Exploring Faith Leaders' Experiences in Supporting Individuals with Mental Health Challenges in Ottawa, Canada.

Faith leaders are often called upon to provide mental health support to their congregants, yet there is limited research on how these leaders experience this aspect of their role. The objective of this study is to understand the experiences of faith leaders who are sought by individuals for mental health support. We report on the findings from a qualitative study based on interviews with faith leaders of different denominations in Ottawa, Canada. The results indicate that faith leaders are asked to provide support for a wide - but not comprehensive - range of mental health issues; that faith leaders experience various challenges in managing role boundaries; and that these leaders believe that training not only in mental health issues, but also on subjects of liability and self-care to maintain their own wellness would be valuable. We address implications for research and practice.

Transcending technology boundaries and maintaining sense of community in virtual mental health peer support: a qualitative study with service providers and users.

BACKGROUND: This qualitative study explores the experiences of peer support workers (PSWs) and service users (or peers) during transition from in-person to virtual mental health services. During and following the COVID-19 pandemic, the need for accessible and community-based mental health support has become increasingly important. This research aims to understand how technological factors act as bridges and boundaries to mental health peer support services. In addition, the study explores whether and how a sense of community can be built or maintained among PSWs and peers in a virtual space when connections are mediated by technology. This research fills a gap in the literature by incorporating the perspectives of service users and underscores the potential of virtual peer support beyond pandemic conditions. METHODS: Data collection was conducted from a community organization that offers mental health peer support services. Semi-structured interviews were conducted with 13 employees and 27 service users. Thematic analysis was employed to identify key themes and synthesize a comprehensive understanding. RESULTS: The findings highlight the mental health peer support needs that were met through virtual services, the manifestation of technology-based boundaries and the steps taken to remove some of these boundaries, and the strategies employed by the organization and its members to establish and maintain a sense of community in a virtual environment marked by physical distancing and technology-mediated interrelations. The findings also reveal the importance of providing hybrid services consisting of a mixture of in person and virtual mental health support to reach a broad spectrum of service users. CONCLUSIONS: The study contributes to the ongoing efforts to enhance community mental health services and support in the virtual realm. It shows the importance of virtual peer support in situations where in-person support is not accessible. A hybrid model combining virtual and in-person mental health support services is recommended for better accessibility to mental health support services. Moreover, the importance of organizational support and of equitable resource allocation to overcome service boundaries are discussed.

Occupational stressors and coping mechanisms among obstetrical nursing staff during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Due to heightened occupational stress throughout the COVID-19 pandemic, hospital nurses have experienced high rates of depression, anxiety, and burnout. Nurses in obstetrical departments faced unique challenges, such as the management of COVID-19 infection in pregnancy with limited evidence-based protocols and the unknown risks of the virus on pregnancy and fetal development. Despite evidence that obstetrical nurses have experienced high levels of job stress and a decrease in job satisfaction during the COVID-19 pandemic, there is less known about the working conditions resulting in these changes. Using the Job Demands-Resources (JD-R) model, this study aims to offer insight into the COVID-19 working environment of obstetrical nurses and shed light on their COVID-19 working experiences. METHODS: The study was conducted using a qualitative approach, with data collection occurring through semi-structured interviews from December 2021 to June 2022. A total of 20 obstetrical nurses recruited from the obstetrical departments of a tertiary hospital located in Ontario, Canada, participated in the study. Interviews were audio-recorded, transcribed verbatim, and coded using NVivo. Data was analyzed using a theoretical thematic approach based on the JD-R model. RESULTS: Four themes were identified: (1) Job stressors, (2) Consequences of working during COVID-19, (3) Personal resources, and (4) Constructive feedback surrounding job resources. The findings show that obstetrical nurses faced several unique job stressors during the COVID-19 pandemic but were often left feeling inadequately supported and undervalued by hospital upper management. However, participants offered several suggestions on how they believe support could have been improved and shared insight on resources they personally used to cope with job stress during the pandemic. A model was created to demonstrate the clear linkage between the four main themes. CONCLUSIONS: This qualitative study can help inform hospital management and public policy on how to better support and meet the needs of nurses working in obstetrical care during pandemics. Moreover, applying the JD-R model offers both a novel and comprehensive look at how the COVID-19 hospital work environment has influenced obstetrical nurses' well-being and performance.

Work-life boundary management of peer support workers when engaging in virtual mental health support during the COVID-19 pandemic: a qualitative case study.

BACKGROUND: Mental health care needs have increased since the COVID-19 pandemic was declared. Peer support workers (PSWs) and the organizations that employ them have strived to provide services to meet increasing needs. During pandemic lockdowns in Ontario, Canada, these services moved online and were provided by PSWs from their homes. There is paucity of research that examines how providing mental health support by employees working from home influences their work-life boundaries. This research closes the gap by examining experiences of work-life boundary challenges and boundary management strategies of PSWs. METHODS: A qualitative case study approach was adopted. Interviews with PSWs who held formal, paid positions in a peer support organization were conducted. Data was analyzed thematically using both inductive and deductive approaches. Descriptive coding that closely utilized participants' words was followed by inferential coding that grouped related themes into conceptual categories informed by boundary theory. Member checking was conducted. RESULTS: PSWs provided accounts of work-life boundary challenges that we grouped into three categories: temporal (work schedule encroachments, continuous online presence), physical (minimal workspace segregation, co-presence of household members and pets) and task-related (intersecting work-home activities). Strategies used by PSWs to manage the boundaries consisted of segmenting the work-life domains by creating separate timescapes, spaces and tasks; and integrating domains by allowing some permeability between the areas of work and life. CONCLUSION: The findings from this study can help inform management, practices, future research and policy on health care workforce. The study highlights the need to attend to the consequences of greater work-life integration for mental health workers since their successful practice is largely dependent on maintaining self-care. Training regarding work-life boundary management is highlighted as one of the ways to approach situations where work from home is required.

A Narrative Review of Factors Influencing Peer Support Role Implementation in Mental Health Systems: Implications for Research, Policy and Practice.

With increasing calls to incorporate recovery principles into conventional mental health care, the importance of peer support worker (PSW) services has gained attention. However, studies consistently show that PSWs remain underutilized. Although research addresses several factors that influence formal implementation of their role, there is lack of a comprehensive framework that synthesizes the factors and addresses their interlevel interactions. This paper provides a narrative review and synthesis of literature on multilevel factors that influence formal PSW role implementation in mental health systems. We conducted a search of literature and reviewed 38 articles that met inclusion criteria. Our thematic analysis involved identifying first and second order categories that applied across studies, and developing third order interpretations through iterations. We synthesized the findings in a multilevel framework consisting of macro, meso and micro level influences. Influencing factors at the macro level include broader socio-cultural factors (medical model, recovery values, professional power dynamics, training and certification), regulatory and political factors (policy mandates, political commitment), and economic and financial factors (funding, affordability of services). Factors at the meso level include organizational culture, organizational leadership, change management, and human resource management policies. Micro level influences pertain to relationships between PSWs and team members, and PSW wellbeing. Interlevel interactions are also outlined. Limitations and implications for research, policy and practice are addressed.

"The Land Nurtures Our Spirit": Understanding the Role of the Land in Labrador Innu Wellbeing.

We examined Indigenous views of wellbeing, aiming to understand how the Labrador Innu view influence of land on their health. The Innu live in two First Nation communities (Sheshatshiu and Natuashish) in the subarctic portion of the province of Newfoundland and Labrador, Canada. Their views on land and wellbeing are context specific and have not been studied; our research addresses this significant gap in literature. Findings highlight that the experience of being on the land with family and community, learning cultural knowledge, and gaining a sense of identity play a major role in enhancing wellbeing. Externally imposed policies and programs conceiving Indigenous land as a physical place only fail to understand that land sustains wellbeing by emplacing knowledge systems and cultural identity.

A process of healing for the Labrador Innu: Improving health and wellbeing in the context of historical and contemporary colonialism.

In light of the negative effects of historical and contemporary colonialism on the Labrador Innu, healing initiatives grounded in self-determination, renewal of cultural practices, and non-reliance on Western bio-medicine, are known, taught and widely practiced among the Innu. The value of Indigenous healing practices in the treatment of Indigenous people is well-recognized in Indigenous wellness literature, yet non-Indigenous health practitioners know little about healing processes. Moreover, to our knowledge, no studies have examined any contemporary Labrador Innu healing process. The main aim of this paper is to describe the process of healing among the Innu. Although there may be multiple processes of healing, we shed light on a major process that emerged from interviews and focus groups with 39 participants. Five stages of healing were described: being "under the blanket"; finding spiritual strength; extending hands out; finding strength and power; and helping others. Findings highlighted enablement of healing through spiritualities, support from Elders, return to culture, and resistance to negative stereotypes. We provide health professionals with valuable information for considering Innu healing as a model that expands their views for the benefit of Innu seeking mental health services. Implications for non-Innu health and social service providers are about broadening their understanding of the significant role of self-determination among Innu, learning Innu ways-of-knowing and being, recognizing one's own biases, and acknowledging the power imbalances between themselves and Innu people.

Learning from health system reform trajectories in seven Canadian provinces.

In publicly funded health systems, reform efforts have proliferated to adapt to increasingly complex demands. In Canada, prior research (Lazar et al., 2013, Paradigm Freeze: Why is it so Hard to Reform Health Care in Canada?, McGill-Queen's Press) found that reforms at the end of the 20th century failed to change the fundamentals of the Canadian system based on physician independence and assured universal coverage only for medical and hospital services. This paper focuses on reforms since the turn of the millennium to explore the transformative capacities developed in seven provinces within this system architecture. Longitudinal case studies, based on scientific and grey literature, and interviews with key informants, trace the patterns of reform in each province and reveal five objectives that, to varying degrees, preoccupied reformers: (1) address chronic disease, (2) align health system actors with provincial objectives, (3) shift from hospital to community-based care, (4) integrate physicians, and (5) develop improvement capacities. The range of strategies adopted to achieve these objectives in different provinces is compared to identify emerging pathways of reform and extract lessons for future reformers. We find significant cross-learning between provinces, but also note an emergent dimension to reforms, where multiple strategies aggregate through time to create unique patterns, presenting their own set of possibilities and limitations for the future.

Developing an Innu framework for health research: The canoe trip as a metaphor for a collaborative approach centered on valuing Indigenous knowledges.

Indigenous communities increasingly assert their right to self-determination by requiring that participatory research approaches be used, valuing and prioritizing Indigenous knowledges, for the purpose of improving Indigenous health. While frameworks that focus on Indigenous knowledges are being developed, these must be adapted or developed by Indigenous communities because their knowledge is specific to place and inherent to their lived experience. No community-based participatory research (CBPR) framework for health research has been developed with the Labrador Innu. In addition, while the literature emphasizes the importance of relationship in research with Indigenous communities, the process of establishing relationships is underspecified. Within this context, we describe our experience in developing a CBPR framework for health research in a study that is community-initiated and fitting within Innu self-determination. We highlight the importance of paying attention to the theoretical roots of CBPR, arguing that this helps researchers focus on the centrality of Indigenous knowledges (in this case, Innu knowledge). This requires that non-Indigenous researchers question assumptions of universality regarding their own knowledge and see all knowledges as equitable. Such posture of humility allows non-Indigenous researchers to enter relational spaces that join researchers and Indigenous communities. Within these spaces, a true collaborative approach is enabled and Indigenous knowledges are uncovered and become foundational in the inquiry process. We illustrate these ideas by describing a model for opening relational spaces that include Indigenous and non-Indigenous researchers. We then present a framework that uses the metaphor of canoeing together to capture our CBPR approach for use in Innu health research. We outline the behaviors of non-Indigenous researchers to build and solidify relationships with Indigenous community researchers over time. This article is useful for non-Indigenous researchers interested in relational approaches to research with Indigenous communities, and for Indigenous leaders and researchers who seek community solutions through research.

Examining health care providers' and middle-level managers' readiness for change: a qualitative study.

BACKGROUND: Readiness is a critical precursor of successful change; it denotes whether those involved in the change are motivated and empowered to participate in the change. Research on readiness tends to focus on frontline providers or individuals in non-managerial positions and offers limited attention to individuals in middle management positions who are expected to lead frontline providers in change implementation. Yet middle-level managers are also recipients of changes that are planned and decreed by those in higher positions. This study sought to examine both frontline provider and middle manager readiness for change in the context of primary care program integration. METHODS: Using a qualitative case study approach, we examined how frontline providers and middle managers experienced six readiness factors: discrepancy, appropriateness, valence, efficacy, fairness and trust in management. Data were collected through documents, meeting observation and semi-structured interviews with frontline providers and middle managers involved in the change. RESULTS: The findings highlighted similarities and differences in readiness experiences of frontline providers and middle managers. Across both types of participants, we found that the notion of valence should be expanded to consider individuals' evaluation of benefits to patients and the health system; efficacy applies to both content and process of change; fairness and trust in management findings require further exploration to determine their appropriateness to be incorporated in models of readiness for change; and trust in management (or lack of trust) has a cascading influence across the levels in the organization. CONCLUSIONS: Our study makes a contribution by nuancing and extending conceptualizations of individual readiness factors, and by highlighting the central role of middle manager readiness for change. Implications of the study include the need to consider readiness factors prior to the implementation of change and the importance of fostering readiness throughout all levels of the organization.

Residents' perceptions of radon health risks: a qualitative study.

BACKGROUND: Radon is a high impact environmental pollutant and is the second leading cause of lung cancer in Canada. Building design, extended winter, and geographical location expose residents of Ottawa-Gatineau (the national capital region in Canada) to an increased risk. It is surprising that residents have an inadequate awareness of the risk - despite its gravity - and have taken minimum preventive actions. This study explores perceptions of radon health risk and examines the factors that enable and hinder the adoption of preventive measures among Ottawa-Gatineau residents. METHODS: We conducted semi-structured interviews with 35 residents with varying educational and income levels to inquire about their knowledge and perception of radon, and to explore their views of enablers and obstacles to taking action to reduce radon risks. Thematic, inductive data analysis was undertaken. RESULTS: The results indicate that: 1) Residents obtained information on radon from various sources that include the media, their education or occupation, their social network, and home renovation events. Limited references were made to the National Radon Program responsible for testing for radon and informing residents. 2) Awareness of radon risk varied, and the knowledge retained by some residents is insufficient to adequately protect their health. 3) Enablers for taking protective action included: having an understanding of the risk along with health consciousness; caring for family and children; knowing others who had contracted lung cancer and having financial resources. Obstacles consisted of: lack of awareness; cost; lack of home ownership; and potential difficulty in selling the house. 4) Residents attributed primary responsibility to public agencies for disseminating information, and incentivizing or mandating action through more stringent regulation. CONCLUSION: Risk perceptions are subjective, and are influenced by micro and macro level factors. Inducing protective action to reduce risk requires comprehensive interventions taking into account the dual cognitive and emotional aspects of risk perception. Future research may explore the dual aspects of risk perception and examine the contents of the risk communication message. Policy should address the responsibility of both governments and residents in tackling the issue.

Barriers and enablers to a physician-delivered educational initiative to reduce low-acuity visits to the pediatric emergency department.

BACKGROUND: Use of the pediatric emergency department (PED) for low-acuity health issues is a growing problem, contributing to overcrowding, longer waits and higher health system costs. This study examines an educational initiative aimed at reducing low-acuity PED visits. The initiative, implemented at an academic pediatric hospital, saw PED physicians share a pamphlet with caregivers to educate them about appropriate PED use and alternatives. Despite early impacts, the initiative was not sustained. This study analyzes the barriers and enablers to physician participation in the initiative, and offers strategies to improve implementation and sustainability of similar future initiatives. METHODS: Forty-two PED physicians were invited to participate in a semi-structured individual interview assessing their views about low-acuity visits, their pamphlet use, barriers and enablers to pamphlet use, and the initiative's potential for reducing low-acuity visits. Suggestions were solicited for improving the initiative and reducing low-acuity visits. Constant comparative method was used during analysis. Codes were developed inductively and iteratively, then grouped according to the Theoretical Domains Framework (TDF). Efforts to ensure study credibility included seeking participant feedback on the findings. RESULTS: Twenty-three PED physicians were interviewed (55%). Barriers and enablers for pamphlet use were identified and grouped according to five of the 14 TDF domains: social/professional role and identity; beliefs about consequences; environmental context and resources; social influences; and emotions. CONCLUSIONS: The TDF provided an effective approach to identify the key elements influencing physician participation in the educational initiative. This information will help inform behavior change interventions to improve the implementation of similar future initiatives that involve physicians as the primary educators of caregivers.

Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices.

OBJECTIVES: Voluntary reporting of incidents is a common approach for improving patient safety. Reporting behaviors may vary because of different frames within and across professions, where frames are templates that individuals hold and that guide interpretation of events. Our objectives were to investigate frames of physicians and nurses who report into a voluntary incident reporting system as well as to understand enablers and inhibitors of self-reporting and peer reporting. METHODS: This is a qualitative case study-confidential in-depth interviews with physicians and nurses in General Internal Medicine in a Canadian tertiary care hospital. RESULTS: Frames that health care practitioners use in their reporting practices serve as enablers and inhibitors for self-reporting and peer reporting. Frames that inhibit reporting are shared by physicians and nurses, such as the fear of blame frame regarding self-reporting and the tattletale frame regarding peer reporting. These frames are underpinned by a focus on the individual, despite the organizational message of reporting for learning. A learning frame is an enabler to incident reporting. Viewing the objective of voluntary incident reporting as learning allows practitioners to depersonalize incident reporting. The focus becomes preventing recurrence and not the individual reporting or reported on. CONCLUSIONS: Physicians and nurses use various frames that bound their views of self and peer incident reporting-further progress should incorporate an understanding of these deep-seated views and beliefs.

Incident reporting systems: a comparative study of two hospital divisions.

BACKGROUND: Previous studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions' use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process. METHOD: The data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature. RESULTS: The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback). CONCLUSIONS: The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. Implications for practice are addressed.

Double checking: a second look.

RATIONALE, AIMS AND OBJECTIVES: Double checking is a standard practice in many areas of health care, notwithstanding the lack of evidence supporting its efficacy. We ask in this study: 'How do front line practitioners conceptualize double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?' METHOD: This is part of a larger qualitative study based on 85 semi-structured interviews of health care practitioners in general internal medicine and obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. RESULTS: Weaknesses in the double checking process include inconsistent conceptualization of double checking, double (or more) checking as a costly and time-consuming procedure, double checking trusted as an accepted and stand-alone process, and double checking as preventing reporting of near misses. Alternate views of double checking that would render it a more robust process include recognizing that double checking requires training and a dedicated environment, Introducing automated double checking, and expanding double checking beyond error detection. These results are linked with the concepts of collective efficiency thoroughness trade off (ETTO), an in-family approach, and resilience. CONCLUSION(S): Double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.

Distributed leadership in health care teams: Constellation role distribution and leadership practices.

BACKGROUND AND PURPOSE: Recent literature has been critical of research that adopts a narrow focus on single leaders and on leadership attributes and has called for attention to leadership that is distributed among individuals and to practices in which leaders engage. We conducted a study of health care teams where we attended to role distribution among leadership constellation members and to loose or tight coupling practices between leaders and the remainder of the team. This focus provides insights into how leadership can be practiced and structured to enhance team functioning. METHODOLOGY: A qualitative, multicase study of four teams was conducted. Data collection involved 44 interviews with almost all the members of the teams and 18 team meeting observations. Thematic analysis was conducted by the two authors. FINDINGS: Leadership constellations can give rise to leadership role overlaps and gaps that may create ambiguity within teams, ambiguity is diminished if the leaders can agree on which leader assumes ultimate authority in an area, the presence of more leaders does not necessarily entail more comprehensive fulfillment of team needs, and teams' needs for tight or loose leadership practices are influenced by contextual factors that we elaborate. PRACTICE IMPLICATIONS: (a) It is important to recognize areas of overlap and gaps in leadership roles and to provide clarity about role boundaries to avoid ambiguity. Role mapping exercises and open discussions should be considered. (b) Attempting to spread formal leadership responsibilities informally among individuals is not always a workable strategy for addressing team needs.

Peer Support Providers' Role Experiences on Interprofessional Mental Health Care Teams: A Qualitative Study.

This study explores how peer support providers' roles are defined and integrated in inter-professional mental health care teams, and how these providers relate to other practitioners and clients. Interviews were conducted with peer support providers in two different formal models of peer support employment. Qualitative data analysis was undertaken. The findings indicate that: peer support providers experience ambiguity and that some ambiguity may offer benefits; peer support providers enhance team acceptance of their role through several means and strategies; setting boundaries with clients is a delicate issue that requires several considerations that we discuss.

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting.

INTRODUCTION: Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches. METHODS: We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature. RESULTS: 'Fixing and forgetting' was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients' safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was 'fixing and reporting' mentioned as a way that the providers dealt with problems that they could resolve. CONCLUSIONS: We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice.

Role construction and boundaries in interprofessional primary health care teams: a qualitative study.

BACKGROUND: The move towards enhancing teamwork and interprofessional collaboration in health care raises issues regarding the management of professional boundaries and the relationship among health care providers. This qualitative study explores how roles are constructed within interprofessional health care teams. It focuses on elucidating the different types of role boundaries, the influences on role construction and the implications for professionals and patients. METHODS: A comparative case study was conducted to examine the dynamics of role construction on two interprofessional primary health care teams. The data collection included interviews and non-participant observation of team meetings. Thematic content analysis was used to code and analyze the data and a conceptual model was developed to represent the emergent findings. RESULTS: The findings indicate that role boundaries can be organized around interprofessional interactions (giving rise to autonomous or collaborative roles) as well as the distribution of tasks (giving rise to interchangeable or differentiated roles). Different influences on role construction were identified. They are categorized as structural (characteristics of the workplace), interpersonal (dynamics between team members such as trust and leadership) and individual dynamics (personal attributes). The implications of role construction were found to include professional satisfaction and more favourable wait times for patients. A model that integrates these different elements was developed. CONCLUSIONS: Based on the results of this study, we argue that autonomy may be an important element of interprofessional team functioning. Counter-intuitive as this may sound, we found that empowering team members to develop autonomy can enhance collaborative interactions. We also argue that while more interchangeable roles could help to lessen the workloads of team members, they could also increase the potential for power struggles because the roles of various professions would become less differentiated. We consider the conceptual and practical implications of our findings and we address the transferability of our model to other interprofessional teams.

Radical change in healthcare organization: mapping transition between templates, enabling factors, and implementation processes.

PURPOSE: The purpose of this paper is to examine: the content of radical change by mapping differences between two templates for organizing delivery of healthcare; the enabling and constraining mechanisms underlying major change from one template to another; and the processes implicated in change implementation. DESIGN/METHODOLOGY/APPROACH: Longitudinal, qualitative case study design allowed the tracking, over a four-year period, of the transformation of healthcare service in a community from provider-centered, fragmented delivery to patient-centered, integrated delivery. The authors conducted 90 interviews at three intervals, observed meetings, and analyzed internal and external documents. Concepts on content, process and mechanisms were used to analyze the data. FINDINGS: Transition from one template to another involves radical change in structures/systems and underlying values. Mechanisms precipitating and enabling change include: powerful stakeholders' dissatisfaction with current template and commitment to a new one, willingness to resource the change, provision of credible leadership, and manipulation of incentive programs. Radical change is underlain by a series of micro change processes that involve emergent, non-linear dynamics, and that follow their own track with enabling and constraining mechanisms. ORIGINALITY/VALUE: The paper describes a case of positive, successful change. Implications include importance of: attention to power dynamics, persistent leadership, elimination of boundaries between collaborating groups, and aligning incentives with desired practice changes; and attending to both variance and process in understanding healthcare change.