Nurse Leaders Perceptions of an Approaching Organizational Change

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1 481501QHRXXX / Qualitative Health ResearchSalmela et al. research-article2013 Article Nurse Leaders Perceptions of an Approaching Organizational Change Qualitative Health Research XX(X) 1 11 The Author(s) 2013 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / qhr.sagepub.com Susanne Salmela 1, Katie Eriksson 1 and Lisbeth Fagerström 2 Abstract The aim of the study was to achieve more profound understanding of nurse leaders perceptions of an approaching organizational change. We used a three-dimensional hermeneutical method of interpretation to analyze text from 17 interviews. The results suggest that nurse leaders were positive toward and actively engaged in continual change to their units, even though they perceived themselves as mere spectators of the change process. The nurse leaders believed that change might benefit patients and patient care, yet their adaptation lacked deeper engagement. The approaching merger affected the nurse leaders identities on a deeply personal level. They experienced uneasiness and anxiety with regard to being nurse leaders, the future of nursing care, and their mandate as patient advocates. Nurse leaders are in a critical position to influence the success of organizational change, but the organizations covered in this study were not incorporating their knowledge and experiences into the change. Keywords health care, managed, hermeneutics, interviews, nursing, qualitative analysis When politicians decide to cut costs in the health care sector, the structural changes that the affected health care organization must make lead to additional challenges for anyone involved in the change process, including the nurse leaders (NLs). These leaders are responsible for providing high-quality care and for developing and rendering care activities more effective. They must also rein in costs in accordance with the directives and decisions that politicians institute. Accordingly, NLs must be able to manage change processes cognitively and emotionally. In this article, we present a longitudinal research project that resulted in two different studies. The researchers gathered data for the first study by sending a questionnaire to the staff at two health care organizations prior to, during, and after a merge (cf. Salmela & Fagerström, 2008). The aim of the second and actual study was to achieve deeper understanding of NLs perceptions of an approaching organizational change. In 1998, a city council in western Finland considered a motion for the merger of a health care center and hospitalbased specialist care in the area. After studying a report detailing the effects of an eventual merger, the city council decided in 2002 to merge the two organizations. The aim of the merger was to reduce cost increases, develop care pathways, and utilize available resources more efficiently through restructuring. The merger, which resulted in a new, common organization, was scheduled for January 1, The population of the health care district, which covered three member municipalities, was 34,176, and the number of care staff was approximately 900. The merger leadership group consisted of representatives from each municipality and included a project coordinator who was responsible for overseeing the preparation and completion of the merger; various staff workgroups contributed under the guidance of the leadership group. The hospital staff had prior experience of a merger (two smaller hospitals in the area had merged in 1991 to form a single regional hospital, which was then integrated into a health care district), but the health care center staff possessed no experience with mergers. This merger was a larger, strategic organizational change as well as a response to economic and political factors, and the representatives made these decisions in accordance with presented analyses (cf. Carney, 2006). Our literature search revealed that transforming organizational culture and values constitutes a long-term developmental task during a larger organizational change (Hartley, Benington, & Binns, 1997). According to Graetz (2000), organizational leaders should provide a clear and 1 Åbo Akademi University, Vaasa, Finland 2 Buskerud University College, Drammen, Norway Corresponding Author: Susanne Salmela, Vaasa Central Hospital, Hietalahdenkatu 2-4, Vaasa, Finland susanne.salmela@vshp.fi

2 2 Qualitative Health Research XX(X) comprehensive vision and focus prior to strategic change, and they should encourage interactive thinking and actions on all levels (McPhail, 1997). The task of middle management during a change is to balance operational dimensions with strategic and interpersonal dimensions, so these managers must balance leading processes with leading relationships (Salmela, Eriksson, & Fagerström, 2012). To minimize the gap between the perceptions of upper management and staff, the managers must allow staff to voice their perspectives of the change early enough for the leaders and the staff to have time to discuss them (McPhail; Salmela & Fagerström, 2008; Salmela et al., 2012). Kerfoot (1996) explained how change leaders should perceive the process of change, especially focusing on what they should expect and how they should handle each change phase. Kerfoot claimed that leaders should reframe change as a positive challenge and communicate effectively during all change phases. Research on how NLs perceived an approaching merger, or what feelings such a merger could evoke, did not exist at the time we searched the literature. However, we were able to find similar insights in the field of organizational studies. Shanley (2007) determined that leaders often ignore the emotional aspects of a change and the influence that the change has on individuals. Sinkovics, Zagelmeyer, and Kusstatscher (2011) found that the staff members involved in mergers and acquisitions often considered these events extremely emotional. Moreover, researchers working in the late 1990s found that NLs were of great importance during a change process (Hendel, 1998; Knox & Irving, 1997; Sofarelli & Brown, 1998). NLs are in a critical position to influence the success of an organizational change by directing care staff to the vision and mission of the desired change (Knox & Irving). Kerfoot established that NLs must serve as role models for desired behaviors, because leaders driven by a mission and a purpose will inspire the people they lead, and they can overcome both external and internal resistance with this inspiration. Kullén Engström, Rosengren, and Hallberg (2002) stated that strategic, structural, and work-related uncertainty created the confusion that arose during a change process. Strategic and structural uncertainty contributed to work-related stress, which influenced the staff s ability to manage organizational change. Moreover, this uncertainty indicated feelings of inadequate control with regard to roles and tasks. Accordingly, leaders communication and information could have minimized strategic uncertainty, and they could have increased staff members feelings of control by communicating to them the details of the change and by asking them to participate in decision making. To adapt to uncertainty, the staff must know that their leaders are managing the change process fairly (Bordia, Hobman, Jones, Gallois, & Callan, 2004). Even during an ongoing change process, NLs are still called to serve; that is, they must still serve the cause of caring, so they must continue to provide the best care to their patients (Eriksson & Nordman, 2004; Lindström, Lindholm, & Zetterlund, 2006). As leaders, they hold the ultimate responsibility for patients and their care (Eriksson, 2001), and the mission of NLs is to create conditions that are conducive to good care (Fagerström, 1999). One of the challenges that NLs face during a change is the maintenance of the caring tradition. They must support the caring that emanates from a caritative culture, a culture based on love and charity, and develop evidence-based caring cultures regardless of ongoing change processes (Eriksson & Lindström, 2000; Eriksson & Nordman; Lindström, Lindholm, & Zetterlund, 2006). Theoretical Framework The theoretical framework of the present study consists of three main parts: (a) a theoretical model of leading change that covers leading relationships, processes, and culture (Salmela et al., 2012); (b) Kotter s (1996) model of eight phases for understanding the processes prior to a change process; and (c) earlier research on emotional reactions to change processes. In accordance with the model of leading change (Salmela et al., 2012), NLs play different roles in a change process. When NLs lead relationships, they embrace the roles of team player, coach, and parental figure. NLs lead processes by assuming the roles of coordinator, conductor, and/or director, and by weaving a tapestry. They should lead a culture by creating an open, confirming, and evidence-based atmosphere. The leaders of change should influence, focus, and direct in accordance with their commitment to authority and the desired change when the change relates to listening, acting, and doing (Chenoweth & Kilstoff, 2002). Regarding NLs roles and what they are expected to do as leaders of change, they require support, confirmation, and knowledge of the changes that upper management intends to institute (Knox & Irving, 1997). Kerfoot (1996) insisted that change leaders understand the process of change, such as what to expect and how to handle each change phase, how to reframe change as a positive challenge, and how to communicate effectively during all stages of change. Leading relationships during a change process entails giving support during the mourning process that can stem from a loss of status and identity (Hendel, 1998). Carnall (2007) argued that strategic change is an intellectual challenge as well as a process of handling people and uncertainty, because change creates anxiety, uncertainty, and stress at all levels. Changes seem to significantly impact the self-esteem and performance of the staff. Barriers to effective change include perceptual, emotional, cultural,

3 Salmela et al. 3 environmental, and cognitive blocks. Driving a change process to conclusion does not merely involve leading and driving the change to fruition. The leaders must also manage the reactions that arise from change and the dynamics of change. Kotter (1996), and Kotter and Cohen (2002) maintained that leaders are particularly important during the various phases of a change process because of their communication and ability to anchor a vision, among other abilities. Kotter (1996) proposed a model that included eight steps, and stated that leaders must successfully implement these steps if they desire successful change. According to Kotter and Cohen (2002), emotions comprise the heart of change, and the leaders largest challenge is to persuade care staff to see the truth of the change so that the truth can influence their feelings and thus their behaviors and actions. Kotter s (1996) model is viable for our purposes, even though he primarily intended it for top managers/top management who might not necessarily work in the health care sector. In the following paragraphs, we explain the eight phases that leaders should know prior to a change process so as to succeed (Kotter, 1996; Kotter & Cohen, 2002). These phases do not need to occur in any particular order. The first phase is to increase the feeling of urgency or crisis. During discussions with staff, the leader should convey a feeling of urgency or crisis by presenting convincing evidence so that the staff understands the need for change, as well as the importance of addressing the problem and the possibilities that exist. Second, the leader should enlist a team that leads the way. This team should have key individuals with the right characteristics and sufficient power to lead and drive the change and guide other staff members. These key individuals should possess a confident and devoted approach to the specific task and toward one another. The third phase is to create the right vision. The challenges of any change behoove a leader to create a convincing and lucid vision that clearly anchors direction and steers input. A leader should also create an unambiguous strategy that demonstrates how the staff can realize the vision but does not exclude flexibility. During the fourth phase, the leader must communicate to convince. Communicating a simple vision and repeating it in many forums will greatly help to convince staff that the change is necessary, since they will develop understanding of the change. The leader s goal in this phase is to persuade as many individuals as possible to act in a manner that turns the vision into reality. The fifth phase involves allowing actions. Leaders must also eliminate obstacles that block desired actions on both the individual and organizational levels. In addition to confronting opponents, the leaders might choose to develop structures, provide education, direct information, and lead staff toward the vision. The sixth phase includes creating short-term rewards. These rewards can be small but should provide continued sustenance to individuals beliefs in the change effort and should contribute to the mitigation of cynicism, pessimism, and skepticism. Thus, a reward system simultaneously motivates staff and maintains the driving forces behind the effort. Preserving is vital to the seventh phase. After administering the first short-term rewards, the leaders must follow a direction and driving force. They will proceed with wave after wave of change until they realize the vision, while seeking ways to maintain a sense of urgency in the face of what appear to be insurmountable problems. Letting the change take hold is part of the last phase. The leaders ensure that individuals continue to adhere to the change, despite the allure of traditions, by allowing the new styles of working to take hold in the reformed organizational culture. A new, supportive culture readies the ground for new ways of acting and working. Another theorist, Yukl (2010), delineated 14 points that correspond to the phases mentioned above, and he included additional advice. Yukl claimed that leaders should prepare staff by explaining how the change will affect them, by helping employees to cope with the stress and difficulties caused by the comprehensive change, and by keeping employees informed of the progress. The completion of a successful change process in an organization demands a broad range of leadership styles or behaviors, including motivating, supporting, and guiding staff. If staff members believe in their leaders and believe that a change is necessary and effective, then they are engaged in the change. To achieve successful change, leaders must first understand the reasons why staff accept or oppose change, and then attempt to interpret the staff s reactions to change. Young (2009) believed that emotional reactions to a change resemble emotional reactions to sudden, traumatic events. Both reaction patterns follow the phases of denial, anger, sadness, and adaptation, but the duration and scope of these phases can vary greatly during a change process, and employees can become trapped in various phases. These employees might need help with overcoming denial, channeling their anger constructively, finding the time to mourn, and feeling optimistic about a successful adaptation (Young). Stenvall and Virtanen s (2007) views on change dynamics contrasted with Young s (2009) views, because they organized change progresses into different types of stages, and they believed each individual goes through an emotional and cognitive process that they express through their actions, which Ahrenfelt (2001) called the emotionalcognitive triangle. According to Stenvall and Virtanen, anxiety becomes acknowledgment when an individual

4 4 Qualitative Health Research XX(X) begins to accept the need for change and proceeds to a stage where everything seems clear. With this clarity, the individual can commit to the change. At the final stage, the employees reach an understanding that appreciates the new goals, and they can begin to learn new manners of thinking and acting (cf. Stenvall & Virtanen). The aim of the original study was to describe intimately the NLs perceptions of an approaching organizational change (i.e., a merger between a health care center and a hospital). In the study we attempted to answer two research questions: How do nurse leaders describe the approaching change process? What are the nurse leaders perceptions of the approaching change process? Informants and Data Collection Prior to the merger, we invited the head nurses of the various units and the directors of nursing at the two organizations involved in the merger to participate in the study (n = 30). Ultimately, 17 NLs accepted the invitation: 14 head nurses and 3 directors of nursing. The informants were women from 42 to 61 years of age, with a mean age of 49 for those working at the hospital and 51 for those working at the health care center. How long they were in a leadership position varied from 2 to 31 years, with a mean of 8.5 years for the hospital and 10 years for the health care center. Many of those from the hospital had previously experienced a larger merger. The informants professional education varied from 3.5 to 7.5 years, with a mean of 5 years for the hospital and 4 for the health care center. Semistructured, in-depth interviews were conducted in Finnish and Swedish and lasted approximately 1 to 2 hours. In addition, we asked follow-up questions as needed during the interview process. The interview questions related to NLs views of change and the approaching merger and change process; their role as leaders during the change; and their previous change experiences. The majority of the interviews took place between March 31 and June 4, All of the interviews took place in an open atmosphere at the participants workplaces, which promoted fruitful dialogue. Overall, the interviews totaled approximately 25 hours and were transcribed verbatim. We then translated the interviews from the original Finnish and Swedish languages to English while writing this article. Salmela conducted all of the interviews and had exclusive access to all of the interview material, including background factors. All informants received information about the study and were ensured anonymity, confidentiality, and the option of ending their participation at any time. We also removed the informants names during the transcription of the interviews to ensure anonymity, and omitted any statements and comments that risked informants identity and confidentiality, without compromising the content. The hospital district granted ethical permission for the study, and we carefully followed the ethical guidelines for research during the course of the study (World Medical Association, 2008). Data Analysis To analyze the data, we followed a three-dimensional hermeneutical method of interpretation and understanding inspired by Ödman (1992) and Fagerström (1999). Ödman maintained that three stages or phases exist in the interpretive process of expressing the meaning and understanding of central phenomena: rational understanding, contextual interpretation, and existential interpretation (Ödman, 1992; Fagerström). Fagerström modified Ödman s (1992) method by clearly describing how the same phenomenon can be interpreted and understood on three different levels: the rational, contextual, and existential. In this three-dimensional hermeneutical method of interpretation, explanations and interpretations help the researchers to achieve deeper understanding. They shape a hermeneutical circle between the rational level, which forms the preunderstanding, and the existential level, which forms the final hermeneutical understanding. For the present study, we chose to interpret and understand the interview phenomena on these three different levels of abstraction to achieve a comprehensive hermeneutical understanding of the personal meaning that NLs give to approaching change processes. According to Ricoeur (1993), understanding is the reason underlying human beings being-in-the-world. In order to orient life more consciously, individuals undertake interpretations by selecting one aspect of interpretation so that they can understand the meaning of what they are interpreting. Ricoeur sees human beings amid a continual effort to understand their lives. He believes humans use this explanatory interpretation as a means to reach understanding, and they interpret a phenomenon by exposing it and assigning meaning to it. One connects explanation and understanding dialectically when his or her understanding precedes, accompanies, and includes an explanation and when one uses explanations to understand meaning, that is, when he or she reaches meaning (Ricoeur, 1993). By virtue of its explanation of reason and reasonable reasons, a goodreason-assay can serve as a step toward explanatory interpretation (Ödman, 2007). Interpretation is a hermeneutical-existential approach that allows one to understand the meaning of his or her life conditions and existence (Ödman, 1992). Heidegger (1962) expressed this as being-in-the-world, which comprises a collection of observations of reality. For

5 Salmela et al. 5 Table 1. Positive and Active Engagement in Continuous Change. Rational Understanding Contextual Interpretation Existential Meaning Change as a part of the daily routine Willingness to participate and influence as nurse leaders Many of the nurse leaders had previously experienced various processes in the organization, such as change, improvement, restructuring, and development, both in nursing care and in activities that benefit patients Nurse leaders were positive toward change. They wanted to participate in the change and to influence, develop, renew, and direct nursing care for patients best interests by keeping up to date with developments and decisions. Continuous change as part of personal existence in nursing care Positive and active engagement as a personal basic attitude example, the dynamics between what a text is expressing and what the text is recounting forms understanding. Any description of reality is dependent on interpretation, so each interpretation should be a reasonable, valid clarification of the information available (Ödman, 1992). During the first phase of the study s interpretative process, which was rational interpretation, we read through the text material several times, focusing on finding answers to the two central research questions. According to our findings of NLs perceptions of change and the approaching merger, themes, and phrases, we discerned and structured words on the rational level. When interpreting contents, motives, or intentions in relation to actions, a researcher s first or immediate understanding forms his or her preunderstanding, which can also be described as the good-reason-assay (cf. Ödman, 2007). Several readings during the first phase resulted in our preunderstanding or rational understanding of possible central themes, which serve as the central meaning of the content of NLs perceptions of the approaching merger. Salmela performed the interviews and subsequently analyzed the encoded material in close cooperation with Fagerström. In the second phase, contextual interpretation, we explored the central meanings of NLs perceptions in relation to their situational context or the sentence and/or text as a whole. We gathered contextual meaning by comparing the texts to existing knowledge. This allowed for a clarification of NLs perceptions and the meaning of the texts, including the various aspects relevant to the situation and possible influences, such as change, the merger at hand, and the surrounding context. After discovering and preunderstanding the central phenomena during Phase 1, we contextually interpreted and understood these concepts in Phase 2. In the third phase, we conducted existential interpretations of the central themes from the earlier phases and thus reached a final understanding. Through an existential interpretation of the text as a bearer of meaning, we reconstructed the deeper meaning of the NLs perceptions as part of their existential world or lived conditions, which we then interpreted and hermeneutically understood. We arrived at three main themes that represent a comprehensive understanding of NLs perceptions of change and the organizational change at hand. The existential meaning expressed that which is meaning bearing in the NLs perceptions of the approaching merger (i.e., their personal experiences on an existential level). Findings The hermeneutic interpretative process resulted in three main themes that we interpreted and understood on the rational, contextual, and existential levels of abstraction. With Tables 1 to 3, we illustrate how we interpreted the central meanings of the NLs perceptions during the rational, contextual, and existential analyses (cf. Ödman, 1992), with the existential level representing our comprehensive and final understanding of the NLs personal experiences. Positive and Active Engagement in Continuous Change On the basis of our rational understanding of the first main theme, we found that NLs possessed previous experience with various changes and developments within their own units, and had experience with mergers between units and organizations for the purposes of restructuring, changing, and developing activities and nursing care (see Table 1). One NL stated, Because we have, of course, in specialist health care, always, or as long as I can remember, had change after change, and units have been merged. Another NL expressed, I have been working with changes all the time, so I do not know anything else than change. I, like, think that change is everyday for me. The NLs felt positive in relation to participating in the change, and could therefore be part of and influence the change: If I think about the word change I experience [it] as a positive word. Another NL stated, Develop and try to change and get it to work. Work for the patients best. A third NL commented, There are constantly 105 of these: Can this or that be improved or altered? and this needs to be studied, and this should be done.

6 6 Qualitative Health Research XX(X) Table 2. Confidence in Change and Adaptation Without Deeper Engagement. Rational Understanding Contextual Interpretation Existential Meaning Having a positive attitude enables one to see possibilities Change is necessary Nurse leaders were positive toward the change process because they saw new possibilities regarding cooperation and the preservation of activities that would allow them to continue providing care that benefits patients. Nurse leaders were forced to adapt and make the best of the situation despite lack of preparation, because the pressure to change was external. Confidence that change will benefit patients Adaptation without deeper engagement Table 3. Feelings of Insecurity and Anxiety. Rational Understanding Contextual Interpretation Existential Meaning Uncertain view of the nurse leader role Anxiety over the extent of work as a nurse leader Anxiety regarding the influence of nursing care and its mandate Experience of formal participation and disappointment Nurse leaders were uncertain of their roles and the impending merger with a different leadership culture. Anxiety existed regarding what the change process would entail and the extent of the work that nurse leaders would face in the future. Anxiety existed regarding how the change would affect nursing care and regarding the task and mandate of driving nursing care forward. The majority of nurse leaders did not know much about the merger process and their roles in it. They did not feel that they were active participants and therefore could not be considered actors in the change process. Uncertainty regarding one s identity as a nurse leader Anxiety regarding the demands placed on nurse leaders both in the present and in the future Anxiety regarding nursing care s future place and position Experience of being a spectator and outsider From our contextual interpretation and understanding, we discerned change as a natural part of NLs daily work. NLs wished to be engaged so they could influence patient care and the surrounding context, while simultaneously motivating and inspiring care staff so that the staff could cope with implementing change for the patients best interests. While examining the existential meaning, we found that NLs were positively and actively engaged in continuous change on a personal level and seized any opportunity to influence patient care and nursing care as a whole. Confidence in Change and Adaptation Without Deeper Engagement From our rational understanding of the second main theme, we discerned that NLs felt either cautiously positive or positive toward the change process, despite the negative opinions that some leaders voiced immediately prior to the merger between the two organizations. The NLs expressed themselves with comments such as the following: I think the merger process in and of itself is good, and we will surely benefit economically from it, because we get rid of many double functions. There are of course many challenges. I am also cautious about the merger, that we will start to work together. That we should find new possibilities that we do not have today when we have been in separate organizations. The NLs considered the merger necessary despite the fact that they were not prepared, and they discerned new possibilities and a new beginning through their positive attitudes (see Table 2): Usually almost all changes are positive, at least those that I have seen here. To leave something old and start something new. Now it was decided that you can actually manage, that you must take it. I do not know if this is the best, but you will probably know after a few years. A third NL stated, That everyone can manage and that everyone expresses interest in this subject. Because naturally this benefits the patient, as well. By conducting a contextual interpretation of the second theme, we found that NLs were well prepared for the change process because they could envisage possibilities with regard to patient care and they could continue to lead activities in the units with a new emphasis on efficient resource usage. The NLs also wished to further develop cooperation between the two organizations involved in the merger, believing that they could confer upon one another the best of both organizations and develop a common culture of caring that would offer patients the best care. At the same time, they understood the necessity of adapting when change was politically mandated, because

7 Salmela et al. 7 they understood that the restructuring would reduce cost increases. From the existential meaning of the second theme, we discerned a benevolent attitude toward adaptation, even though the adaptation occurred without any deeper engagement. NLs believed that the merger could be beneficial for patients and patient care and could help them to provide the best service to patients. They also believed that they could develop a common culture comprised of the best traits of both cultures. Feelings of Insecurity and Anxiety On the basis of a rational understanding of the third main theme, we discerned frustration on behalf of the NLs pertaining to their roles as NLs and what was expected of them: That is currently my main concern, as we have a good organization at this point in time in this unit, from a managerial point of view. We interact directly with our superiors. At first we experienced some insecurity because of cultural differences between the health care center and our own, and because I have sort of understood that a slightly different leadership culture exists there. A third NL commented, I, of course, do not know what will be mine, but I hope, of course, that I get to continue with the work I have had. The NLs expressed anxiety regarding how the merger would affect nursing care and their authority: Perhaps to gain a wider perspective and it will, of course, be more comprehensive. Perhaps it can be narrower, as well. When we do not know how it is going to be either. Upper management has, like, not agreed on anything yet. We do not have an umbrella organization yet. They also offered the following observations: That we have just a nurse leader who does not possess the authority to represent [us], and she ends up presenting these issues to the manager who then presents them to [her] superior according to [her] preferences and wishes. One of the NLs expressed her disappointment with the change process: I have to say that I am disappointed in the entire merger process because we continually receive very little information. Of course we get all of these memorandums, but the attachments are missing. Concerning the NLs participation in the merger or change process, one NL expressed, So there is very little we have to do with it. Little or nothing. Another stated, What we talk about, that we are going to be with so and so, that is only formalities, I think. The same NL also said, It goes like that so that everyone can believe they are participating. The NLs were worried, too, about their future roles: I, of course, do not know what my role will be. No, in that sense there is uncertainty. Do I count at all as a leader, and am I an important resource in the process? We do not know our mandate in the new organization. We understood such comments as the leaders expressions of disappointment in the organization s neglect to include them in the change process on a formal level. In effect, the NLs did not possess true opportunities to engage in the change process (see Table 3). On the basis of our contextual interpretation of the third main theme, we found that the NLs seemed uncertain about the nature of their roles during a change process. The NLs did not know how the organizations leadership and organizational cultures would amalgamate. They felt great anxiety not knowing how much work the change would bring in the present and the future. They were also concerned about how the change would influence nursing care and who would advocate for patients and nursing care during and after the merger. The majority of NLs maintained that they did not receive sufficient information regarding the change process, and therefore felt excluded from the process. Finally, we examined the existential meaning of the third main theme to discern the ways the NLs were expressing their uncertainty about their identities as NLs and their anxiety regarding NL roles and the nursing care situation. At the same time, the NLs perceived themselves to be mere spectators of the process and not active agents in driving the change forward. In effect, the NLs did not feel like actors in the change process, and they experienced strong feelings of exclusion from the process. In sum, even though the NLs were positive toward continuous change in their own units and were willing to engage in it actively, they felt like mere spectators. Even though they believed that the merging of the hospital and health care center would benefit the patients and that the organizations were clearly focusing on the best patient care, the organizations carried out the adaptation often without soliciting deeper engagement from the NLs. The approaching merger affected their identities as NLs on a profoundly personal level, and they were anxious about their NL tasks, the status of nursing care, and their mandates as patient advocates. Discussion Our hermeneutic interpretative process resulted in three main themes, demonstrating that the three-dimensional method can improve one s understanding of the meaning of the NLs life conditions on an existential level. We learned the NLs perceptions of the approaching merger process by inquiring after their personally experienced realities (Ödman, 1992). Scrupulousness, integrity, and exactness served as guiding principles during the entire research process so that we would achieve the best possible interpretation and presentation of results (National Advisory Board on Research Ethics, 2002). If the study had occurred following the merger, the results would have been different.

8 8 Qualitative Health Research XX(X) The chosen method proved to be exacting, while yielding a more profound understanding of the material, and the combination of interpretations on the rational, contextual, and existential levels provided new understanding. Content analysis alone would have provided a descriptive yet relatively superficial level of understanding. The interviews resulted in a large amount of material from which we could discern dissimilarities among the views of the NLs, so the interviewing format improved the study s reliability. Some NLs maintained that the merger process would entail something positive, whereas others, who were disappointed in the merger process and the lack of information, felt it would make matters worse. Finally, some of the NLs found it difficult to define and express their views on the change during the interviews, which might have influenced the results. They would have been better able to provide clarifications and more detailed answers if they had received a copy of the interview questions prior to their interviews and/or if they had participated in follow-up interviews. The original study chiefly targeted NLs who held a middle-management position, because middle managers possess different insights than the merger leadership group possessed. Thus, we might have gleaned a view of leadership that differed from that of the leadership. The merger arose from a political decision, and the merger leadership group was responsible for the merger, whereas the project coordinator, who was part of the leadership group, was responsible for preparing and driving the merger through its completion. The demand for change, consequently, was primarily an external demand imposed on both health care organizations, specifically a demand from above. Again, the merger leadership group and project coordinator were allowed to take action, but neither the staff nor NLs at either organization were involved in the process prior to the city council s decision that a merger would occur. The composition of the leadership group deviated from the premises that Kotter recommended (Kotter, 1996; Kotter & Cohen, 2002). Because the merger was a political decision, the leadership group was not tasked with guiding the change; instead, they merely drove the council s decision. They focused on persuading the staff to embrace the vision behind the change, which was to reduce an increase in costs. The leadership also attempted to develop care pathways and to help the hospital and care center use available resources more efficiently, but their inclusion of these policies in the merger vision was hardly noticeable. Because the study took place prior to the merger, we did not attempt to incorporate the last three of Kotter s eight phases. The results of a previous partial study (Salmela & Fagerström, 2008) suggested that the vision the leaders voiced during the merger was not sufficiently clear. Only one third of the staff at both organizations thought that the vision was clear, whereas one third did not. The majority, however, were of the opinion that it was important for the new organization to have a common goal and a shared vision of the merger. The main administrative argument for the merger was a reduction in costs, but the administrators did not seem to have made the vision for patient care sufficiently clear. In addition, they did not clearly express any preparation of staff, and they provided an explanation of how the change would affect staff only because the NLs expressed their insecurity and anxiety. We also found no evidence that the NLs received help with managing the stress and difficulties that arose from the change process, so we presumed that the NLs received neither guidance nor support (Yukl, 2010). Even though the NLs were positive toward and actively engaged in ongoing change for the patients best interests on their own units, they were merely spectators of the merger as a change process. We found no clear evidence that the first step of Kotter s (1996) model, increasing the feeling of urgency or crises, had occurred. Furthermore, we were unable to discern any other phases from Kotter s model in the study material, and the respondents sentiments indicated that upper level management did not succeed at relating the vision of the merger process to the middle management. Whereas the NLs believed that the change benefited patients, the NLs adaptation occurred without any greater engagement. The majority were not involved as actors, and as such were extraneous to the change process, which explains the adaptation of the change without any greater engagement. The adaptation was the last step in a pattern of reaction that included denial, anger, and sadness. The NLs accepted the merger and considered it to be necessary (Young, 2009). They had reached the stage where they committed to the change, cognitively accepted the change, approved the need for change, and understood the goals (Stenvall & Virtanen, 2007) because they believed that the change would benefit patients and patient care. The NLs ultimately held the responsibility for patients and patient care, so their mission during the change was to create the conditions for good care (Fagerström, 1999). Their desire to achieve what was best for patients and patient care was the same as serving the cause of caring, which means striving to provide what is best for patients (Eriksson & Nordman, 2004). The willingness to do what was good for patients emanated from NLs internal attitudes as a part of caritative ethos (Eriksson & Lindström, 2000; Eriksson & Nordman). The interviews revealed that during the change process, some of the challenges NLs faced included maintaining a living tradition, supporting a caring culture, and developing evidence-based caring cultures, despite ongoing change processes (Eriksson & Lindström; Eriksson & Nordman).

9 Salmela et al. 9 We learned from the study s theoretical framework that NLs should lead their care staff to achieve good care. The art of leadership entails being a leader of individuals (Ahrenfelt, 2001) as well as engaging in continuous change to one s own unit. NLs who do not do this are failing to put their knowledge to use. As actors and bearers of a culture with a caritative ethos, NLs maintain the tradition and the essence of caring while also maintaining an open and supportive atmosphere. By leading relationships, NLs can provide care staff with support and guidance throughout a change process, and by leading processes, NLs can function as links, coordinators, and conductors during the change process (Salmela et al., 2012). During the interviews, the NLs revealed their insecurity and anxiety and explained that they felt like spectators. We presume that the NLs felt the administrators were invading their personal sphere or territory, and thus invading the self (Ahrenfelt, 2001; Carnall, 2007). We interpreted their insecurity as coming from a lack of control over their own roles and task issues (Bordia et al., 2004). During our analysis, we noted that strategic and structural insecurity made the largest contributions to the NLs feelings of work-related insecurity, and these feelings, in turn, deteriorated the staff s ability to manage organizational change (Kullén Engström et al., 2002). The feelings caused by a merger influence an individual s understanding of the merger, and leaders can improve these feelings through communication, information, and learning (Ahrenfelt). Bordia et al. observed that communication and information effectively reduce strategic insecurity, so they presumed that participatory communication would have provided the NLs with a feeling of control over the change process and their work. Through adaptation, the leader can once again establish his or her identity (Carnall, 2007). Although the upper management s experiences were not the focus of this study (cf. Kerfoot, 1996; Knox & Irving, 1997), we do wish to stress that the NLs themselves needed the support of upper management to help eliminate their feelings of insecurity and anxiety. The organizations upper managers were implicitly engaged in patient care, regardless of the circumstances (Knox & Irving). The NLs also needed affirmation and security in their knowledge of the nature of the change per their roles and what their superiors expected of them (cf. Knox & Irving), and we assume that they did not possess this sense of security when they felt excluded from the process. The NLs responses should make clear that change leaders must consider emotional reactions during a change process. However, previous studies on organizational change usually ignored the emotional effects of change on individuals, as Shanley (2007) pointed out. Significant organizational changes can even result in a mourning process (Hendel, 1998) in which emotions are involved (Hendel; McPhail, 1997). The NLs might play different roles in the change process (Salmela et al., 2012) and might support the mourning process that the other staff members experience in relation to the loss of status and identity, yet the NLs should also receive support during their own mourning process. The NLs in the present study could have benefitted from knowledge or understanding of the change process as a sociopsychological process. This information could help them to counteract insecurity, given that change is a matter of listening in addition to acting and doing (Kerfoot, 1996; Hendel). To become actors in the change process and to motivate, inspire, influence, and overcome resistance, the NLs in the study needed schooling (Hartley et al., 1997; Hendel, 1998; Kerfoot, 1996; Kullén Engström et al., 2002; McPhail, 1997). Specifically, they needed knowledge of change as a phenomenon (cf. McPhail), because the staff s opinions, actions, feelings, and understanding of organizational cultures enable them to understand and facilitate the change process. The NLs should approach the change from a holistic point of view, with a realistic attitude and adequate preparation and planning. To understand a change process, NLs must know what to expect and how they should address every phase of the change (Kerfoot). Schooling would have facilitated the NLs roles as internal change actors in the change process, affecting all the individuals involved in diverse ways. This schooling is a question of focusing, directing, engaging, and communicating (Hartley et al.) while excluding, telling, and selling the idea or vision behind the change (Kullén Engström et al.). Conclusion In sum, change leaders should consider the NLs/middle management an immense resource during a change process, but in this study, they did not seem to be utilizing this human resource, and many NLs found themselves in a difficult position. Although the NLs engaged in continuous change within their own units for the purpose of guaranteeing good patient care, the change leaders never seemed to put their knowledge and experience toward advancing the change. The NLs held a critical position with regard to influencing the success of organizational change but did not always possess a holistic perspective of the organization or the change process, because they were not involved in the change process as a resource. One could conclude that the NLs might have provided staff with support, prevented anxiety, and built a new organizational identity after receiving the support of upper management, the knowledge of what they needed

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