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Caredeliverymodel
DIMENSION
Change in healthcare organizations is rapid, complex, such changes, may perceive organizational change as
and, at times, chaotic.1 Often change has been man- imposed from above. As a result, they may feel little
dated because of new regulations, advances in technol- involvement in how it is initiated or how it proceeds.
ogy, and changes in healthcare reimbursement. Over the Most studies on organizational change and impact
past 20 years, these changes in healthcare have led to of skill mix changes have been quantitative. Few studies
new staffing models and skill mixes in acute care have explored the changes from the perspective of the
settings. In particular, in the United States during the staff nurses. This qualitative study was initiated because
1990s, the onset of managed care and emphasis on the investigators believed in the importance of capturing
holding down healthcare costs resulted in the increased the experience of the staff nurses working in a unit that
use of unlicensed personnel in acute care, including underwent a change in care delivery model. This article
intermediate care units (IMC) and intensive care units reports the findings from that study. Although the
(ICU).2 Personal anecdotes from staff nurses in that era results cannot be generalized from a qualitative descrip-
often told of doubled number of patients, with one tive study, they reinforce findings on the importance of
assistive staff member shared with another registered involving staff in change and on the powerful impact
nurse (RN). The staff nurses, the ones most affected by that nurses can have in supporting one another.
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
January/February 2009 31
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
from areas from the initial quantitative study that were provided at each session. Participants received no
seemed to need additional exploration. The research other remuneration. Extra care was taken to ensure
team members used their background knowledge and confidentiality because of the small number of partici-
diverse experience to finalize the interview questions. As pants and the potential for sensitive answers. During
is common in qualitative studies, the interviewer used the audiotaping, members were asked to use initials to
the questions as a guide, seeking elaboration from the identify themselves and others. They were reminded that
participants when needed. the discussion in the groups was confidential. In
addition, the audiotapes were transcribed by a person
not associated with the medical center. No names were
The interviewer used the questions as used on the transcriptions. Finally, the 2 members of the
a guide, seeking elaboration from the research team affiliated with the medical center did not
know which staff members attended the focus groups.
participants when needed.
Data Analysis
At each focus group, participants were given study After receiving the printed transcriptions of the focus
information and asked to sign the consent form and groups, the 3 research team members met to review the
complete the demographic questionnaire. Refreshments analysis method and begin the analysis process. Each
January/February 2009 33
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
researcher individually read through the transcripts to like, how they’re voiding, how they walk, if dizzyI
get a feel of the whole, circling words and phrases that when you have CNAs, you let those Ftrivial_ things go,
seemed to capture key concepts. However, since 2 team but they’re very important to the overall care of the
members were not experienced with qualitative re- patient.’’ Others noted how much more knowledgeable
search, they found it difficult to know how to proceed they felt when talking with the physicians and how
and thought that it would be most productive to jointly much more attuned they were to the patients’ needs.
analyze the data. They discussed their first-level con- Along with increased knowledge of their patients,
cepts and the words and phrases identified in the first the RNs noted more respect from physicians, staff, and
reading. Then an affinity diagram method was used to patients. The nurses in the focus groups believed that
sort the concepts into like categories or themes.11 Each they could participate more knowledgeably in rounds
researcher wrote the words identified onto self adhesive with the physicians, as they were better able to report on
notes. Next, the researchers affixed the self adhesive their patients’ status. As a result, most of the nurses felt
notes to the walls of the conference room, grouping the as if their relationships with the physicians were more
concepts into like content areas. collegial. They also noted that the unit now seemed
A conceptual scheme emerged from the transcripts more professional with an atmosphere more ‘‘like a
as the team members discussed how they saw the critical care unit.’’ From the nurses’ perspective, the
seemingly unrelated concepts linked together as themes. patients and families also had more respect for the
They quickly reached consensus on the themes. As they nurse’s role and knew who their nurse was. The nurses
reflected on the themes, the team members further asked reported that there had been an improvement in patient
one another: how were these related? What is it that the satisfaction, there were fewer patient complaints, and
nurses were describing? What does it mean? Using this the patients seemed to like the change.
information, a model was created to represent the Next, the nurses were nearly unanimous in their
findings as the team had conceptualized them (Figure satisfaction with the new skill mix and care delivery
2). As the team members reviewed the conceptual model, emphasizing its benefits. The nurses believed that
model, they discussed and refined further to ensure that the new skill mix and the new care delivery model
the model remained faithful to the data. In the next worked better than that of the previous system, and they
section, the findings as conceptualized in the scheme are attributed that to a more professional environment.
presented. They liked that they were now doing primary nursing
and really enjoying their role as nurses. Some of their
statements were as follows: ‘‘I can’t even say how much
KNOWLEDGE GAINED FROM THE STUDY I love it,’’ ‘‘I wouldn’t go back,’’ and ‘‘I’m very
After reviewing and analyzing the qualitative data, the satisfied.’’ A few commented that this was all they had
researchers found that most of them were organized into ever known, but they also emphasized their satisfaction.
2 major themes: autonomy/control and interdepen- In all, the focus groups described a positive, professional
dence. There were 5 subthemes for each of those, with atmosphere on the unit.
a substantial amount of supportive data in each. The final subtheme in the area of autonomy and
control was labeled running the show by the research
team. This was a direct quote from one of the nurses,
Autonomy/Control who stated with pride that she was now running the
The first major theme was the RN’s feeling of increased show. The nurses described feelings of increased pro-
autonomy and control. Within this theme, there were 5 fessional autonomy, accountability, and a sense of being
subthemes: (1) knowledge of patient; (2) respect from the one in charge of everything. They reported being the
physicians, patients, and families; (3) patient satisfac- ‘‘hub’’ of the team. Most expressed a preference for this:
tion; (4) nurse satisfaction; and (5) one labeled ‘‘running ‘‘The way I work is: I’d rather get it done myself,’’ ‘‘I
the show.’’ There was minimal overlap among these like to be there for my patients and give 100%,’’ ‘‘I
subthemes, and each was well supported by the quali- don’t like to depend on others,’’ ‘‘I’d rather do it myself
tative data. and make sure it gets done right.’’ The participants
Nearly every nurse mentioned knowledge of the reported that, when they had worked with CNAs, they
patient as one of the major advantages to the change. sometimes felt as if they did not have all the informa-
The nurses noted that they were able to better assess the tion. In addition, it sometimes seemed to them that it
patients, get to know them better, and be more focused took more work to make sure the CNAs were following
and attuned to their needs. One respondent noted, ‘‘I through. There was also a downside to the increased
know skin care issues, I know what theirI patterns are autonomy. Some of the nurses described how they
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
January/February 2009 35
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
physicians. For the most part, this interdependence was somehow diminished because they now had to do
viewed positively. However, lack of support also fell CNA work. For example, one nurse told how a patient
into this theme. commented, ‘‘you do great work down in the kitchen,’’
The focus group nurses identified multiple supports. as she delivered the food tray. Another nurse com-
They praised the manager and the unit pharmacist. Day plained, ‘‘I feel like I have so many tasks. You know, we
shift nurses noted that there are many adjunct depart- get here and clock inI we’re on a treadmill: vital signs,
ments and always ‘‘tons of people around to support’’ get going. I’m doing so many tasks that I’m not doing
them. Newer nurses pointed to the preceptors and other the critical things like I used toI that’s how I feel.’’ One
staff as being especially helpful to them. Nurses participant noted that when CNAs were on the unit,
appreciated their colleagues. The focus group attendees they (the CNAs) would be monitoring the patients and
painted glowing pictures of the guidance and support answering call lights, freeing the RNs to make rounds
that the all-RN staff gave one another. Colleagues were with the doctors. There were also concerns about
praised for their knowledge and experience and their interactions with the CNAs themselves, ‘‘I thought it
desire to help. Some of the comments were as follows: ‘‘I [the change to primary nursing] was smooth, but
yell, Fplease help me_ and they’ll be there.’’ ‘‘There’s an somehow it created a lot of animosity from CNAs in
RN who can help you and who is more skilled than the whole hospital, because they all talk together.’’
you.’’ ‘‘The nurses around here are so incredibly smart However, despite these reports, when the focus groups
and I love that.’’ In addition to the positive relationships were asked directly, ‘‘do you want to go back?’’ The
with other nurses, the participants also noted more RNs responded with an emphatic ‘‘No!’’
rapport and respect from the physicians.
However, the other side of the interdependence was DISCUSSION
both the increased need for help and perceived lack of This study added to quantitative data on one unit’s
some forms of support. Patients in this unit have a variety change in the care delivery model by including the views
of diagnoses and healthcare problems. As in other acute and experiences of the actual staff nurses who lived it.
care settings, patients are sicker and they need more care. The findings are consistent with others in the literature
One nurse stated, ‘‘It’s a very difficult time for patients about factors that influence nurses’ job satisfaction.4,5
and families.’’ As a result, the work seemed more hectic Multiple studies have reported autonomy, control over
and more chaotic for the nurses. When the ‘‘resource work, and involvement in decision making as key
nurse’’ and lift team were available, they felt the work- satisfiers for nurses.12-15 Conversely, when nurses are
load was manageable. However, since the completion of unhappy with staffing levels and patient-to-nurse ratios,
the year-long pilot, the nurses reported that at times, there is an increase in turnover and decrease in satisfac-
these were more a luxury than an expectation. In tion.6,16,17 This group of nurses was vocal in expressing
addition, there was no lift team in the hospital after satisfaction and feelings of reward about their experi-
3:30 PM. Often there were as many as 5 patients weighing ences with the current care delivery model and skill mix.
more than 400 pounds on the unit, leaving only the
nurses to do all the turning and transferring at night.
Finally, some dissatisfaction seemed to be emerging.
During the pilot study, the skill mix and the new model This group of nurses was vocal in
were ‘‘protected.’’ However, recently, the participants expressing satisfaction and feelings of
reported that RNs were being floated from the IMC and reward about their experiences with
replaced by CNAs. The nurses lamented this lack of the current care delivery model and
resources, ‘‘We need a lift team at nights,’’ ‘‘We can’t get
the baths done,’’ and ‘‘Like, we’re not Fsuper nurses._’’
skill mix.
Some recognized that this may be due to the overall
nursing shortage, but others thought that it might be a
lack of understanding of the acuity of the patients on the Relationships with managers and relationships with
IMC. Although this was just a minor part of the findings, physicians have also been related to nursing job sat-
the lack of resources was probably the biggest cause of isfaction.4,5 In this study, collegial (RN-RN) interactions
dissatisfaction expressed by the IMC focus group nurses. were highly positive and an additional satisfier for RNs.
This may give increased support to the importance of
Other Findings mentor programs and new graduate programs.
Some of the focus group’s comments did not fit into the The nurses’ involvement in this unit change may
2 major themes. A few felt that their status was have played a strong role in how positively it was
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
perceived by the nurses in these focus groups. The involving staff in change, from the perspective of
management clearly valued their opinion and participa- both nurse retention and satisfaction, and the pos-
tion and was, in turn, respected by the staff. Most focus itive impact on multiple aspects of care are clear. In
group members were highly enthusiastic and positive addition, research on organizational change needs to
about their unit and the change. also focus on those most affected by change (RNs,
An emerging area of concern is the nurses’ percep- CNAs, physicians, administrators, and other health-
tion of ‘‘deficits of support’’ at times. Although care providers). Qualitative studies that give voice to
autonomy and control over practice were cited by the their concerns continue to have value in augmenting
nurses in this study as highly rewarding, these were other data. Staff nurses too often perceive those in
balanced by the interdependence they reported with management and academia as being so far removed
other team members, including supportive management. from the bedside, as having lost understanding or
An appropriate RN-to-patient ratio is only one part of perspective of the struggles of providing direct pa-
the picture. If the RN does not have adequate assistive tient care. These nurses remind us that although
support, both patient care and job satisfaction may there are many rewards, nursing is hard work, at
suffer. The care delivery model and staffing mix may times, it is hard physical work. By listening to their
continue to be an important issue, as some of the study concerns and supporting the work of those at the
participants pointed to the continued need for assistive front lines, nursing leaders can better support and
personnel. The study findings and these concerns are seek changes that will impact the nurses’ satisfaction
being reviewed by the unit-based practice council for and patient outcomes.
recommendations and actions.
Finally, the study confirmed that it is hard to quantify
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January/February 2009 37
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
15. Larrabee J, Janney M, Ostrow C, Withrow M, Hobbs G, Linda Urden, DNSc, RN, CAN-BC, FAAN, works as the executive
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ABOUT THE AUTHORS Medical Center in Escondido, California.
Maryanne Garon, DNSc, RN, is the coordinator of the Graduate Address correspondence and reprint request to: Maryanne Garon,
Programs and an associate professor at the Department of Nursing, DNSc, RN, California State University, Fullerton, P O Box 6868,
California State University, Fullerton in Fullerton. Fullerton, California 92834 (mgaron@fullerton.edu).
Coming in the
March/April 2009 Issue
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& A Brief Report: Evaluating the Effects of Ketamine on Memory
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& Compassionate Use in Research
& Pediatric Research Abstracts
& News Bits: Information for Critical Care Nurses
& Medical Futility: A Paradigm as Old as Hippocrates
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