Implementation of change in health care in Sweden: a qualitative study of professionals’ change responses

Change is pervasive in health care. Changing disease patterns, aging populations, new discoveries of treatment of diseases, technological advancements, political reforms, and policy initiatives place demands on health care organizations and professionals’ capacity to implement change [1‐4]. Health care is facing a wave of new technologies and business models (e.g., telemedicine), which is likely essential if health care is to meet growing needs in areas such as chronic disease management. The patient experience is evolving into a broader patient experience as more patients are becoming involved in decisions about their care, pointing to patient/provider relationships based on partnership and mutual empowerment [5].

Changes within an organization are usually associated with employee psychological uncertainty about how the change will affect their lives [6, 7]. The demand to change has well-documented effects on employee health and well-being, as assessed by a range of indicators and constructs, e.g., work-related stress, mental health problems, change fatigue, poor self-rated health, adverse sleep patterns, sickness absence, hospital admissions, and stress-related medicine prescriptions [6, 8‐12].

Health care professionals’ change responses may have important implications for the implementation of evidence-based practices in health care. Theories, models, and frameworks used in implementation science, as well as extant evidence, typically view health care professionals’ responses to the change associated with the implementation of a specific practice, e.g., a particular intervention, program or service. For example, the Consolidated Framework for Implementation Research [13] conceptualizes health care professionals’ change responses as their knowledge and beliefs about the implemented practice. Klein and Sorra [14] describe health care professionals’ responses to changes as the fit between evidence-based practice and health care professionals’ values (“innovation-values fit”). However, changes associated with implementing evidence-based practices represent only one type of change in health care due to the fast pace of change in this sector. Therefore, more general change responses, e.g., negative experiences from numerous and/or large organizational changes impacting health care professionals’ work, may be an important underlying influence on health care practitioners’ implementation intentions and behaviors.

Change responses have usually been described in terms of resistance to change, a concept which was introduced by Coch and French [15]. However, later conceptualizations have expanded beyond conceptualizations of resistance to change to encompass various degrees of acceptance (or readiness) for change, thus creating a continuum of change responses. Coetsee [16] describes seven forms of change responses, from aggressive resistance, active resistance and passive resistance to indifference, support, involvement, and commitment (please see further details in Table 1). Change response in the framework is conceptualized as a tridimensional attitude composed of three components: cognitive (opinions about changes, their usefulness, advantages and disadvantages, etc.), affective (feelings about changes), and intentional/behavioral (actions already taken or which will be taken for or against changes). This tridimensional concept of change response was proposed by Elizur and Guttman [17] and is widely used [18].

Understanding health care professionals’ change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. However, responses to change in health care remain circumscribed in implementation theory, as described above, and poorly understood empirically. Hence, the aim of this study was to investigate health care professionals’ responses to organizational and workplace changes that have affected their work. We used Coetsee’s analytical framework to categorize different change responses. Knowledge of health care professionals’ change responses could be important to identify opportunities for promoting acceptance to change and limiting resistance to change inherent in the implementation of evidence-based practices in health care.

We conducted semi-structured individual interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses (Table 2). The participants were employed in 6 different health care units, all located in cities, with 67,000, 135,000, and 150,000 inhabitants, respectively, all located in the south-east part of Sweden.

Analysis of the data yielded 10 types of change responses, numbered 1 to 10 below and in Table 3. The different types of responses could be mapped onto five of the seven change response categories in Coetsee’s framework [16]. Participants did not report change responses that corresponded with Coetsee’s two most extreme forms of responses, i.e., commitment and aggressive resistance. Several representative quotes for each type of change response are provided in Table 3.

Implementation of evidence-based practices in health care implies change [23]. In practice, health care professionals typically face many concurrent changes [24], and individuals’ responses to these changes vary [18].

We found Coetsee’s [16] change responses framework to be useful for a nuanced understanding of how people respond to changes, describing responses that range from a strong acceptance of the change to strong resistance to change. We identified in our study 10 types (i.e., sub-categories) of change responses, which could be mapped onto five of the seven response categories of Coetsee’s framework. We did not identify any change responses that could not be fit into the framework.

The participants did not report change responses that corresponded with Coetsee’s two most extreme forms of responses, i.e., Aggressive resistance and Commitment. The lack of change responses characterized by Aggressive resistance may be attributed to the Swedish workplace culture, including health care, which typically promotes stability and favors consensus over arguing or expressing strong emotions or opinions [25]. Commitment is a powerful acceptance of change which has been described by the willingness of employees to direct their energy and loyalty to the benefit of the organization to such an extent that a strong attachment is created to the values, goals, and vision of the organization [26, 27]. The lack of statements that conveyed this type of change response can be explained with reference to the overall paucity of examples of change responses categorized as involvement or support, i.e., the two less enthusiastic forms of change acceptance. These findings suggest that health care professionals are insufficiently engaged in efforts to solicit their commitment, which means that it may be unrealistic to expect a strong commitment from health care professionals when implementing change, including evidence-based practices.

The two forms of change acceptance we identified, involvement and support, were generally associated with changes that were initiated by the health care professionals themselves or featured their active input, changes they viewed as well-founded because they could see the utility of the changes or changes they considered well communicated and predictable. These findings are in line with previous organizational research which shows that resistance to change is more likely if employees consider a change initiative pointless and do not have a say in the planning or implementation of the change, while acceptance of change is more likely if they consider the change to be sensible and respect the individuals behind the change initiative [19]. How change is carried out is important, with open strains of communication and leadership that is perceived as competent and truthful in its implementation of change increasing the chances of change acceptance [18]. In line with this, research has demonstrated that organizational changes cause stress when changes create uncertainty (e.g., [28, 29]), are poorly communicated (e.g., [30]), are considered unfair (e.g., [31, 32]), and take place too quickly or too slowly (e.g., [32]).

Organizational theorists have acknowledged that sense-making processes are essential to understanding individuals’ responses to change [24, 33]. Interestingly, the characteristics of changes associated with involvement and support are consistent with Antonovsky’s sense of coherence theory [34], which can be applied at different system levels, from the individual to the societal level. The theory posits that we constantly are exposed to changes that function as stressors. A sense of coherence, therefore, reflects a coping capacity to deal with stressors and consists of comprehensibility, manageability, and meaningfulness. Changes which are seen as well founded, well communicated, and predictable are likely viewed as comprehensible, changes that are initiated by health care professionals or involve their active input are perceived as manageable, and changes seen as well founded are considered meaningful. The sense of coherence concept has been applied in many studies, e.g., concerning stress, burnout, and working circumstances [35], but to our knowledge the three elements of comprehensibility, manageability, and meaningfulness have not been applied in organizational research to provide understanding of why certain changes might be more successful than others. Further research is warranted to explore the extent to which implementation of evidence-based practices are perceived as comprehensible, manageable and meaningful. Future research should also assess the influence of variables such as involvement in planning, quality of communication regarding changes, and perceived relevance of changes on change responses. Research is also needed to find out whether these conditions have an additive or interactive effect on commitment.

Three of the 10 types of change responses were mapped onto the indifference category. This is considered a zone between acceptance and rejection of change in Coetsee’s framework, characterized by neutral cognitive and affective responses and passively resigned behaviors. Change apathy seemed to be a particularly common response to changes among health care professionals who had previously experienced changes impacting on their work which they considered unsuccessful. The organizational literature usually purports, with some empirical support, that 70% of all organizational change initiatives are failures [36]. Perceiving many organizational and workplace change initiatives as unsuccessful can yield change cynicism [37], which represents feelings that often combine pessimism about the likelihood of successful change with the blame of those responsible for change as incompetent [38]. Change cynicism appears to be a reaction to experiences from within an organization rather than being a general characteristic or trait [7]. Health care professionals who experience change cynicism are unlikely to have positive responses to changes involving the implementation of evidence-based practices.

Another sub-category of indifference, physical responses were described in terms of tiredness or change fatigue, which is exhaustion associated with feelings of being drained and depleted beyond one’s capacity to handle workplace demands and everyday work tasks [39, 40]. Change fatigue is different from various forms of change resistance since the behaviors are often passive, whereas change resistance behaviors are intentional. With change fatigue, individuals become disengaged and do not express their dissent about changes. Because of this passive behavior, change fatigue often is undetected by managers and leaders in organizations [41]. Research suggests that new graduate health care professionals and professionals newly transferred to a unit are more vulnerable to change fatigue [42]. Implementation of evidence-based practices in settings where change fatigue is prevalent can be expected to be difficult.

Physical responses seemed to be intertwined with emotional responses, with the health care professionals reporting a range of emotions, from anxiety and stress to frustration and anger. It is noteworthy that emotional change responses are not highlighted in descriptions of the Coetsee framework [16], but they clearly played an important role among the participants of this study. Emotional responses were only expressed in relation to change resistance and not with regard to change acceptance, i.e., involvement or support. It has been argued that affective aspects of change responses have been overlooked, although both theoretical and empirical studies point to the relevance of the affective element of attitudes [11]. This also has relevance for the implementation of evidence-based practices. For example, a Swedish study found that it was challenging to implement evidence-based palliative care in nursing homes as the desired behavior, providing existential care for the dying, was emotionally charged and presented difficulties even after the staff’s participation in educational interventions to acquire necessary skills and knowledge [43].

We also identified statements attributable to passive resistance. Resistance is the most studied response to change [44], being viewed as any set of intentions and actions that slows down or hinders the implementation of change [45]. Passive resistance revealed itself in reduced work effort, something which could potentially limit the effectiveness and efficiency of implemented evidence-based practices because policies and procedures may not be followed when delivering them, thus limiting their potential benefit. Implementation failure may result in type III error, i.e., attributing null results to an evidence-based practice’s inherent lack of effectiveness when, in actuality, the null results are due to implementation failure [46].

Passive resistance was also expressed in terms of health care professionals’ complaints about changes and thoughts about quitting the job in response to changes. Discontent was expressed by all three professional groups of the study, but physicians more often than registered nurses and assistant nurses complained about their working conditions. Although this response was passive, the participants described how negativity could spread and affect others, thus likely contributing to a culture of discontent that can have negative effects on the productivity.

Our findings concerning passive resistance and active resistance are aligned with research that has shown that physicians often are dissatisfied with their job, which can have negative consequences for their productivity, intent to leave the job, work ability, and amount of sick leave days [47‐49]. The increased workload in combination with reduced autonomy has been identified as key sources of this dissatisfaction [50]. Physicians tend to be critical toward managerial control of their work [51‐53] and are often reluctant to become involved in management-initiated quality improvement initiatives [4]. The central role of physicians for implementation of evidence-based practices in health care is well recognized, as they often act as informal leaders in daily health care practice, functioning both as change agents and gatekeepers to desired changes [54, 55].

Some methodological issues must be considered when interpreting the findings. A qualitative approach was chosen because little is known about change responses in Swedish health care. Interviews with physicians, registered nurses, and assistant nurses were considered the most relevant method for collecting information and gaining a deeper understanding of the topic. The change responses identified in this study are not intended as an exhaustive list of all possible responses; other studies may yield different responses or give different priorities to other factors. The results cannot be directly transferred to other health care settings in Sweden or internationally.

We used Coetsee’s [16] framework to analyze different change responses. According to De Casterle et al. [56], using a preconceived framework runs the risk of prematurely excluding alternative ways of organizing the data that may be more illuminating. However, we did not use Coetsee’s framework to inform the questions presented to the participants, and it was not applied until the second phase of the data analysis, after the data had first been analyzed inductively to arrive at change responses. Choosing one theory, model or framework often means placing weight on some aspects at the expense of others, thus offering only partial understanding [57]. However, Coetsee’s framework [16] was found to be sufficiently broad to allow for a fairly inductive approach. Some of the change response categories were difficult to distinguish from each other, including active and passive change responses although the former category involved taking some sort of action in response to changes whereas the latter category did not. We have sought other studies that may have applied Coetsee’s framework [16] to empirical studies, but we have not been able to find any. Given the usefulness of Coetsee’s framework for understanding change responses, we recommend that the framework be used in future implementation research on change responses.

The multidisciplinary research team was a strength of the study, because it permitted different perspectives on the issue of change responses in health care. The team consisted of the following professions: registered nurse (KS), behavioral scientist (CE), political scientist (IS), behavioral economist (PN), and organizational sociologist (SB). Another strength was the relatively high number of interviews. This allowed us to use quotations from many different participants, which added transparency and trustworthiness to the findings.

In terms of implications for implementation science, our study suggests that change responses may be an underlying explanation for some of the barriers for successful implementation of evidence-based practices often described in implementation research, e.g., lack of awareness, insufficient motivation, negative attitudes or ingrained habits among health care professionals [54]. Change responses may be associated with and/or influence implementation constructs such as receptive context for change [58], readiness for change [13] and tension for change [13, 58, 59], and optimism and beliefs about consequences and capabilities, as described in Theoretical Domains Framework [60]. Also, health care professionals’ change responses may be analogous to change commitment in the Organizational Readiness to Change theory [23]. Coetsee’s framework offers a nuanced way of understanding changes involved in implementation of evidence-based practices, but further research is needed to explore the relationship between change responses and various implementation constructs.

The study also points to the importance of the “timing” of implementing evidence-based practices, i.e., when implementation occurs. While lack of time is described as a barrier in many implementation studies and determinant frameworks (e.g., [61‐63]), the temporality of implementation in relation to other changes seems neglected despite the fact that health care professionals usually face many concurrent changes of relevance for their work. Further, implementation studies typically investigate one change, i.e., one evidence-based practice, at a time rather than viewing changes, including those required when implementing evidence-based practices, in a broader perspective of many simultaneous changes.

In conclusion, this study of health care professionals’ change responses identified 10 types of change responses, which could be mapped onto five of the seven response categories of a framework developed by Coetsee [16]. We found that the many changes are met with indifference or passive resistance. Changes are more likely to be accepted if they are initiated by the health care professionals themselves or feature their active input and when changes are well founded and well communicated. This is valuable knowledge for use in the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.