The Themes Have to Be Considered in the Change Process Within Healthcare Organizations: Critical Analysis Review

Background

As healthcare organizations work in environments that are always changing, measuring change attitudes is necessary to address the climate of change and positively affect implementation processes. Because healthcare workers and managers are under a lot of stress and have a lot of work to do, measuring change attitudes in healthcare settings is challenging.¹

Change, as the phrase goes, is the only constant in healthcare institutions. Technological improvements, shifting illness patterns and novel discoveries in disease treatment necessitate virtually constant change in healthcare institutions and practitioners.² Change can be unacceptable in general because it contradicts people’s intrinsic demand for a stable situation. Ambiguity about how changes would affect employees’ psychological condition, their work circumstances, job, and overall life has been linked to organizational changes.³ Organizational adaptations are also expected to reflect shifting cultural norms and beliefs, which have resulted in increased expectations for enhancing patient outcomes and increasing patient involvement in care decision-making.⁴ Policy decisions are also linked to organizational changes affecting healthcare personnel. Nonetheless, reduced organizational commitment, loss of productivity, work-related stress, emotional tiredness, change fatigue, and horrible self-health are all well-documented outcomes of high rates of organizational change, as measured by a variety of metrics.⁵

Many healthcare organizational reforms fail to meet their objectives because of the context-dependent nature of change, issues with criteria and measurement, and achievement or failure levels that can be clashed. In addition to these, other contextual considerations also put pressure on the major players in health systems, whether at the micro, meso, or macro level, to embrace system-wide transformations and make significant changes. Environmental pressure, the quality and integrity of the policies, the role of important change leaders, the alignment of the change agenda with the local context, and the clarity of organizational goals and priorities are some of these aspects. These constantly interconnected characteristics emphasize how crucial organizational, institutional, and political components are to being open to change.⁶

However, without properly addressing the particular challenges of healthcare settings, a large number of earlier studies on organizational change relied on generalized management ideas. Healthcare organizations, in contrast to other industries, are subject to stringent regulatory frameworks, ethical considerations, and patient-centered care models. Furthermore, standard change management models do not adequately account for the difficulties presented by elements like multidisciplinary teamwork, shifting stakeholder objectives, and erratic patient needs. Because of this, current research frequently fails to offer customized approaches that take into account the realities of healthcare institutions.

Thus, this critical analysis review is intended to scrutinize all study types shown between 2000 and 2023 that were conducted to encourage and understand change as a complex topic in healthcare organizations and to offer a framework that can be more extensive and realistic for the delivery of healthcare. This issue is addressed by offering a comprehensive assessment of the literature on the subject. The critical analysis literature review is a type of research that examines, evaluates, and composes representative literature on a topic in order to provide new frameworks and perspectives on the subject.^7,8 This strategy is especially useful when existing research is dispersed across multiple fields and has not been thoroughly analyzed and integrated such as the literature on the change in healthcare organizations and the considered themes. This literature was analyzed and combined into a new study agenda that provides a comprehensive view of the subject.⁹

Methodology

An electronic search of healthcare organizations was undertaken, as well as title of “change” in three databases. The PubMed, Google Scholar, and EBSCOhost databases were used to conduct searches. The terms “health care” and “organization”, as well as the key term “change”, were searched in the articles’ titles. These terms were determined as the most important terms to utilize in regard to the study’s aim. Articles were limited to those published in English between 2000 and 2023, with duplicates eliminated. For all academic investigations, a comprehensive search for peer-reviewed literature was done.

Three major inclusion criteria were assumed (Figure 1):

• Published articles papers
• Papers with full-text access opportunity
• Papers written in English language

Figure 1 Prisma Flow Chart of the Review Search.

Studies that did not match the inclusion criteria were excluded, while those that did meet the requirements were identified and studied further. The results of the studies were assessed and analyzed critically. Each of the research included in this review (Table 1) yielded the following data: Title, authors, and year of publication, country, research aim, study design, and key findings.

Table 1 A Summary of Reviewed Studies

Inclusion and Exclusion Criteria

The author individually evaluated each article’s title, abstract, and content at each stage of the review. In the first stage, articles without the defined change terms were excluded. The second stage was utilized to narrow down the papers to those that addressed the study’s main goal. During the third stage, publications where the abstracts were insufficient to determine the article’s criteria were excluded.

Analytic Strategy

The data was examined by taking into account the aims, designs and findings of the research that were reviewed. No specific concept of change definition is adopted in this study, as the author desires to review and analyze all the possible used themes of change process within healthcare organizations. Using the primary findings as a guide, descriptions of change determinants were first retrieved, and the ways in which these factors impacted healthcare organizations were recognized and summarized. The author revised the included articles for 3 times then categorized the data and then incorporated it into themes based on shared meanings and major issues. Figure 2 shows an overview of six categories and two additional themes that have been developed.

Figure 2 Integrated framework for change in healthcare organizations (Strategic dimensions include experiences and metaphors. Process dimensions include readiness, tangible factors, intangible factors, teambuilding and technology. Outcome is the scale of change). This framework is developed by the author.

Concepts of Change in the Context of the Reviewed Articles

The articles focused on diverse concepts of change and also on different methods on the topic. The articles emphasized on change readiness assessment,¹⁰ external change agents,¹¹ large-scale change,¹² the most relevant factors that is necessary to manage and presents how change occurs,^13,14 previous used models of change,^15,16 evaluation of the psychometric characteristics of change measurement,¹⁷ the progress and success and characteristics of successful changes and why necessary change has not occurred, explain change strategies; failures and successes,^18–21 organizational actors bounce sense to their emotions in change,²² healthcare staffs’ experiences of policy change and the experiences of nurses and primary care groups,^23,24 design the training program,²⁵ investigation staff attitudes towards the merger change,²⁶ the macro-level of organizational change,¹⁴ and how accreditation process helps introduce organizational changes.²⁷

Main Themes for Change Framework in Healthcare Organizations

The author after the review analysis, divided the most closely related themes into two categories: 1) process dimensions: change readiness, change scale (measurement), staff tangible and intangible factors (attitudes and emotions), team-building and technology; and 2) strategic dimensions: change metaphors, experiences and time.

Results

Our searches in the EBSCOhost, Google Scholar, and PubMed databases yielded a total of 234 results. After reading titles, abstracts, and removing duplicates, 203 articles were chosen for full-text reading. Then, 184 articles were excluded and only 19 publications that fulfilled the previously specified inclusion criteria were included in this evaluation. The process of studies identification for the review is depicted in Figure 1. Table 1 shows the results of the investigation of the articles’ descriptions and related information. Finally, selected studies’ analyzed themes were integrated into framework for change (Figure 2).

Characterization of Articles Included in the Review

In the previous 24 years, twenty articles on this issue have been discovered, indicating that publishing studies on more precise and complete healthcare organizations’ frameworks to change processes is still in its early stages around the world. The publications took place between 2000 and 2023 throughout the study period.

Among 19 included studies, four were undertaken in the United States and the United Kingdom, three in Canada and Sweden, one in Taiwan, and one each in Pakistan, Nigeria, Italy, and Germany. Eight studies were qualitative^{15,17,18,20,22,23} or quantitative^14,15 or mixed.²¹ Four articles were reviews,^11,25,26,28 two were case studies,^19,24 one was approach design,¹³ one was a multi-phase strategy,¹⁰ one was several contemporary theories²⁷ and one was a perspective article.¹² The research covered a wide range of healthcare settings. Ten studies were conducted in multiple settings, five studies in hospitals and three studies in primary care settings.

Theoretically, this study adds to the existing literature by examining fluctuating passions during radical transformational change. It also exhibits the lens of responses as a “resource” for understanding the microprocesses involved in the change process by highlighting the key difficulties. Thus, professionally initiated changes were thought to be the easiest to implement and were rarely challenged and also changes that were made public where preparation could begin, improved the chances of success.

Process Dimensions

The Organizational and the Individual Level Change Readiness

According to research,²⁹ readiness for change is a key factor in successful implementation. It is a psychological condition in which organizational members feel committed to achieving an organizational change and confidence in their collective skills to accomplish that.³⁰ The idea of change readiness is defined as a multilayer concept and metric (individual, group, or organizational level) with multiple operationalizations (eg, attitude, behavior, culture).²⁰

Organizational change readiness is determined by four underlying constructs that combine to determine an organization’s readiness to adopt a change intervention;³¹ 1. Individual psychological factors that show the extent to which people hold key ideas about the possibility of change; 2. Individual structural factors that are relevant to the individual’s knowledge and ability to execute when the change is implemented; 3. Organizational psychological factors relevant ideas about the collective commitment and efficacy of organizational members; 4. Organizational structure; human and quantifiable resources, communication routes, and formal policy issues.⁹

Aspects of abilities and willingness – at the individual, group, or organizational level – are indicators of change preparedness. Both levels and facets are interconnected and affected by one another.^29,30 Yet, much research suggests that leaders’ attitudes regarding change may not always match those of their staff.³² It is critical to analyze attitudes toward change from several viewpoints in order to understand and successfully execute innovations in healthcare organizations.³²

Moreover, when viewing change preparedness as the main concern that increases the possibility of successful implementation, one of the most crucial characteristics is organizational members’ attitudes toward change.²⁹ The attitudes of individuals toward change have been highlighted as a facilitator or an obstacle to successful implementation.²⁹

Experts believe that when an organization’s readiness for change is strong, people are more invested in the change endeavor, put forth more effort in the change process, and show greater persistence in the face of setbacks—all of which lead to more successful change implementation.³² Thus, purposeful interventional activities can improve and stimulate people’s readiness for change.

Tangible and Intangible Variables to Accept Change

There are two primary ways for encouraging core human resources to accept change and support healthcare organizations’ goals. The former is founded on tangible variables (human resources, material resources and informational resources), whereas the latter is built on intangible variables. Organizational culture, communication and leadership are the topics of the second technique. Negotiation, contracting and sharing corporate values are all important aspects of intellectual capital. The commitment of the personnel to efficient implementation of the organization strategy is predicated on their consensus on the healthcare unit’s aims. Human resources must be secure, involved and challenged when it comes to organizational values sharing.³³

The tangible method is based on remuneration for accomplished effectiveness, whereas the intangible method is based on a psychological approach to team management. Successful organizations now change their corporate culture³⁴ based on an understanding of their internal and operational environments. This might also work in a healthcare setting because the internal organizational structure changes frequently, producing new bottom-up patterns. Managers find it difficult to track employee performance since healthcare services are intangible (unmeasurable). As a result, the best answer is to train employees to be completely competent in monitoring their own performance. Internal coordinators must also assist employees in completing their tasks.³⁵

External change agents that discussed in article¹¹ are critical to many implementation techniques in the study literature of organizational change in healthcare. Often, the external change agent is the one in charge of executing the implementation strategy, and is mostly accountable for sticking to the plan and completing the required organizational change.¹⁰ To support quality improvement, organizations can utilize a variety of levers and processes to translate evolving external and internal inputs³⁶ and implementing organizational quality improvement strategy that can help organizations measure and monitor performance with suitable data.³⁶

Finally, well-balanced management of core properties, both tangible and intangible, is intended to enable the greatest exhibition and cope with obstacles and changes, even if it necessitates a complex and likely costly reengineering of all healthcare organizations’ components.

Team-Building for the Change Process

Studies^18,19,23 found that the leader/manager is in charge of planning, coordinating and monitoring the operations of the group, as well as communicating a vision and encouraging team participation.³⁷ In order to qualify group dynamics principles to team development, it is critical for the leader/manager to grasp them.³⁸ Setting clear goals and priorities is critical to the overall success of a transformational change program because it fosters a favorable organizational culture and helpful inter-organizational networks.

Team-building originally intended to improve individual relations and social interactions as a collaborative learning intervention (eg, Schein³⁹), likewise team-building has developed to include a focus on obtaining results, fulfilling goals, and completing tasks.⁴⁰ There is generally widespread agreement that there are four basic models of team development. The models include goal-setting, strengthening interpersonal relationships, clarifying responsibilities, and increasing problem-solving capacity, however mixtures of these approaches are typical action.⁴¹

To develop a great work atmosphere, you must first build a successful team. Team-building tasks must be repeated on a regular basis; nevertheless, the leader/manager must cultivate personal relationships and encourage staff to communicate effectively. A managerial goal should be well-identified to develop communication skills. Team members will feel more secure addressing concerns among themselves, solving problems collaboratively, and settling disagreements as inter-staff communication improves.⁴²

Scale of the Needed Change

Studies^12,15,17,22 considered the scale of the needed change. Previously, organizational capacity for change was described as a mixture of management and organizational characteristics that enables an organization to adjust to changing situations more rapidly and effectively than its competitors.⁴³ However, according to Shea et al,⁴⁴ the healthcare sector may benefit from a more comprehensive, specialized, valid, reliable, and standardized method to evaluate change implementation that is adapted to the many unique issues that healthcare organizations encounter.⁴⁵ However, from the reviewed studies^43–45 the author can conclude that the organizational change was assessed using three inquiries that rate the impact of various events (changes) on their organization; (1) management changes, (2) rearrangement, and (3) the formation of new general goals and plans.

Understanding the Impact of Technology on Change

The included studies^13,15 showed that the new technology will frequently alter how occupations and activities are completed, as well as the scope of organizational supervision and coordination. Changes brought on by new technologies would necessitate changes in healthcare organizational practice and design. The use of technical tools for conveying, storing, and managing shared data is critical in the implementation of organizational change. Susanto⁴⁶ considered the organization’s competitive advantage, market position and technological developments and concluded that technological innovation would lead to effective change implementation.

Managing change in a complicated institution (where there are heterogeneous processes) is no different, for example, than managing change in a multifaceted institution (where different services are produced) in general. Defining and supporting; creating an appealing change narrative; helping employees to comprehend and adopt change through engagement, learning, and continuing support; and connecting change to existing processes to stimulate good performance are all critical elements that must be addressed. As technology solutions supplant and automate procedures, healthcare workers’ functional life becomes more rewarding and joyful, allowing them to spend more time with patients while decreasing inefficiency and operational duplication.

Strategic Dimensions

The Factor of Time

The significance of time demonstrated in the study of healthcare change.²⁴ According to Lee and Liebenau,⁴⁷ another key criterion for separating organizational studies that deal with the chronological issue is how they classify the key role of time. Time is considered as a separate variable in some research, with the goal of understanding how several timing elements interact within individual actions, groups, and organizations. This study of change has revealed that time is not a simple linear term, but rather a multidimensional one that is more appropriate for healthcare as a dynamic process. In addition, it has determined which improvements are complementary enough; to make a difference on a broader scale; necessitates timing judgments.⁴⁸ While top management may have time plans in place for implementing changes across the healthcare organizations, this might change as individuals and groups work on their own agendas.

Teams can reduce disruption in the implementation of change projects that can undermine the anticipated gains.⁴⁹ The need to bridge the gap between abstract theorization and empirically based studies in order to produce time-sensitive explanations remains a major challenge for organizational change management’s scholars. Thus, Du Gay and Vikkels50 argue that grounding theoretical perspectives does provide a useful positive alternative in bringing attention to what they call “the lost specification of change”.⁵⁰

Researchers cannot assume that everyone will notice when the time is ripe for a change or that everyone will be ready for change at the same time.⁵¹ Individuals have different viewpoints on time, as well as how they interpret and value time has an impact on the change actions they choose.⁵² A person with a short time perspective, for example, will prefer actions that create change quickly, as opposed to someone with a longer period perspective who is concerned with long-term consequences.⁵² However, various cultures have established certain times for certain events to occur and how long they can last. Working cross-culturally entails considering how various cultures’ timing for engagement and action may differ, as well as respecting the different cultural groups’ temporal conventions.⁵³

In another study,⁵⁴ time is treated as a predictor variable, and researchers are more interested in learning how diverse individual, situational, and environmental aspects in organizations influence how people think about time use. As a result, which directs to concentrate on how people configure their sense of time in the face of organizational changes, as well as how these settings impact the significance that the consumers adhere to the changes.⁵⁴

The Experience Role

Study²¹ considered the role of experience in healthcare change. Although individuals’ subjective experiences may not correspond to more objective measures of organizational changes’ outcomes, it is critical to understand healthcare professionals’ perspectives on changes in healthcare because their attitudes toward changes may influence the success of changes.⁵⁵

However, individual reactions to organizational change are becoming more important.⁵⁶ According to the statements of the healthcare professionals who were interviewed, three characteristics of successful changes were discovered to be of critical importance for healthcare professionals to be considered as successful; (1) have the chance to stimulus the change, (2) are prepared for the change, and (3) distinguish the worth of the change.²⁰

The external factors (eg, governmental regulation, unethical environment and media), the accessibility of resources (eg, trained care providers), and history are all elements that affect the strategy for healthcare organizations (eg, experience with adverse patient outcomes). Additionally, these outcomes may be stated at several levels (eg, organizational level, explicit sections, etc).⁵⁷

Using Metaphors to Communicate Plan for Change

Metaphors are a type of cognitive tool that may be used to explain the world and are useful in health, illness, and medicine.⁵⁸ A metaphor is a figure of speech in which an analogy is used, or where a term from one domain is used in another.⁵⁹ Metaphors can help to communicate complex ideas, new viewpoints and difficult situations.⁵⁹

Metaphors are utilized to make sense of a complex theoretical topic by offering a map. The study of metaphors sheds light on how people construct and shape their environment in order to make it actionable.⁶⁰ This is a long-standing issue, and there are several works rich in metaphoric language that explain both organizations and their constituents in mechanical, ecological, mythical, and economic terms.⁶¹ The use of metaphors in such examples is framed in terms of serving a better understanding of the complicated link between a variety of elements that can influence an individual’s and/or an organization success.²¹

The use of metaphors in healthcare reform was investigated by Millar and Dickinson.⁶² Organizations frequently utilize metaphors to make themselves more simple and understandable. Metaphors enable a socially shared perspective and reality to pervade all stakeholders in an organization, resulting in a unified frame of mind. Metaphors can also help with the creation of organizational theory, as well as visions, objectives, and actions.⁶²

The author concluded that there is an importance poured on gaining information as a method for navigating internal and external politics, as well as identifying and tackling poorly coordinated operations, and moving expertise across boundaries in metaphors that view organizations as fully integrated towards a common goal (eg, organizations as collections of organized procedures).

Discussion

Hospitals and other healthcare institutions have their own distinct culture of trust and operate according to professional etiquette, hierarchy, and levels. Employee commitment to follow and maintain organizational changes can be aided by an understanding of the work culture, structure, communication, and significance of professional levels in healthcare organizations. From the standpoint of change management, individual capacities to adjust to timetables, adjust to change, and process new information are crucial. Healthcare organizations are impacted by a number of factors, including declining funding, an aging population, the need to improve efficiency, innovative and costly medical procedures in response to illnesses, and public expectations and the benefits of the decision-making process.

However, neo-institutional theory is commonly used in studies of transformation in healthcare organizations, with an emphasis on how these organizations grow more uniform over time. Organizations end up adopting the practices of others in an effort to obtain credibility.^63,64 The effects of change in healthcare organizations can be unanticipated, interrelated, and affect various stakeholders at various times and sizes, according to literature on the subject.^65,66

Prior research on organizational change in the healthcare industry has tended to concentrate mostly on managerial viewpoints, frequently ignoring the concerns and contributions of patients, legislators, and frontline healthcare workers. However, how these various stakeholders engage, negotiate, and contribute to the successful implementation of change is not well explored in the literature now in publication. A collaborative strategy is necessary for effective change management in the healthcare industry, incorporating perspectives from a variety of fields, including physicians, administrative personnel, IT specialists, and legislators.

However, the National Health Services (NHS) Change Model is an effort to address the shortcomings of current frameworks. The Change Model is a framework for organizing, implementing, and maintaining both small- and large-scale change that aims to integrate the best features of current frameworks and tools.⁶⁷ This strategy runs the risk of using the Change Model as a tool or a means of manipulation to force change, which would make the change less sustainable and refute its assertion that it offers a different strategy.¹⁶

Numerous healthcare organizational reforms fall short of their intended outcomes; a 70% failure rate is frequently mentioned.⁶⁸ However, given the context-dependent nature of change and the difficulties in defining and measuring it, failure rates may be called into doubt.²⁰ They frequently neglect to consider the long-term viability of transformation projects, though. Organizational culture and changing healthcare regulations are two important factors that affect how long change initiatives last. Existing research gives an incomplete picture in the absence of longitudinal studies or follow-up evaluations, which makes it challenging for healthcare organizations to predict long-term issues and modify their tactics appropriately.

Even though, there is a proof that evaluating change readiness is crucial for successful implementation, many implementation teams fail to evaluate readiness before implementation or do so inaccurately.⁶⁹ Because an individual’s inclination to accept or reject a proposal to modify the status quo influences overall organizational readiness for change, the research suggests that it is crucial to incorporate individual level components in an assessment of organizational readiness for change.⁷⁰ Moreover, individual judgments of organizational readiness may differ even while members of the organization share a common background.⁷¹

Nonetheless, the factors’ categories recognized in this study’s framework could be beneficial in developing initiatives to encourage healthcare organizations change. However, little is known about the relative importance of each highlighted category in the healthcare organizations’ change process. To close this gap, a variety of methodological studies are advised. Future studies before beginning the change process should focus on the psychometric features of organizational scales for healthcare contexts. The research will aid in the identification of dependent, independent, linking and driving elements of change readiness. The current changes in the healthcare industry, technological advancements, resource availability and departmental interconnectedness are all driving factors for change preparedness. Team-building tactics aid healthcare management in forming a successful work team by improving interaction and social interactions, allowing the employees to work together more effectively.

However, the benefit of paying attention to metaphors also comes from the potential to ask new questions, invite fresh ideas, and explore conceptual connections that might otherwise be overlooked. The framing of organizations matters for conceptions of learning in change, as explored through the examination of metaphors of organizations.^21,60

Moreover, our findings imply that organizational readiness for change is a four-dimensional concept that refers to the motivation and capability of organizational members to undertake intentional organizational change. This four-dimensional perspective reflects the common understanding of the word ready, which is being willed and capable of doing something. Furthermore, one of the study’s main premises was that healthcare professionals’ subjective experiences with changes influenced their chances of making successful adjustments. Individual responses to organizational changes are becoming more and more imperative.

This analytic review’s focus is also on the internal forces that keep the healthcare industry competitive and successful. Two primary techniques are suggested for motivating internal human resources to accept change and achieve organizational goals. The former is based on tangible characteristics, whereas the latter is based on intangible factors. Furthermore, in order to deal with change, it is necessary to improve the management of information technology and reengineering of supply processes, taking into account both the costs and advantages of such innovations.

Nonetheless, the popular implicit understanding of time as a forward movement, emphasis the inevitability of novel advancement as a necessary component of change. In the different ways that individuals and groups experience change in organizations, there is also a need to connect with numerous temporalities. These pressing concerns highlight the importance of critically considering the role of time, experience in conducting change and building healthcare organizational transformation theories.

Conclusion

There has not been much research done on the connections between different aspects of healthcare organizations and dimensions toward change. Nonetheless, the framework offers significant implications for healthcare organizations of how to plan and manage healthcare improvements to improve their chances of success. During transformation, certain organizational components need to be periodically targeted. Healthcare organizational leaders need to perform a comprehensive diagnostic examination before choosing how to respond to change. They must, in particular, become open to the necessity of more extensive organizational reform rather than reflexively assuming that the issue is either clinical or technological.

Change must be accomplished with the aid of several ways and support systems that are all a part of a long-term plan, a carefully considered set of methods that are in harmony with each other and in line with the change objective. Future research could reevaluate the framework and its dimensions to better understand how the aforementioned components or other situational factors altered over time as the change progressed.