Background
Despite global investment into the development of new innovations, relatively few research findings are translated into health care practice [
1‐
3]. British acute mental health wards, in particular, have attracted criticism over recent decades for being slow to deliver improvements in care [
4,
5], and for low levels of activity in promoting social engagement and therapeutic interaction [
6,
7]. More research is clearly needed to examine what prevents such changes from being delivered successfully in these settings.
To explore barriers to change in mental health wards, this study will examine the impact of a programme of change on staff perceptions 12 months after its implementation. It should be noted that in the U.K. the term “ward” is commonly used with no negative connotation to refer to an in-patient setting. In this study, “ward” was the term used in the setting where the study was conducted, and as such, will be used to describe the in-patient settings that participated.
Why are improvements needed in mental health wards?
The changes which provided the basis for this study were delivered as part of DOORWAYS, a U.K. National Institute for Health Research funded clinical trial (which is described in more detail later). DOORWAYS was conducted in response to concerns expressed by both patients and staff that acute in-patient wards provide poor quality care, with limited access to activities with an established evidenced base, and insufficient therapeutic interaction [
8,
9]. Indeed, some in-patients have expressed concerns over their safety on mental health wards, with staff who appear too busy to listen to their problems, poor communication and unnecessary reliance on coercive interventions, all factors which damage the nurse/patient relationship [
5,
10]. Given these criticisms and wide concerns that improvements have been not gone far enough [
7], more empirical evidence is needed to understand what supports and prevents changes to move this important area of mental health care forwards. DOORWAYS also investigated the sustainability of positive effects by examining the whether exposure to the programme and the number of increased activities affected staff morale.
What might prevent successful change in acute mental health wards?
In their article [
11], Powell et al. argued in favour of linking implementation strategies to barriers that consider the context of the setting involved. This is important because any impact from health innovations is likely to be influenced by social and organisational factors, which may either enhance or hinder implementation [
12]. In the U.K. (and across Europe) mental health care is now largely delivered in the community after a 20 year process of de-institutionalisation [
13]. As a result, service users are often admitted to mental health wards in acutely unwell states and nurses spend more time responding to crises and less time in therapeutic engagement, a situation which may impede implementation processes [
8,
9,
14,
15]. Mental health wards are dynamic environments with frequent shift rotations of staff and a rapid patient turnover in response to increased demand for beds inner-city areas where demand for beds is high [
16‐
18]. Even before introducing changes, these complex environments are prone to volatility and disruption because the client group are acutely unwell and often distressed [
19], and may be affected either personally or vicariously by the Mental Health Act (2007), which can lead to detention, enforced medication and in some cases to violence [
20].
As well as considering the environment, the views of nursing staff are key because nurses are the largest staff group working in the National Health Service (NHS). As such, nurses can make a significant contribution to the development and running of the services. In mental health wards, nursing staff are responsible for co-ordinating most of the ward activities. They deliver daily care through extensive interactions with those who are admitted as service users. Their cooperation is essential if ward level changes are required. However, research that explores why mental health staff might have difficulties when incorporating innovation into practice is lacking [
21,
22], and the longitudinal impact of changes on staff working in mental health wards has not yet been explored.
Moreover, intensive programmes of change are likely to bring disruption before improvements, and as it is generally well accepted that employees thrive on stability and resist changes that cause uncertainty and disruption [
23,
24], it may be that certain staff in mental health wards find changes harder to cope with than they might, in a more stable setting. This may depend on where they are positioned in the organizational hierarchy of the ward. In the general health literature there is evidence that nurses respond differently to changes according to their occupational status, with managers having more positive responses to change than more junior staff [
25]. In our previous studies, we found that occupational status predicted perceptions of barriers to change in mental health ward staff [
26,
27]. This study will develop that finding by examining whether staff perceptions in two different occupational categories (senior staff and direct care staff) changed over time, as a result of participation in DOORWAYS.
Although it is clear that changes are challenging in mental health wards, there is little evidence to support strategies for change in these settings. To minimise potentially damaging impacts on staff morale and on the nurse/patient relationship when changes are made, more empirical evidence is required which explores how changes affect staff. This will support the development of evidence-based strategies which empower staff to make changes that take the environment into account, as part of the process. There is some evidence that ward climate adversely affects how mental health nursing staff respond to changes [
17]. Our previous work also showed that ward climate affects how staff perceive barriers to change in mental health wards [
28]. However, there is a particular lack of evidence which takes the longitudinal effects on changes on staff into consideration. This study develops current evidence by exploring whether different ward settings influenced the perceptions of the staff who worked there, across time. Taking a longer term view of the effects of change on staff may help inform why changes have been difficult to embed in mental health wards.
Results
Overall, the analyses revealed that nursing staff who participated in the DOORWAYS intervention had significantly worse perceptions of barriers to change at the twelve month follow up, whilst the perceptions of those in the control group did not change over time. In both the intervention and control groups (N = 120), both ward and occupational status affected staff perceptions of barriers to change. However, across time, direct care staff in the intervention group exhibited more negative perceptions of barriers to change than those in the control group.
Given all staff with baseline data were included in the analysis whether or not they had follow up data, and those with follow up data were limited, the most representative picture of the sample characteristics can be seen at baseline. Table
3 describes the baseline characteristics of the staff participants from 8 wards. Wards differed in terms of the number of participants and the range of grades represented.
Table 3
Characteristics of the baseline participants [
27]
N= | No. of staff | 18 (15) | 13 (10) | 16 (12) | 8 (6) | 19 (15) | 15 (12) | 18 (15) | 18 (15) | 125 (100) |
Staff Grade | HCA | 7 | 3 | 6 | 1 | 5 | 4 | 7 | 6 | 39 (31) |
Band 5 | 8 | 7 | 7 | 3 | 12 | 8 | 7 | 6 | 58 (47) |
Band 6 | 1 | 2 | 1 | 3 | 1 | 0 | 3 | 4 | 15 (12) |
Band 7 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 (6) |
missing | 1 | 0 | 1 | 0 | 0 | 2 | 0 | 1 | 5 (4) |
Ethnic Group | White British /Other | 6 | 2 | 3 | 4 | 5 | 3 | 4 | 6 | 33 (27) |
BME | 12 | 11 | 12 | 4 | 14 | 12 | 14 | 10 | 89 (71) |
missing | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 2 | 3 (2) |
Gender | Male | 3 | 7 | 12 | 0 | 9 | 3 | 9 | 3 | 46 (37) |
Female | 15 | 6 | 4 | 8 | 10 | 12 | 9 | 15 | 79 (63) |
Age | Mean | 39.63 (13.0) | 36.38 (7.61) | 38 (7.93) | 44.25 (4.80) | 43.26 (9.94) | 35.38 (8.82) | 39.6 (8.61) | 40.07 (9.85) | 39.57 |
max/ min | 27–50 | 22–62 | 24–55 | 37–49 | 26–67 | 22–48 | 27–55 | 23–54 | N/A |
Table
4 outlines the numbers of staff who participated at follow up, providing repeated measures.
Table 4
The repeated measures sample numbers only
Number of staff | 4 | 10 | 3 | 3 | 12 | 3 | 9 | 10 | 54 (100) |
Group (INT/CTL) | CTL | CTL | INT | INT | INT | CTL | CTL | INT | INT:28 (52) CTL:26 (48) |
Although all repeat participants remained on the same ward at both baseline and follow-up, shift rotations and sickness absences had the largest impact on follow-up participation. By using unstructured multivariate linear models the number of cases included in the final analyses (shown below in Table
5) was
N = 120. At baseline, more than 60% of staff identified the following barriers (which are original items from the VOCALISE measure [
27]) in 8 areas (detailed in Appendix):
-
We can easily fit new changes in with our usual ward practices (72% agreed)
-
I feel disheartened when others do not want to get involved in changes (77% agreed)
-
I think that managing risk is more important than delivering new changes (64% agreed).
-
I find it de-motivating when new changes do not take patients’ wishes into account (86% agreed).
-
I think that some staff would rather let others take the lead in making changes (79% agreed).
-
When some staff stop engaging with planned changes resistance spreads through my whole team (65% agreed).
-
Inadequate staffing prevents changes being successful on my ward (89% agreed).
-
Poor leadership prevents changes happening on my ward (61% agreed).
Table 5
Unstructured multivariate linear model (N = 120, 8 wards) exploring whether participation in the intervention affected staff perceptions of barriers to change, adjusting for time, ward and occupational status
Intervention effect | −5.16 | 2.62 | 0.05 | −10.30 | −0.02 |
Time | 5.39 | 1.84 | 0.003 | 1.78 | 9.00 |
Ward | CTRL | Ward 2 | −0.45 | 3.83 | 0.91 | −7.95 | 7.05 |
INT | Ward 3 | −6.31 | 3.72 | 0.09 | −13.60 | 0.98 |
INT | Ward 4 | −11.12 | 4.57 | 0.01 | −20.08 | −2.16 |
INT | Ward 5 | −12.06 | 3.50 | 0.001 | −18.91 | −5.21 |
CTRL | Ward 6 | −9.67 | 3.88 | 0.01 | −17.27 | −2.07 |
CTRL | Ward 7 | −8.14 | 3.53 | 0.02 | −15.07 | −1.22 |
INT | Ward 8 | −7.48 | 3.64 | 0.04 | −14.61 | −0.35 |
Occupational status: manager/direct care staff | −4.91 | 2.45 | 0.04 | −9.71 | −0.11 |
_cons | 69.81 | 2.56 | 0 | 64.79 | 74.83 |
Unstructured multivariate linear model exploring impact of the DOORWAYS intervention on staff perceptions of barriers to change, including covariates time, occupational status and ward
The impact of the intervention effect, time, occupational status and ward on VOCALISE were tested in an unstructured multivariate model (Table
5).
Overall this model was significant (χ2 (10) = 31.48; p > 0.001).
Intervention effect
In this model, the constant is the predicted mean score at baseline, if study group = 0 (control) and time is 0 and occupational status = 0 (or 1 for ward). The constant is the same for both the control and intervention groups, because a zero treatment effect is enforced at baseline. This meets the assumption of an RCT that there is no difference between scores at baseline, because any actual difference is assumed to exist by chance.
Perceptions of barriers to change were significantly higher (and therefore more negative) in the intervention group than the control group at follow up, after adjusting for all other covariates. At follow up, the estimate for the intervention effect variable shows that the predicted mean score in the intervention group was 5.16 more than the predicted mean score in the control group. This interpretation was not affected by reversing the coding.
Time
There was a difference in the way that the two groups responded to change over time. There was evidence (p = 0.003) of a change (adjusted for all other included covariates) in the estimated mean outcome score between baseline and follow up, in the intervention group. Over time, the scores in the intervention group became significantly worse because they increased by 5.39 points. The predicted mean outcome score in the intervention group at follow up was (75.20; C.I: 69.02 to 81.38). There was no significant change over time in the control group (Coef β: 0.23; S.E: 1.86; p = 0.90; C.I: − 3.42 to 3.89), if the model was rerun, changing the coding. The predicted mean outcome score in the control group at follow up was (70.04; C.I: 64.01to 76.07), showing little change from the baseline score.
Covariates
Occupational status significantly affected staff perceptions of barriers to change across time (
p = 0.05), after adjusting for all other predictors. Post hoc, the mean predicted perceptions of barriers to change for those in direct care positions were more negative than those in more senior positions (Table
6).
Table 6
Predicted mean estimates for staff perceptions of barriers to change, according to (1) occupational status and (2) the interaction between time and occupational status
1. Occupational status only | Both groups | 0 | 69.77 (64.75 to 74.79) | 65.40 (58.80 to 71.99) |
Control group | FU | 70.85 (64.66 to 77.03) | 63.23 (55.08 to 71.37) |
Intervention group | FU | 75.85 (69.56 to 82.13) | 68.23 (59.76 to 76.69) |
2. Occupational status*time | Both groups | 0 | 69.77 (64.75 to 74.79) | 65.40 (58.80 to 71.99) |
Control group | FU | 70.85 (64.66 to 77.03) | 63.23 (55.08 to 71.37) |
Intervention group | FU | 75.85 (69.56 to 82.13) | 68.23 (59.76 to 76.69) |
The model does not explain whether the direct care staff perceptions of barriers to change grew more negative as a result of participation in the intervention. However, adding an interaction between time and occupational status showed a significant effect at follow up, in both groups (Coef β: -7.62; S.E: 3.55;
p = 0.03; C.I:-14.59 to − 0.65). Table
6 shows more negative change in the perceptions of direct care staff in the intervention group.
The estimate for ward shows that there was a direct effect of certain wards on the outcome across time. The staff on ward 1, which was the reference category and a control ward, had the most negative perceptions as indicated by the constant (69.81). There was a significant difference between the reference ward and wards 4 to 8, which shows that perceptions of barriers to change varied by ward.
The adjusted mean outcome scores were computed post hoc (Table
7), which showed that perceptions on the intervention wards became more negative across time than those on the control wards.
Table 7
Mean estimates for staff perceptions of barriers to change by ward
1 (CTRL) | 69.81 (64.79 to 74.83) | 70.04 (64.01 to 76.07) |
2 (CTRL) | 69.36 (63.62 to 75.10) | 69.59 (63.32 to 75 86) |
6 (CTRL) | 60.14 (54.39 to 65.89) | 60.37 (53.61 to 67.13) |
7 (CTRL) | 61.67 (56.73 to 66.60) | 61.90 (56.14 to 67.65) |
3 (INT) | 63.50 (58.15 to 68.86) | 68.89 (62.59 to 75.19) |
4 (INT) | 58.69 (51.08 to 66.30) | 64.08 (55.89 to 72.26) |
5 (INT) | 57.75 (53.00 to 62.50) | 63.14 (57.61 to 68.68 |
8 (INT) | 62.33 (57.11 to 67.55) | 67.72 (61.85 to 73.59) |
Including an interaction between ward and time was not possible in the model because there were a limited number of participants per ward.
Discussion
Although the Nursing & Midwifery Council in the United Kingdom states that nursing staff should practice in line with the best available evidence [
43], there is still a prominent disconnect between frontline practice and research evidence. Previous attempts to improve the uptake of research evidence into healthcare practice have generally targeted service users to adopt new interventions. This means that the role of ward staff in innovation has not been adequately investigated.
This study was part of an RCT (DOORWAYS) to improve the therapeutic milieu by delivering predominantly nurse led, CBT-based interventions. Although DOORWAYS had a positive impact on involuntary service user perceptions of, and satisfaction with, mental health wards [
8,
9], there were also negative side effects from the changes, as staff perceptions of barriers to change worsened in those who participated in the intervention group. This finding provides support for the theories of Lewin [
23] and Schein [
24], who suggested that change brings disruption that can create resistance amongst staff. As well as barriers which were linked to resourcing issues, such as staffing, a number of the barriers perceived by staff at baseline also reflected a sense of demotivation amongst the workforce, an issue which may have perpetuated in the intervention group as the implementation process progressed (see Appendix, Table 8).
Given DOORWAYS was an externally devised change delivered in the form of a randomised controlled trial that was imposed at the ward level using a top down approach, it is perhaps unsurprising that staff responded negatively. This finding is in line with the wider management and heath literature which shows that changes implemented using a top down approach, with little input from front line staff can produce negative outcomes of increased stress, reduced job satisfaction, reduced psychological well-being and lower motivation [
44,
45].
However, DOORWAYS did involve nursing stakeholders, and many of the practical suggestions made by frontline staff were adopted at the implementation stage. Senior ward staff (but not frontline staff, who were expected to implement the changes) were involved in discussion about the project upfront. Feedback from frontline staff was incorporated into the strategy via the psychologist who helped staff to set up each wards groups and also provided training, support and leadership to staff to enhance the learning process. It may be, therefore, that these findings reflect insufficient front line staff involvement or the high levels of nursing input required by the DOORWAYS intervention, in addition to their other tasks, with no time/resource allowance for that. As resources are limited in mental health wards, additional support may be required if complex RCTs are to be conducted in mental health wards in the future. Policy makers, National Health Service trusts and higher education settings might give further thought to how resources can be better allocated, given RCTs bring valuable learning experiences, which develop frontline staff, as well as measureable improvements and increased funding.
Although developing and implementing changes at the local level can produce more positive responses in frontline staff [
46], these types of studies are rare. Future research programmes that seek to deliver substantial changes may need to develop implementations strategies which incorporate much greater stakeholder involvement, which could also be formally assessed over the period of change. This would also allow an exploration of whether more active stakeholder involvement might improve how staff regard barriers to change on the wards. In this way, feasibility issues might be addressed by encouraging staff generated adaptations that better suit the clinical environment.
Including contextual covariates in the model provided additional information to show that both occupational status and ward are involved in how staff respond to changes. In both groups, direct care staff had more negative perceptions of barriers to change than more senior staff. These findings are in line with previous literature [
17,
25]. In both groups, the estimated mean VOCALISE scores on each ward at T1 revealed that some wards had significantly different scores from the reference ward (ward 1, a control ward). Irrespective of group allocation, there were also staff with more positive perceptions of barriers to change, both at the outset and at follow-up. It may be that staff who are more optimistic at the outset, simply remain more positive throughout, which suggests that some staff are better at coping with changes than others.
The model was not able to explain whether the relationship between ward climate and participation in DOORWAYS resulted in a negative effect on perceptions of barriers to change. However, by including an interaction between occupational status and time, it was possible to show that the changes introduced by DOORWAYS had a more detrimental on direct care staff than managers, over the 12 moth time period. This finding extends the current literature, and suggests that future change programmes should be sensitive to those working in demanding, direct care roles, at the inception of change, and through the implementation phase, as this sub-group may need extra support.
This study highlights negative side effects in terms of worsened perceptions of barriers to change as a result of a Trust-wide planned change, in a sample of mental health ward nurses. However, there were some limitations. First, as only one type of change was explored the results may not explain how ward staff might react to other types of innovation.
In addition, as this research was conducted in one trust, our understanding of the impact of DOORWAYS is restrictive. To ensure that future findings are widely generalizable, more than one organisation should be sampled. To better understand the impact of ward on perceptions of barriers to change, a larger number of wards should be included.
In implementation studies which are concerned with barriers in complex settings, the need to include contextual variables can mean that very large amounts of data are necessary to fully understand the picture. The large dropout rates in staff measures prevented an exploration of the bigger implementation picture (from initial disruption to embedding and sustaining changes), which might have been provided by the month long, stepped-wedge design of the DOORWAYS trial. This study was limited to using data from the 12 month time point, where 4 control wards could be compared to 4 wards that had received the intervention. This also meant that the amount of exposure to change was different (either 6 months or 12 months) which was a limitation. Nonetheless, unstructured multivariate linear models were used to overcome the reduced sample size. This method may therefore usefully inform future implementation studies.
Conclusion
This study showed that participation in a clinical trial (DOORWAYS), which represented a period of intense change, had a negative impact on mental health ward staff perceptions of barriers to change. Given the large and often stressful workloads of mental health ward staff, careful thought should be given to supportive change management strategies that take the perspective of these staff into account. Involving staff in the development of research initiatives early on, may help to reduce resistance later on. Research programmes should also consider including a flexible implementation strategy, which may be informed by ward staff, to assess the impact and reduce the burden of changes.
In addition, occupational status (being from the direct care group) worsened staff perceptions of barriers to change in both the intervention and control groups. However, those in the intervention group became more negative in their views of change across time, having participated in DOORWAYS. This suggests that staff who provide direct care should be offered extra support when changes are introduced.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.