensed status, the time period of
most recent change within their organization, and the attitudinal Likert scale
portions completed. One questionnaire was returned blank, and therefore, could
not be used in the study.
Information obtained from the demographic section of the three-part
questionnaire is contained in Table 1. The information included sex, age, licensed
or unlicensed status, and the most recent time the respondents experienced change
within their organization. These data were collected to describe the composition
of the sample population.
24
Table 1
Frequency Distribution of Descriptive Characteristics of the Sample Population
Factor
f
Percent
(n = 42)
Sex
Female
Male
Age
29 or under
30 to 39
40 to 49
50 to 64
65 or over
Status
RN
LPN
UAP
Time of change
0-6 Months
7-12 Months
1-3 Years
No Change
41
1
1
9
25
7
0
27
12
98
2
2
21
60
17
0
64
29
3
7
23
9
55
10
0
21
24
0
25
Description of the Research Participants
Forty-one of the forty-two (98%) study respondents were female. One
male registered nurse participated in the survey, representing 2% of the sample
population.
The population surveyed included unlicensed assistive personnel, licensed
practical nurses, and registered nurses. The majority of nursing staff members in
this sample were registered nurses. Twenty-seven (64%) of the forty-two
respondents were identified as registered nurses. Twelve (29%) were identified as
licensed practical nurses and the remaining three (7%) respondents were classified
as unlicensed assistive personnel. The majority of the participants (25) were in
the 40 to 49 age range, representing 60% of the sample population. Nine
participants (21%) were in the 30 to 39 age group and seven nursing staff
members (17%) were in the 50 to 64 age group range. One participant (2%) fell
in the youngest category of 29 years or under. There were no participants in the
65 or over age range. This sample population represented a fairly broad age span
for nursing staff members.
The majority, twenty-three (55%), of the respondents had experienced
change within their organization during the last 6 months. Nine (21%) had
experienced change 7 to 12 months ago. Ten (24%) had experienced change 1 to
3 years ago. Everyone in the sample population had experienced some type of
change within their organization within the past 3 years which met the
researcher’s criteria for participating in this study.
26
Attitudinal and Organizational Support Scores
The attitudinal scores and the organizational support scores are presented
in Table 2 with the mean scores and standard deviations for each nursing group.
Registered nurses had the highest mean score (4.69) out of a possible 7 points on
the attitudinal scale, and the unlicensed assistive personnel had the lowest mean
score (4.00). On the organizational support scale, the licensed practical nurse
group had the highest mean score (4.64) out of a possible 7 points, and the
unlicensed assistive personnel had the lowest mean score (3.20).
Table 2
Attitudinal and Organizational Support Mean Scores by Group
Organizational Support
Attitudinal
SD
M
SD
n
M
RN
4.69
1.12
27
4.19
.99
27
LPN
4.17
1.45
12
4.64
1.94
12
UAP
4.00
2.61
3.20
2.15
3
Total
4.65
1.31
4.25
1.41
42
Group
42
n
The scores of the registered nurses, the licensed practical nurses, and the
unlicensed assistive personnel were evaluated by individual groups and then the
totals of all groups were evaluated. The registered nurses were evaluated within
27
the licensed practical nurse group and the unlicensed assistive personnel group.
Each of the other groups were then evaluated within each other. A 2x3 ANOVA
was performed. In each of the groups, the ANOVA was greater than the .05 level
of significance, therefore there was no significant difference between the groups’
attitudinal and organizational support scores (Table 3).
The individual group scores were analyzed using Pearson’s r correlation
coefficient (Table 4) to determine the strength of the relationship between
attitudinal scores and organizational support scores. The sample population of
registered nurses revealed a moderate correlation (r=.537) between attitudinal
scores and organizational support scores. The r value indicates the degree of
relationship between the two scores. In a positive relationship, a high score on
one variable is related to a high score on another variable. A positive correlation
also exists when a low score on one variable is related to a low score on another
variable. In this study, registered nurses with positive attitudinal scores tended to
have positive organizational support scores. Those with negative attitudinal
scores tended to show less support for the organization s strategic direction.
The licensed practical nurse group revealed a strong correlation (r=.679)
between attitudinal scores and organizational support scores. Those showing
positive attitudes were more likely to show support for organizational strategy.
Those with negative attitudinal scores were more likely to have scores indicating
less support for the organization’s strategic direction.
28
Table 3
Analysis of Variance for Attitude and Organizational Support
F
Source
df
Attitudinal
Organizational Support
Between Subjects
RN/LPN
38
1.468
1.805
RN/UAP
29
1.645
1.294
LPN/UAP
14
2.701
3.968
Within Subjects
RN
26
1.261
0.985
LPN
11
2.089
3.755
UAP
2
4.542
4.630
The small sample of unlicensed assistive personnel group revealed a very
strong correlation (r=.836) between attitudinal scores and organizational support
scores. The unlicensed assistive personnel with the strongly positive attitudinal
score had a score showing strong support for the organization’s strategic direction.
Those with negative attitudinal scores had scores indicating less support for the
organization’s strategic direction.
29
Table 4
Correlations Between Attitude and Organizational Support
Group
n
Pearson’s r correlation
coefficient
RN
27
0.5372
LPN
12
0.6790
UAP
3
0.8369
Total
42
0.6344
Successful Change Efforts
Answers to the “yes” or C4.
“no” question of the survey (#12), regarding the
respondent’s perception of successful change efforts within their organization,
were tabulated. Table 5 displays frequency distribution and percent of the “yes”
and “no” responses for registered nurses, licensed practical nurses, and unlicensed
assistive personnel.
The majority of the sample population (59%) did not perceive successful
changes within their organizations. The highest group of respondents that
perceived successful changes (67%) within their organization was the unlicensed
assistive personnel group. However, the small sample size of this group made it
30
Table 5
Perception of Successful Changes Within the Organization
Yes
Percent
No
Percent
RN
n=26
10
39
16
61
LPN
n=12
5
42
7
58
UAP
n=3
2
67
1
33
Total
n=41
17
41
24
59
Group
difficult to analyze or trend the findings. In the licensed practical nurse group,
42% perceived successful changes within their organization. A total of 39% of
the registered nurse group perceived successful changes within their organization.
Table 6 displays frequency distribution and percent of comments grouped
in one of three main categories from the comment section of the yes or no
question regarding successful or unsuccessful changes. This section yielded
thirty-one comments from twenty-seven respondents. Issues pertaining to safety,
quality patient care and staffing accounted for 21 (68%) of the responses.
Comments that related to decision making, planning, and communication
31
accounted for 6 (19%) of the responses. The third category of comments related
to employee attitude and hard work, which accounted for 8 (13%) of the total
comments in this section. A list of the respondents’ exact comments can be found
in Appendix D.
Table 6
Respondents Comments Concerning Successful and Unsuccessful Organizational
Change
f
%
21
68
2. Decision making, planning, communication
6
19
3. Employee attitude, hard work
4
13
Category
1. Safety, quality patient care concerns, staffing
Note. Twenty-seven of the 42 respondents (64%) wrote 31 comments following
the uyes” or uno” question of the questionnaire. Fifteen (36%) respondents left
this comment section blank.
Factors Affecting Successful Change Process
The final two open-ended questions were analyzed and described in
descriptive formats. Table 7 and Table 8 contain summarized lists and frequency
of comments that nursing staff members believed helped (Table 7) or hindered
(Table 8) the change process within their organizations.
32
After reviewing and analyzing the data in Table 7, trending was identified
in the sample population’s comments (Appendix E) about factors that helped
make the changes in their organizations successful. Positive attitudes, employee
cooperation, and open-mindedness were the most frequently (14) noted responses.
Patient safety, quality of care, and hard working employees that maintain patient
care standards were the next most frequently (12) noted responses. Responses
related to supportive management attitudes accounted for seven of the total
responses read.
Table 7
Respondents Comments Concerning Factors that Helped Successful Change
Process
f
%
1. Positive employee attitude, cooperation, open-mindedness
14
35
2. Patient safety, quality of care, hard work of employees
12
30
Category
3. Supportive management attitudes
7
17.5
4. Supportive management attitudes
5
12.5
5. Inservice, education, available resources
2
5
Note. Thirty-five of the 42 respondents (83%) yielded 40 comments and seven
respondents (17%) left the comment section blank.
33
In the category of effective communication and follow through, five responses
were written that pertained to these factors. The two least mentioned factors were
those that pertained to inservice, education, and availability of resources. Seven
respondents left this comment section blank.
Trends were also noted in the factors that the nursing staff members felt
hindered the successful implementation of the change process. The sample
population comments (Appendix F) were summarized and grouped under five
categories as displayed in Table 8. The most prevalent (17) comments noted were
those that pertained to lack of patient safety, poor quality of care and staffing
issues. Fifteen comments pertained to poor communication, lack of employee
input, and poor planning. Comments relating to a mistrust of upper management
and negative administrative attitudes accounted for ten of the total responses.
Eight responses related to negative employee attitudes and two responses
pertained to lack of inservice and education programs prior to implementation of
change. Two respondents left this comment section blank.
Summary
In summary, more nursing staff participants believed changes within their
organization were not successful. The participants’ comments were analyzed and
summarized revealing that the majority of participants from all of the groups
believed patient care, safety, quality of care, attitude, staffing, planning, and
communication were among the most important factors affecting the change
process. Correlational trending was identified with attitudinal and organizational
34
Table 8
Respondents Comments Concerning Factors that Hindered Successful Change
Process
Category
f
%
1. Lack of patient safety, poor quality of care, and staffing issues
17
33
2. Poor communication, lack of employee input, poor planning
15
29
3. Negative administrative attitudes, mistrust of upper management
10
19
4. Negative employee attitudes
8
15
5. Lack of inservice, and education programs prior to change
2
4
Note. Forty of 42 respondents (95%) wrote 52 comments and two respondents
(5%) left the comment section blank.
support scores, however, a level of significance was not obtained. Additionally,
there was no significant difference between or within the groups’ attitudinal and
organizational support scores.
35
Chapter V
Discussion and Recommendations
Few references were found in the literature that addressed nursing staff
attitudes toward the process of change. This study was undertaken to explore
nursing staff attitudes towards the process of change and determine the
relationship between attitude and organizational support. A survey questionnaire
was used to examine and measure nursing staff attitudes and support for the
organization’s strategic direction. The participants were asked about their
perceptions of the effectiveness of organizational change and their perception of
the organization’s commitment to address employees’ needs during change.
Nursing staff participants were asked: Overall, do you feel that the changes that
have taken place in your organization have been successful? Two additional
questions requested nursing staff participants to document what they felt had
helped or hindered the success of the changes within their organization.
Discussion
The research questions addressed by this study were: a) What is the
relationship between nursing staff members who have positive or negative
attitudes towards the change process and their support or nonsupport for the
organization’s strategic direction? b) Are there any differences in attitudes
towards the change process and degree of organizational support among nursing
staff members with different licensure status? c) What are the perceived factors
identified by nursing staff members that helped or hindered the successful change
36
process within the organization? The sample group for this study consisted of
forty-two nursing staff members employed as registered nurses, licensed practical
nurses, or unlicensed assistive personnel in two acute care rural hospitals in
northwestern Pennsylvania.
Relationship Between Attitudes and Organizational Support
The attitudinal mean scores in each nursing group were compared to the
organizational support scores and a 2x3 ANOVA was performed between and
within the groups. The ANOVA was greater than the .05 level of significance,
therefore, there was no significant difference between the groups’ attitudinal and
organizational support scores. However, the results showed a high level of
agreement existed with each group’s attitudinal and organizational support
responses.
Relationship trending was identified in that in each of the three nursing
staff groups, those participants with positive attitudes tended to show favorable
support for the organization’s strategic direction, while those with negative
attitudes tended to show less favorable organizational support. However, this
trending did not reach a level of significance in this research study.
Licensure Status Comparison
In answering the second research question, the analysis of the Pearson’s r
revealed that the registered nurses, licensed practical nurses, and the unlicensed
assistive personnel groups tended to have scores that correlated positive attitudes
with organizational support as well as negative attitudes that correlated with less
37
support or nonsupport of the organization’s strategic direction. Therefore, there
was congruity within the groups. However, the results of the analysis of variance
showed that there were no significant differences between the attitudinal scores
and the organizational support scores between or within the groups.
Factors Identified that Helped or Hindered Organizational Success
After reviewing and summarizing the sample population comments, many
remarks were noted to be consistent with Allport’s (1935) theory on attitude and
change. Allport wrote that an attitude is a mental and neural state of readiness,
just as several employees wrote that it was difficult to accept change if they were
not aware that change was coming and did not feel ready to accept the change.
Many respondents wrote about the importance of communication from
administration. Many nursing staff members indicated they would have been
more willing to accept change and to be more supportive if they had been
informed and given time to be ready for the change. Respondents also wrote that
more inservice and education programs would have helped prepare them for the
change process. They perceived that an educational component would have
helped increase their awareness and knowledge about the changes, which in turn,
would have helped to ensure safe, quality care for patients. Patient safety, quality
of care and staffing were the most prevalent factors mentioned by the respondents.
Nursing staff respondents felt change in their organization would have
been more successful if they had been recognized and appreciated for the good job
they were doing. Hovland, Janis, and Kelley (1953) wrote about a theory on
38
attitude change. The theory is oriented towards the effect of persuasive
communication and the importance of changing attitudes with the presence or
absence of rewards. While the rewards of being appreciated and being recognized
may not be tangible, they seemed to be an important factor that the sample
population believed would have led to more positive outcomes.
This study, like Gaertner’s (1989), found that overcoming resistance to
change includes things such as employee participation, communication, and
education. These efforts are useful for helping employees understand the meaning
of change and for gaining acceptance of the change. A few final points are
noteworthy. The strongest correlates of successful change efforts within the
organization were perceived by this study sample to be commitment to quality
patient care, patient safety, communication adequacy, and concern for people.
This study represents only a beginning in our understanding of the ways in
which attitudes toward the process of change are interpreted, and organizational
support given, by nursing staff members. The researcher’s sample was relatively
small and only from two hospitals, so it cannot be presumed that the results are
generalizable. Moreover, this study showed only attitudinal evidence of support
for the strategy, not behavioral evidence. The results, however, are indicative of
the need to further explore the effects of attitudes during periods of substantial
organizational change.
39
Implications for Nurse Administrators
Based on the results of this study, the following recommendations are
made to nurse administrators and nurse leaders that will be going through a
change process.
1. Nurse administrators should create an atmosphere that conveys quality
patient care and positive patient outcomes as priorities.
2. Administration and nursing leaders should conduct regular staff
meetings to communicate the proposed changes, then follow up with regular
progress reports. Provide as much positive feedback as possible.
3. Nursing staff members should be included in the planning and
implementation of the proposed change process to create a “buy-in” by
employees.
4. Inservice education programs, designed to meet the needs of the staff in
relation to the particular type of change they will be encountering, should be
developed and presented.
Recommendations for Further Research
Further research is needed to investigate the most appropriate, effective
way to manage nursing staff attitudes towards the process of change. Based on
the results of this study, the following recommendations are made.
1. The study should be replicated using a larger sample size and more
hospitals in other geographic locations.
40
2. Comparison studies are recommended to examine attitudes and
organizational support before and after implementation of any change process.
3. The questionnaire should be revised to replace the three separate
comment sections with one comment section available at the end of the
questionnaire. This revision would eliminate the redundant remarks written under
each of the comment sections yet still provide an opportunity for the participants
to further respond. The comment section provides valuable information to the
researcher and gains further insight from the participant’s perspective regarding
the change process.
4. Utilizing results from this study, develop a check list of predetermined
categories that identify factors that helped and factors that hindered the change
process. Participants should be instructed to prioritize the importance of each
factor. Additional comments could be written in the comment section for further
analysis on the successful change process.
Summary
This study suggests that nursing staff members experiencing change within
their organization have a need to be informed and to be kept informed of the
process. An important aspect in a successful change process is keeping the focus
on the patient. Much planning and organization should be in place prior to
implementing any change. The study determined that employees with positive
attitudes were more likely to accept change and support the organization s
strategic direction. Conversely, negative attitudes resulted in less support or
41
nonsupport of the organization’s strategic plan. However, these findings did not
reach a level of significance.
The study population and the literature agree: maintaining quality patient
care as the focus throughout the change process is an important factor if nursing
staff employees are to perceive changes as being successful within their
organizations. Another key strategy that these research findings support is
allowing those affected to be active participants from the very beginning (Doerge
& Hagenow, 1995). Administrators and nurse managers need to ensure effective
two-way communications while fostering positive attitudes to guide and support
nursing staff employees through the dynamics of the change process. Finally,
administrators and nurse managers must keep positive interventions in mind when
planning any change process. Successful outcomes are dependent on these highly
meaningful points.
42
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46
Appendix A
Letter to Vice Presidents
3/2/98
Vice President Patient Care Services
Dear
Thank you for volunteering to spend a few minutes of your time distributing the enclosed
questionnaires. Please distribute the questionnaires randomly among your Registered Nurses,
Licensed Practical Nurses and unlicensed assistive personnel on each shift. The questionnaire is part
of a research study, titled “Evaluating Nursing Staff Attitudes Toward the Process of Change” being
supervised by Dr. Judith Schilling, at Edinboro University of Pennsylvania. The study is in partial
fulfillment of the requirements for my Master’s degree in nursing.
The purpose of the research project is to evaluate nursing staff attitudes to determine what
factors enhance or inhibit hospital redesign, reengineering, or restructuring efforts.
This survey is not an evaluation of your hospital nor of your orientation or communication
programs, and will only be used for research purposes. All responses will remain confidential and
only grouped data will be reported. My target population for the study is nursing staff members that
provide direct patient care. Participants are being instructed to complete the questionnaire, place it in
the attached self-addressed stamped envelope and mail directly to me before March 15, 1998. If you
are interested in the results of the study, please contact me.
Again, thank you for your time and assistance. I truly appreciate your help in this
undertaking. If you have any questions, I can be reached at either (814) 589-5138 (home) or (814)
827-1851 (work).
Sincerely,
Ronda Anderson, RN, BSN, CNA
RD # 2 Box 154 A
Titusville, PA 16354
47
Appendix B
Participant Cover letter
March 2,1998
Dear Participant,
I would greatly appreciate your assistance in completing the attached questionnaire. This
survey is being conducted in partial fulfillment of the requirements to complete the Master of Science
in Nursing degree at Edinboro University.
The purpose of the research study is to evaluate nursing staff attitudes toward the process of
change in order to determine what factors enhance or inhibit a hospital’s restructuring, redesign, or
reorganizational efforts. Your name has been randomly selected to participate, and your participation
is completely voluntary. Please be assured that all individual responses are anonymous and will be
kept completely confidential. Only grouped data will be reported.
Please answer all the questions and place the completed questionnaire in the attached self
addressed stamped envelope. Seal it and mail before March 15,1998.
Your responses and interest are appreciated; be assured that your contribution will add value
to this study. Thank you.
Sincerely,
Ronda Anderson, RN, BSN, CNA
RD # 2 Box 154 A
Titusville, PA 16354
48
Appendix C
Research Questionnaire
DEMOGRAPHIC INFORMATION
Please complete the following information. Do not write your name on this
questionnaire. Your responses will remain confidential.
1.
Please indicate your sex:
Male
Female
2.
Your present age is:
29 or under
30 to 39
40 to 49
50 to 64
65 or over
3.
What is your current licensed or unlicensed status?
Unlicensed Assistive Personnel
L.P.N.
R.N.
Other (Describe):
4.
Which best describes the most recent time your organization
or unit experienced change (work redesign, restructuring, reengineering,
layoffs, increased patient assignment, or decreased staffing)?
Experiencing changes now or wit
Experienced change 7-12 months ago
~ Experienced change 1 - 3 years ago
Experienced no change
Please turn to next page
49
page 2 of 3
°F THE
ORGANIZATION'S COMMITMENT TO ADDRESS
CHANGE. PLEASE CIRCLE THE pSSE?™™8 DUWNG A
FEELINGS TOWARD ORGANIZATIONAL CHANGR ™AT MST DESCRIBES YOUR OWN
* For the purposes of this survey, “change” is used to denote any type of restructuring,
reorganization, reengineering, layoffs, increased patient assignment, or decreased staffing
within your organization. (1) INDICATES THAT YOU STRONGLY AGREE WITH
THE STATEMENT AND (7) INDICATES THAT YOU STRONGLY DISAGREE
WITH THE STATEMENT.
5.
The changes necessary to keep this organization competitive have been
implemented with enough consideration given to employees.
1
Strongly
Agree
6.
3
2
4
5
6
7
Strongly
Disagree
When changes are made in this organization, the employees usually lose
out in the end.
1
Strongly
Agree
3
2
4
5
6
7
Strongly
Disagree
I think that changes in this organization tend to work well.
7.
1
Strongly
Agree
2
3
4
5
6
7
Strongly
Disagree
Changes in this organization always seem to create more problems than
they solve.
8.
1
Strongly
Agree
9.
I am
1
Strongly
Agree
10.
3
4
5
6
7
Strongly
Disagree
encouraged by the direction I see this organization taking today.
2
This organization
1
Strongly
Agree
11.
2
2
3
4
5
6
7
Strongly
Disagree
has chosen a strategic direction that is going to be a winner.
3
4
5
6
7
Strongly
Disagree
6
7
Strongly
Disagree
This organization’s future does not look bright.
1
Strongly
Agree
2
3
4
5
50
page 3 of 3
PLEASE ANSWER THE REMAINING THREE QUESTIONS.
12.
Overall, do you feel that the changes that have taken place in your
organization
successful?
As
changes inhave
yourbeen
organization
have taken place, what do you feel
helped make these changes successful?
Yes
No
Comments:
13.
14.
As changes in your organization have taken place, what do you feel
hindered the success of these changes?
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS
SURVEY. PLEASE PLACE YOUR COMPLETED SURVEY IN
THE ATTACHED SELF-ADDRESSED STAMPED ENVELOPE
AND MAIL DIRECTLY TO ME BY MARCH 15,1998-
51
Appendix D
List of Respondents Exact Comments Concerning Changes in their Organization:
1. Pt care seems to be the least concern, decreased staffing = increased stress
2. I answer yes to the major changes but the smaller changes that are made
interdepartmentally do not seem to go smooth or even work at the end. Not
enough though process before implementing.
3. The unit I work on is comprised of highly skilled nurses but since we are well
organized and work as a team, we are the last to get any assistance. As for the
majority of the organization - too management heavy.
4. Due to excellent staff participation and desire to help the organization survive.
5. Changes in middle managers have given both middle and upper management a
more overall perspective. However, changes on a staff level have been
sporadic & appear unorganized & not thoroughly thought through.
6. Its hard work because nobody wants to change even though everyone thinks
things should change.
7. For hospitals to survive - changes are a necessity, it has caused heavier work
load, less help.
8. However, question the changes due to quality patient care.
9. Changes have been successful but have taken much time for employees to
adjust to the changes.
io. Lack of two way communication has hindered any progress.
52
11. It’s the people who never have pt contact making the staffing decisions,
sometimes even accounting decides the ratio or whether we need a secretary or
not.
12. We went to a new computer system a couple of years ago- not user friendly-
caused nothing but gnef. Also when they downsized a couple of yrs ago
didn’t feel they gave enough notice and didn’t ask for input from staff.
13. Not enough staff, make cuts which don’t directly involve pt care!
14. 80% of the changes seem to take place to the nursing staffs being cut and the
patient load higher. Therefore the quality of care suffers and the patients
aren’t satisfied with their care.
15. Pts wonder if they have a nurse! Excessively high stress levels for staff leads
to less efficiency, greater job dissatisfaction, less loyalty to hospital
organization, less willingness to participate in implementation of new
programs.
16. Example - the closing of expresscare (where minor pts are seen) was done
without adding the appropriate physical space or staff. Prior to expresscare
closing our ER census increased from 16,000 to 21,000 without any
readjustment in staffing or space. Then attempting to see an increase in
volume with 1 physician & 1 nurse practicionier.
17. Changes have resulted in fewer direct care givers, poorer quality care & an
inability to flex up to meet increased census or acuity penods.
53
18. Decreased staff lead to poor pt care - as evidenced by what the community is
saying.
19. They have lost good work that go elsewhere - people have lost jobs.
20.1 think pt. care has decreased, less staff with the same amt. of pts., then with
computer charting, the problems were compounded.
21. The decrease in staff has not benefited the patient care, many patients and
family are dissatisfied and angry.
22. Low morale throughout work place, numerous injuries due to decreased staff,
increased stress, increased workload, pt safety has become a big issue due to
decreased staff, decreased restraint useage, unable to monitor pt due to
workload increases.
23. Valued LPNs have lost their jobs - then management saw it did not work &
had to hire inexperienced LPNs.
24.1 don’t know if you can call them successful or not. They cut nursing bad and
its the patients that suffer with poor care and tired nurses. I think cuts can be
done elsewhere in the organization that don’t affect pt care so badly. Overall
yes this organization will make $, but at what expense.
25. It has caused a lot of hard feelings with staff towards adm. which effects the
pts in the long run.
26. We work a lot of days under our recommended no. of nurses. Our LPNs were
decreased when we still need them. Their jobs were put up for bid.
54
27. Recently closed xpress care & placed all xpress/er pts in same unit but added
no extra space or beds to accomadate additional pts. Added LPN instead of
RN & a Nurse Practioner instead of MD to help with increased volume.
55
Appendix E
List of Respondents Exact Comments Concerning Perceived Factors that Helped
the Successful Change Process:
1. The employee attitude
2. people working together
3. Attitude of employees/considerate attitude of administration
4. Staff cooperation
5. We’re threatened: “Be thankful you have a job...” Economics force me to stay.
6. Cooperation, willingness to be able to change
7. Managers informing staff. & Senior management having meetings with staff,
8. On my department level - it has been my immediate supervisor. As an
organization as a whole, the help has been sparse.
9. Staff willingness to work together toward common goal. Staff willing and
able to maintain positive attitudes.
10. Individual sacrifice
11. Administrative - manager - employee meetings (informative), Seeing the
positive growth.
12. Understanding administrative decisions.
13. The positive attitudes of the staff.
56
14. Staffs’ positive attitudes toward quality care. Hospital has tried to spread the
“bad news” re: lay-off or less work time over more staff to minimize impact
on a few people.
15. The hard work of the employees
16. The staff has helped each other out - We had to overlook a lot of our faults,
work together even more, maintain good attitudes.
17. The changes just took place and you either adapted or not. They really didn’t
care. They were out to do what they thought needed done. Again, its the
patients that suffer and overworked nurses working doubles, OT, Bonus. So
they decrease staff to save $ But staff is burning out. Can we consider
ourselves successful with increased pts complaints and the public feeling
unsafe here!
18. Many RNs and LPNs worked overtime, on their days off etc. Rns working
“bonus” weekends. If no one would have been willing to work extra - it would
have been unsafe!
19. Our changes haven’t been successful, should be able to change in other areas
without decreasing safety and quality of patient care. Too many adm.
personnel, too little staff to provide pt. care.
20. Staff willing to work very hard with less and to give up days off including
weekends and holidays to make sure pts get safe quality care.
57
21. The ability of the staff to pick up the slack, to work overtime to help maintain
pt. care standards.
22. Mgmt, asking for employees’ buy-in, opinions.
23. Employees extend themselves (especially nursing) to make things go well for
the patients. Some are fearful of speaking out.
24. Nurses working 12 hour shifts without lunch or supper, overtime, increased pt
census leading to poor pt care, unsafe conditions regarding the ratio of acute
care pts to nursing staff.
25. The do it or else attitude of the supervisors, etc...
26. When there is more staff involvement. Honesty from management.
27. Nothing since it seems as if it is a catch up situation.
28. Helped by determination of employees to make it work. The positive attitudes
had to “carry” the negative reactions. Many times it seemed the negatives
were winning.
29. Cooperation of the employees to maintain quality of care.
30. Supportive management attitudes
31. Inservice, follow thru with plans and communication of changes
32. Instituted inservices on new policy changes in restraint care to aide staff on
proper use and proper procedure.
33. Maintaining a positive attitude.
34. Cooperation and open-mindedness of employees and management.
58
35. Good attitudes and being open minded.
59
Appendix F
List of Respondents Exact Comments Concerning Perceived Factors That
Hindered the Successful Change Process:
1. A larger workload on fewer workers.
2. Lack of follow thru, (no note usual progress), lack of contact with updates of
progress.
3. Always the nursing department, more work, less money!
4. Expectations greater than humanly possible; not putting patients need first;
lack of staff involvement in decisions prior to implementing.
5. To much management people not enough workers to take care of patients.
6. Negative attitudes of employees
7. Negative attitudes always are the biggest hinderance to any change. An
unwillingness to try change is also a hinderance. Patients are no longer people
with feelings & problems but are now seen as “money” - & blame most of this
on the HMO’s & regulations. Without reimbursement for the care provided it
is very difficult for any organization to provide quality care.
8. Lack of communication to inform reasons for change and obtaining input from
all that it effects - Poor time frame of implementation.
9. Not really caring for pt care; only the bottom line. Administration making
decisions, we aren’t listened to, they don’t worry about liability and safety,
only money.
60
10. A sense of mistrust and betrayal by the management.
11. Not taking in the consideration once again on pt. care! and staffing!
12. Stress of change, being overworked, feeling guilty about the poor quality of
patient care.
13. Poor planning without any insight, no consulting of experienced nursing staff
regarding their input, ideas.
14. Resistance to change, special interest groups, lack of skills, haste, poor
planning.
15. Not including the workers in the decision-making, those who actually do the
work!
16. They have used number systems to rate the amt of staff needed; whether your
census calls for 2 RNs or 5 RNs - you only get 2 RNs (Rarely get what’s
called for).
17. There seems to be far too many administrative persons that really do not
realize the work load of the staff. They have week-end and all holidays off,
and never need to do shift work. They also get a yearly bonus. This really
doesn’t seem fair. (Poor administrative attitudes).
18. Total disregard for fairness and respect to employees, looking at financial gain
only, poor adm management.
61
19. Too much change all at 1 time - loss of employees - switch to computerized
charting, you get overwhelmed. Not enough staff to cover all shifts, working
too many hours.
20. Rarely looking at the bottom line. Management just tells us what we are doing
wrong. To answer this question honestly: Mistrust of upper management.
21. Administration being self centered & not looking out for lower positions!
22. Not being truthful with us or involving us in the change before it happened -
we prepared for one way of change and a totally different way was thrown at
us.
23. Adm. worries about cost and not quality of care - Nurses have a freeze on all
education except mandatories (ACLS) & step raises for seniority were done
away with. Organization can’t be successful when they don’t view
experienced RN’s as a valuable comodity.
24. Management made the decisions without involving the actual personnel
involved for input so could be workable and employees feel better about
decisions.
25. Could have used a more participatory management approach/more actively
involve staff.
26. The negative attitudes.
62
27. Negative attitudes, the cut & dry coldness of mandatory job position changes.
Statements such as : “This is the way it has to be either take the job that’s
offered to you or you don’t have a job”
28. Changes are made in a fragmented way with little planning and management
acting as if they really don’t know what is really going on - when they really
do!
29. Not enough administration change with staff changes, not enough staff. Lack
of open communication within the organization.
30. The lack of communication & explanation of changes to be made or
implemented is staggering. Staff is told days before changes are made. There
is little follow up done after changes are made. There needs to be more
advanced education re: changes. There was also no acknowledgement of staff
concerns re: changes. Staff was told only of changes specific to them & not
institution-wide changes.
31. Staff negative attitudes. Everyone thinks change should be perfect with no
disruption but its not possible. Thanks.
32. Failure of employees to realize change will occur, we need to try to understand
them to adjust to changes.
33. No input from those affected
34. Nurses were only told that they were going to happen, their opinions were not
sought
63
35. The changes themselves (itself) if they compromised pt care or staff
perceptions of decreased care.
36. Resources available when changes made
37. Peoples unwillingness to change.
38. Management not knowing or caring to listen to the workers
39. Lack of pt safety concerns, less staff - more work!
40. Increased workload for staff, increased week-end work and on-call
assignments.