Use of complex adaptive systems metaphor to achieve professional and organizational change

AIM: This paper uses the experiences of a programme designed to bring about change in performance of public health nurses (health visitors and school nurses) in an inner city primary care trust, to explore the issues of professional and organizational change in health care organizations. BACKGROUND: The United Kingdom government has given increasing emphasis to programmes of modernization within the National Health Service. A central facet of this policy shift has been an expectation of behaviour and practice change by health care professionals. METHODS: Change was brought about through use of a Complex Adaptive Systems approach. This enabled change to be seen as an inclusive, evolving and unpredictable process rather one which is linear and mechanistic. The paper examines in detail how the use of concepts and metaphors associated with Complex Adaptive Systems influenced the development of the programme, its implementation and outcomes. FINDINGS: The programme resulted in extensive change in professional behaviour, service delivery and transformational change in the organizational structures and processes of the employing organization. This gave greater opportunities for experimentation and innovation, leading to new developments in service delivery, but also meant higher levels of uncertainty, responsibility, decision-making and risk management for practitioners. CONCLUSION: Using a Complex Adaptive Systems approach was helpful for developing alternative views of change and for understanding why and how some aspects of change were more successful than others. Its use encouraged the confrontation of some long-standing assumptions about change and service delivery patterns in the National Health Service, and the process exposed challenging tensions within the Service. The consequent destabilising of organizational and professional norms resulted in considerable emotional impacts for practitioners, an area which was found to be underplayed within the Complex Adaptive Systems literature. A Complex Adaptive Systems approach can support change, in particular a recognition and understanding of the emergence of unexpected structures, patterns and processes. The approach can support nurses to change their behaviour and innovate, but requires high levels of accountability, individual and professional creativity.     

District nursing and social work: palliative and continuing care delivery

The growing number of older people has seen a concomitant increase in the number of people with chronic conditions who require continuing and palliative care increasing the need for the relevant professional groups and organizations to work together. This paper reports on a multiple case study which explores the different ways that district nurses and social workers work in delivering palliative and continuing care. Each professional group operationalized their care differently across five themes: assessment, care delivery, focus of care, place of care and funding of care. The balance between care organization and care delivery needs to be addressed within emerging primary care delivery structures as primary care nursing moves towards case management for long term conditions.     

Evolution of the perioperative clinical nurse specialist role

Perioperative nursing roles continue to rapidly change as we enter the twenty-first century. The need for strong leadership skills, expert clinical skills, creative management, ongoing continuing education, and research continues to grow in every department of surgical services. The clinical nurse specialist plays an important role in addressing each of these needs. Great opportunities exist within the field of nursing for perioperative nurses to expand their practice using their creativity, ideas, and skills. Using the clinical nurse specialist in the perioperative setting can foster creativity, stimulate development of new methods based on research, and maximize the delivery of high quality care by the entire OR staff.     

Meeting the policy agenda, part 1: the role of the modern district nurse

The challenges posed by the current context of health and social care offer opportunities for different models of care delivery. District nursing has evolved, and continues to evolve to meet these challenges. The traditional reactive role of district nursing has developed as contemporary practice expects district nurses to meet both planned and unplanned care required by practice populations. Modern anticipatory care approaches to care are being adopted, while care and case management is being facilitated and delivered to patients and families with complex health and social care needs. Additionally, district nurses are recognizing the need to further develop management and leadership skills as the teams delivering care consist of a skill mix of nurses and other disciplines. They are also charged with evidencing the impact of what they do and influencing care delivery at every level of healthcare organizations. This first paper of two will explore the current UK policy context and ways in which district nursing services within each country are changing to meet the challenges posed. A second article will argue the need to ensure the district nursing workforce is underpinned by robust educational standards that ensure protection of the public. The influences of education and development from professional and organizational perspectives will be examined.     

Mental and physical health comordibity: political imperatives and practice implications

Insufficient priority is being given to meet the physical health-care needs of people with mental illness. Mental health nurses, as the largest professional group working in mental health care, have a pivotal role in improving the physical health and well-being of people with mental illness. Through health-promotion strategies, alongside recovery-focused support aimed at avoiding deteriorating physical health, mental health nurses can significantly contribute to improving the current rate of premature death experienced by people with enduring mental illness. Drawing from contemporary policy, alongside practical examples taken from the published literature, this paper considers what constitutes recommended best practice in dealing with the physical health-care needs of people with mental illness. The role that UK-based health-care policy plays in shaping care delivery that meets the needs of people with mental illness is explored and placed within the context of global health concerns. Recommendations are made on how mental health nursing can work to provide evidence for a reassertion that nurses are well placed to work across organizational and professional boundaries to deliver person-centred care and a holistic approach to population health and well-being.     

A reflective model for organizational assessment and interventions

A visionary academic medical center in Colombia, South America, engaged the Institute for Nursing Healthcare Leadership in a multifaceted project for the overall goal of strengthening the model of professional practice. The authors describe a reflective model for organizational assessment that steered the in-depth assessment of the organization. The model combines the constructs of culture, theory, patterns, and phenomenon with an iterative process. The organizational reflection process is applied to assessing key nursing roles and the nursing care delivery system. Recommendations and interventions that emerged from the assessment are included.     

Effects of systematic clinical supervision on psychiatric nurses' sense of coherence, creativity, work-related strain, job satisfaction and view of the effects from clinical supervision: a pre-post test design

There are few investigations of the type and the outcome of interventions aimed at supporting nurses caring for psychiatric patients. Therefore a prepost-test design study was used in which 22 psychiatric nurses, on a general psychiatric ward were examined before, during and after one year of systematic clinical supervision combined with supervised documented, planned, individualized care. The methods used were the Sense of Coherence scale (SOC), the Creative Climate Questionnaire (CCQ), the Work-Related Strain Inventory and 34 statements from the Satisfaction with Nursing Care and Work Questionnaire (SNCW). In addition 14 statements were developed to evaluate the nurses' view of the effects from clinical supervision. The baseline values for the CCQ indicated a stagnant organization and a high score in the conflict dimension indicated personal and emotional tensions within the organization. The intervention led to a significantly increased creative and innovative climate in the dimensions for trust, idea time and reduced conflicts. However, the organizational climate remained stagnant. The nurses' view of the effects from clinical supervision also increased significantly. There were no significant changes in the nurses' SNCW, WRSI or SOC score. The result of the correlation analysis indicated that a strong sense of coherence was related to low work-related strain but not to unsatisfactory working conditions/milieu. The results gave some support to the idea that systematic clinical supervision and supervised nursing care plans constitute one type of support strategy that improves creativity and the organizational climate. It may, not, however, buffer for interpersonal problems. Further research is required to explore the need for effects of various support systems depending on the circumstances in the organization.     

Collaborating with chaplains to meet spiritual needs.

Current accreditation and professional standards in health care reflect the importance of chaplaincy services to patients, families, the health care team, and the organization. However, inadequate spiritual assessment, the organizational structure and climate, and lack of understanding of the chaplain's role can prevent these services from being optimally utilized. Chaplains are trained extensively to provide spiritual care to patients, families, and staff as they assist in meeting the organization's mission to provide patient-centered care. Spiritual assessment is a tool for nurses to recognize patient's needs for spiritual intervention and chaplain referral. By collaborating with chaplains, nurses can help develop an organizational infrastructure capable of timely responsiveness to patients' spiritual needs.     

Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative

Rationale and aims In several countries, collaborative improvement programmes involving multiple health care organizations have been developed to address the issue of patient safety and reliability of care at an organization‐wide level. In the UK, the Health Foundation's Safer Patients Initiative (SPI) was developed to achieve breakthrough improvement in the quality and safety of care in 24 acute hospital Trusts between 2004 and 2008. Research evidence for the effectiveness of programmes of this type and the mechanisms by which positive outcomes are achieved remains limited. We report a multi‐method preliminary study based upon phase 1 of SPI to understand participant's perceptions of the local impact of the programme and to form the basis of future research in this area. Methods Data were collected on the perceived local impact of SPI on a range of clinical, organizational and social dimensions relating to care quality and safety. Data were collected retrospectively from local SPI programme improvement teams using semi‐structured interviews and surveys. Qualitative and quantitative analyses were performed, and the results synthesized under common themes and frameworks. Results Specific dimensions of care systems commonly considered to be affected by SPI, included culture, strategic priority, organizational capability and clinical care delivery. Survey data revealed the perceived importance for success of a range of programme components: quality improvement methodology, learning sessions and programme faculty support, along with predefined clinical practice changes. Safety climate and capability dimensions rated as most sensitive to the effects of the SPI programme related to multi‐professional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Conclusions Study findings support the view that programmes such as SPI have considerable impact upon the cultural, inter‐professional, strategic and organizational aspects of care delivery, in addition to clinical working practices. The specific implications for understanding the effects of complex organization‐level interventions and future research design are discussed.     

Care of the patient with adult congenital heart disease

The adult congenital heart disease (ACHD) patient population has numerous and distinctive needs and comprise a rapidly growing group within the modern day healthcare arena. Current treatment provisions along with recommendations for future specialized multidisciplinary ACHD teams are discussed. The exclusive needs of this patient population have forced professional groups to reconsider the availability and appropriateness of current healthcare delivery to this group of complex patients, whose survivability and life expectancy have continued to improve as a direct result of enhanced research, technology, medical, surgical, and nursing care. General care considerations including psychosocial issues and patient education are presented, and reveal the challenges and strengths of caring for this adult patient population within a pediatric facility. Congenital heart disease is a lifelong illness that requires a dedicated, consistent approach to healthcare delivery in order to guarantee quality care throughout the lifespan.     

Defining and integrating informatics competencies into a hospital nursing department

Expanding use of complex patient information management systems and communication technology in healthcare organizations requires nurses to possess core competencies that until recently were not considered as integral to practice as those of a strictly clinical nature. Organizational changes necessary to formally integrate informatics competencies into nursing practice require strong partnerships among facility nursing leaders, educators, and informaticists. The authors describe a strategic initiative one acute care organization used to develop nursing practice that ensures use of system tools to manage patient information, support clinical decision making, optimize workflow, and communicate with members of the care team. The initiative involved defining nursing computer and informatics management skills for the clinical system applications and technologies utilized in the organization and integrating the introduction, evaluation, and on going professional development of the defined informatics competencies into organizational processes and tools to support the bedside nurse.     

Community management of Alzheimer's disease

Community-based long-term care for victims of AD requires coordination and creativity on the part of a variety of health care professionals, including nurses, physicians, social workers, ancillary therapists, day-care coordinators, and staff in state and federal agencies, as well as of a variety of nonprofessionals who can provide ongoing home care or community agency assistance. The primary role of the health care professional in the community is to assist family members and care agencies in identifying, assessing, and implementing appropriate care for the person with a dementing illness. Much of that role involves matching family and patient needs with available services and participating in local, state, and federal organizations that project the type and extent of services needed now and in the future. Nursing care ranges from participating at the organizational or planning level to actually implementing hands-on care.     

Organizational environment and the support of patient autonomy in nursing home care

This study examined how patient autonomy is associated with the organizational environment in nursing homes, particularly the organizational climate, organization of work and selected staff characteristics, such as age and experience of health care Staff from 13 nursing homes in the county of Stockholm, Sweden, were included The organizational climate was described by staff from two of the nursing homes that, on the basis of staff judgement, were rated as creative, and from two of the nursing homes that were rated as lacking innovation Regarding organization of work, which included the number of patients who required to be fed, together with the incidence of pressure sores and indwelling urinary catheters, there appeared to be no difference in care from both types of nursing home The statistical analyses showed that nursing homes characterized as significantly creative supported patient autonomy to a high degree, and that the staff's experience with health care was associated with the organizational climate     

The informatics nurse: Helping to build the knowledge infrastructure for nursing

As nurse leaders, you are keenly aware that health care is an information-intensive enterprise. As such, knowledge is a strategic asset to the health care organization. To be of organizational benefit however, knowledge cannot reside solely within the individual; rather, it needs to be disseminated. Knowledge can be gained from organizational processes, products, policies, culture, various forms of documentation, and information systems used within a business. It exists for all aspects of the organization's mission: clinical care, education, research, and administrative practices.     

Education for effective case management practice

BACKGROUND: An internal needs assessment in a managed care organization identified the need for more effective case management and a more thorough orientation of new case managers. METHOD: An educational design and development consultant facilitated the process of planning and implementing activities to address those needs. One hundred fifteen employees attended one of five interactive educational sessions that covered key concepts critical to effective case management. RESULTS: Feedback from learners and from the managed care organization indicated that the activity was effective in meeting its targeted goals. CONCLUSION: The use of external facilitators combined with internal resources and implementation of active learning strategies was effective in promoting organizational improvement.     

The mental health needs of people with severe learning disabilities

People with severe learning disabilities can present with complex behavioural and emotional needs that are best understood within a biopsychosocial framework. This article outlines the range of issues involved in the presentation and identification of mental health needs in people with severe learning disabilities. The use of a multidisciplinary and multimodal approach to assessment, care planning and case management is promoted in order to provide effective, comprehensive care in meeting the mental health needs of this client group. The key knowledge and skills required to meet the mental health needs of this client group are outlined and the role of the nurse as a key professional in the coordination of the assessment and care management process is explored.     

Chronic care model for the management of depression: Synthesis of barriers to,and facilitators of,success

Depression is a socially‐ and physically‐disabling condition. The Chronic Care Model (CCM) was developed to promote better management of long‐term conditions, such as depression, in primary care settings. The aim of the study was to identify barriers to, and facilitators of, success when implementing the CCM for the management of depression in primary care. A systematic search was conducted in electronic databases from January 2005 to December 2011. Thirteen articles met the inclusion criteria and were reviewed by means of a thematic analysis. The barriers were categorized under two themes: lack of organizational, administrative, and professional ability to change and implement the components of the CCM; and lack of clarity pertaining to the responsibility inherent in the role of care manager (often a nurse) when it comes to promoting the patient's self‐management ability. In terms of the facilitators of success, two themes emerged: leadership support and vision, and redesigning the delivery system. When shaping an environment for organizational change, leadership and professionals must work towards a common goal and vision. Such processes require a care manager with a clear role and responsibilities in order for the health‐care system to meet the needs of the person with depression.     

Meeting a primary care challenge in the United States: chronic illness care

Leading health care experts in the United States have stated that the greatest primary care challenge today is meeting the complex needs of patients with chronic illness/long-term conditions or impairment.To address this challenge, there is a need for health care system redesign that requires a multidisciplinary team approach, including active participation from professional nurses. In particular, it is essential for advanced practice nurses to provide leadership in health systems design for which they are specifically trained and experienced. In this article, the primary care challenge related to chronic illness care management is addressed. Future implications for community-based, chronic illness care delivery and the education of future health care providers with a focus on advanced practice nurses will also be discussed.     

The NHS as a learning organization: aspirations beyond the rainbow?

Aim It is the intention of this paper to review the issues and challenges organizations face when aspiring to embrace and enact the tenets of a learning organization ; and in particular the perceived impact on management strategy, structure and leadership styles. The paper is predicated on the premise that learning and knowledge act as vital strategic resources, crucial not only to organizations in terms of competitive advantage but to ethical enterprise per se . Background Modern life is characterized by change, against the backdrop of this continual turmoil, organizational learning has emerged as a dominant theme within contemporary management theory, with many commentators increasingly locating the capacity of an aspiring organization to accommodate the ethos of organizational learning, as the vital component in ensuring enduring efficiency, innovation and competitiveness. However, the utility of such learning needs to be scrutinized and evaluated in terms of service need and expectation. Origins of Information The paper will expand upon wider theoretical debates extant within the literature, by considering the concept and utility of the learning organization with specific reference to management reform extant within the British National Health Service (NHS). Data Analysis During the course of the review the various theoretical positions contributing to the notion of the learning organization will be analysed, the practical ramifications of which will be examined in the context of reflective practice, clinical supervision and the wider cultural background of nursing and the NHS. Conclusions The paper concludes that the NHS needs to reorientate management perspectives to focus attention more acutely on systems which are deliberately designed to facilitate shared learning, to unravel the ambiguities of organizational life, to affirm management belief in the nursing contribution and to achieve an as yet unrealized potential in terms of patient care and advanced nursing practice.     

An advanced nurse practitioner-led service - consequences of service redesign for managers and organizational infrastructure

barton d . & mashlan w. (2011) Journal of Nursing Management 19, 943–949 An advanced nurse practitioner-led service – consequences of service redesign for managers and organizational infrastructure Aim A service review of a secondary care advanced nurse practitioner-led service. Background An acute hospital-based elderly care rehabilitation service evolved over a 9-year period from a traditional consultant/junior doctor configuration to a consultant/advanced nurse practitioner configuration. The review evaluated the advanced nurse practitioner team’s role in the clinical setting, and the constraints experienced as a result of the traditions of the hospital organization. Evaluation The review drew its conclusions from opinion data collected from 38 professionals and non-professionals within the rehabilitation service. Key issues The organizational infrastructure and traditions that had an impact on service delivery by the advanced nurse practitioner team. There is a demand for senior management to act on developmental constraints. Conclusions The advanced nurse practitioner-led rehabilitation service was fit for purpose and an emerging model of a non-medical led care. However, important organizational constraints were identified. Implications for nursing management An advanced nurse practitioner team, working in collaboration with medical consultants, was a model for future service redesign in the acute hospital setting. Nevertheless, it presented challenges to senior health-care managers on current organizational infrastructures.