Nurse Managers (NMs) play an integral role in building and sustaining workplaces conducive to improved productivity, cost, quality, and timely delivery of healthcare services (Johnson 2012; Titzer, 2013). Within this context coexist ahost of healthcare trends in Canada, such as rapidly intensifying health costs, inefficiencies, lack of consumer-centeredness, and concerns about the overall quality and safety of healthcare (Fine 2009; Steed, 2012)have undermined the capacity of NMs to perform their role and meet organizational expectations. The LEANmanagementsystem was identified as a viable and sustainable solution for the growing cost, quality, and efficiency challenges faced by healthcare leaders (Brandao de Souza, 2009; Fine; Graban, 2009; Knowles and Barnes, 2013; Zidal, 2006).
LEAN is a complex set of philosophies, assessment and improvement activities aimed at maximizing value by reducing waste (Lawal et al, 2014; Lumas, 2006; Miller, 2005; Rotter et al, 2015; Ward, 2007; Poksinska, Swartling, & Drotz, 2013). Tauted as a revolutionary healthcare management idea to reduce waste, increase time efficiency and human effectiveness while increasing quality exchanges between patients, families and their caregiver, LEAN promised results. Despite the ‘hype’, many institutions found the practices and implementation costs both unsustainable and ineffectual for the intended goals (Hines, 2008). Some believe that the industry (Japanese car production) origins of LEAN render its principles less transferable in the high paced, dynamic and demanding environment of contemporary health care (Dickson et al, 2008; Drotz & Poksinska,2014). While it is commonly accepted that leadership is key to any system transformation (Hines), few studies have empirically investigated LEAN leadership practices and how they influence and impact the actualization of a system transformation of this magnitude.
LEAN as atransformation model requires tactical execution by leaders educated on, and committed to, its process improvement intents (Mann, 2009). LEAN emphasizes the importance of front-line NM presence in engaging employees in actualizing outcome metrics, focusing on root cause analysis and problem solving, and participating in various process improvement initiatives (Goodridge et al, 2015; Mann), with the intent to enhance the quality of care at the intersection of caregiver and recipient. A high level of participation, visibility, and engagement of the NM with frontline workers is necessary to reinforce behaviors and sustain the change. There is currently an incomplete understanding of NM behaviors as they influence health care systems transformation. This research sought to explore the leadership behaviors and managerial practices of NMs that facilitated or impeded the sustainability of the Lean management system in acute care.
Methods:
A qualitative exploratory inquiry was used to identify leadership behaviors and managerial practices of NMs that facilitated or impeded the sustainability of the Lean management system in acute care. Data were collected from 14 NMs employed in urban and rural health regions within one western Canadian province. This purposive sampling strategy allowed for a diversity of organizational contexts and individual experiences, with the following inclusion criteria: 1) must be a registered nurse; 2) have knowledge and participation in Lean training; 3) work in an urban or rural healthcare facility in the province; and 4) have a minimum of one year of experience as a NM. The study used Normalization Process Theory (NPT) to thematically analyze the 14 semi-structured interviews and focus group discussions. Data analysis was conducted according to Braun and Clarke’s thematic analysis (Braun & Clarke, 2006), which involved the search for, and identification of common interview threads. Analytic processes such as concurrent data generation, analysis and constant data comparison helped identify and analyze patterns of meaning (themes). The final phase of analysis focused on theme refinement and identification of NM leadership behaviors that either facilitated or impeded the sustainability of Lean management system transformation.
Results:
Preliminary findings suggest that while NMs are central to the implementation of the LEAN transformation system, they lack understanding of, and confidence in how this care approach actually enhances the quality or effectiveness of direct nursing practice. A sense of ‘futility’ characterized the inconsistent application of processes that appeared to NMs as incongruent with the human dynamic central to patient care optimization. Ambivalence related to the purpose of LEAN as it could actualize quality care, along with fragmented implementation of a system that collided with caregiver values and care visions made the relationship between NMs and LEAN tenuous at best.
Conclusion:
The leadership behaviors and managerial practices of the front-line leaders implementing a contemporary healthcare transformation initiative in the workplace are key to understanding the challenges and successes related to change in the workplace. The major finding of this study suggested that NMs did not have the requisite knowledge and skill to move from managing processes to coaching and developing staff within a Lean management system. Due to considerable workload demands within a dynamic and complex environment, the majority of participants indicated that while Lean had value, the context in which they were to implement Lean was overshadowed and dominated by lack of resources, time, and work complexity that created uncertainties. Successful Lean implementation requires strong leadership that creates a change in organizational attitude, behavior, and culture. Organizations wishing to retain NMs must support them during organizational change.