INTRODUCTION AND RATIONALE FOR THE STUDY

Adaptation to change in health policy is complex and challenging (Williams, 2002; Daft, 2004). Major health care delivery system reforms were introduced worldwide during the early 1990s in line with general global changes (Green, 1999). Environmental and demographic reasons have led to the increase in the global demand for health care. In developing countries the increase in health care needs is mainly the result of diseases related to poverty, infection, malnutrition, war and HIV/AIDS (International Council of Nurses [ICN], 1996). Moreover, in recent times, the public has become more aware of its right to quality health care (ICN, 1996; Booyens, 1998). Consequently, countries throughout the world are trying to balance their available resources in terms of people, facilities and finances to meet the demand for health care (ICN, 1996).

In the Namibian context, during the previous administrative dispensation, health services were structured along ethnic lines and were managed accordingly. Moreover, the health services were curatively biased. In this regard, the Ministry of Health and Social Services (MoHSS) has undergone dramatic political, technological, structural and cultural changes since 1990. A primary health care (PHC) approach has been adopted in Namibia in order to redress the fragmentation of the past. As part of the wider reform process, the Wages and Salaries Commission Report of 1996 proposed measures that included downsizing the civil service and outsourcing and commercialising noncore public health and social welfare functions. At the central level, the eight original directorates were merged into five key functional units, namely Planning and Human Resources Development, Specialised Services, Primary Health Care and Nursing Services, Administration and Finance, and Social Services (Ministry of Health and Social Services [MoHSS], 1995).

The Ministry of Health and Social Services underwent different forms of restructuring. The two departments that existed in the early stages of health sector reform (Health Care Services & Planning and Administrative Support Services) were again restructured into three departments, namely:

• .Department of Health and Social Welfare Policy, consisting of four directorates: Primary Health Care Services, Social Welfare Services, Special Programmes and Tertiary Health Care and Clinical Support Services (MoHSS, 2003).   

• .Department of Policy Development and Resource Management with three directorates: Finance and Logistics, Human Resource Management and General Services, and Policy, Planning and Human Resource Development (MoHSS, 2003). 

• .Department of Regional Health and Social Welfare Services, consisting of thirteen regional directorates (MoHSS, 2003).  

While change is inevitable (Griffin & Moorhead, 2007, p.524; Williams, 2002, p.313), it has been reported that change agents often overlook the impacts change may have on people (Kimberling, 2002; Schermerhorn, Hunt & Osborn, 2003; Daft, 2004). Five conceptual frameworks on change management were therefore reviewed, based on the three stages of unfreezing, changing and refreezing of Lewin’s Change Process Model (1951).  In the unfreezing stage, people who are likely to be affected by change should be prepared to believe that change is needed for their organisation. During this first stage, relations should be built, and the need for change communicated to those involved to reduce their fear of the unknown and make them feel that they own the change process. During the changing stage, workers and managers are being challenged to change their old behaviour and work practices. Strategies are established during this stage to bring about the desired change. These strategies include the following: setting  attainable objectives; designing appropriate roles for the change agent, such as facilitating, involving, convincing and motivating others; identifying areas of support and resistance; offering training; ensuring job security; managing the pace of change; maintaining interpersonal relations, for example by explaining benefits and gaining acceptance. The refreezing stage is based on supporting and reinforcing the new changes so that they stick (Rashford & Coglan, 1994; Welch, 1994; Marquis & Huston, 2003; Williams, 2002).  

Despite the good intentions behind the reform process in the health services in Namibia, and its conceptual significance, nurse managers who had worked in the previous dispensation experienced negative reactions of fear, insecurity and uncertainty during the health sector reform. The health sector reform process was accompanied not only by the structural changes, but by cultural changes as well. These cultural changes include the changes in values, attitudes, expectations, beliefs, and behaviour of the employees. Changes of this kind are in the mind-sets of the employees and are driven by how they think (Daft, 2004). Therefore, the results of this research study lead to the argument that, while the conceptual frameworks on change tend to focus on the management of change, the meaning and magnitude of change seems to be given little attention. This may well be the reason why the nurse managers in Namibia seemed not to be able to deal with change in the health sector. Many of them saw the change as a threat to their daily managerial practice.  

Furthermore, change affects people differently. According to Chapman (2005-2006, p.2), most people feel threatened and disoriented by the challenge of change.  Some authors indicate that people subjected to change experience mixed feelings of excitement, challenge, stimulation, fear, threat and uncertainty (Williams & Johnson, 2004; Kouzes & Posner, 2003; Mills & Bartunek, 2003; Thomson, 2002), as well as feelings of demotion or punishment (Rao, Carr, Dambolena, Kopp, Martin, Rafii, et al., 1996). Therefore, in view of the above statement, it is obvious that change may evoke either positive or negative emotions, and consequently elicit unintended responses, based on the individual emotional meaning a person attaches to the change process. It is therefore crucial to build a shared vision of how to manage change, as such a shared vision may be the platform for the nurturing of competencies, skills and positive attitudes. A nurturing process of this nature could in turn improve collaboration and performance (Moloi, 2002; Kouzes & Posner, 2003). In this respect, Senge, (1999, pp.205-232) asserts that “when people share a vision they manifest a higher degree of ownership and greater commitment to achieving the vision”. In view of the reform in the health sector in Namibia, a more constructive discussion would help to create an understanding of the importance of the new reforms. Against this background, the following aim and objective were identified.

PURPOSE AND OBJECTIVE OF THE STUDY

The main purpose of the study was to gain in-depth insights into the strategies for facilitating a change process by nurse managers during the reform of the Namibian health sector. The following objective was formulated in accordance with the aim:                            

to explore and describe the strategies that are needed by nurse managers to facilitate the change process during the Namibian health sector reform.

METHODOLOGY

To find the answers needed to achieve the overall research objective, it was decided that a qualitative, descriptive and explorative design was most appropriate to provide rich information from in-depth descriptions with regard to the strategies needed by nurse managers to facilitate the change process (Babbie & Mouton, 2001; Fouche, 2002).  

SAMPLING

The sample was selected using the following sampling criteria:

Top nurse managers, for the purposes of this study, were nurse undersecretaries, nurse directors or deputy directors.

Senior nurse managers were drawn from the National Health Directorate, University of Namibia and Namibian Nursing Council.

Middle nurse managers comprised nurses in charge of the three intermediate hospitals and a national hospital, members of regional management teams, regional PHC supervisors, as well as other relevant senior nurse managers at the intermediate level.

Respondents were drawn from the Professional Nursing Association and the Namibia Nurses’ Union.

First-line nurse managers. These were nurse managers who were in charge of the wards of the three intermediate hospitals and the national hospital.

The nurse managers described above were also known to have had some degree of exposure to the ongoing reforms at their respective levels of nursing management and were therefore deemed suitable to participate in this study and contribute to the intended strategies to facilitate the change process during the Namibian health sector reforms.

Thirty nine (39) respondents were purposefully included according to the described sampling criteria to take part in the research reported in this article. Qualitative studies are not intended for generalisation to large populations, but are intended to provide a dense and meaningful description to increase existing knowledge of the phenomenon under investigation. The aim of most qualitative studies is to discover meaning and identify multiple realities.  Thus generalisability is not a guiding principle (Polit & Beck, 2004). The number of respondents included (39) was therefore not necessary to gain generalisability significance. However, the reasons why 39 nurse managers from different geographical orientations and academic and professional levels were included were based on the assumptions of the researchers. The researchers assumed that the cultural differences would reveal unique experiences and strategies needed to facilitate the change process during the Namibian health sector reforms.  The second assumption was that there could be certain differences in the staff ratio that might have an influence on the strategies needed by the nurse managers to facilitate a change process.

DATA COLLECTION

Fifteen (15) individual, in-depth interviews were conducted with top, senior and middle level nurse managers, as well as 5 focus group discussions, consisting of 24 first-line nurse managers in charge of the hospital wards (five in 4 groups each and four in 1 group). Field notes were also taken to supplement other forms of data collection, such as audiotape-recorded interview data, which do not reveal the impressions made by the respondents.  Data was collected until saturation was reached.

ETHICAL CONSIDERATIONS

The following ethical measures were adhered to during this research: written institutional and individual informed consent was obtained prior the study. The information was given to the participants in simple, easy to understand language (Benton & Cormack 1996). Consent for tape recorded interviews was obtained. The researchers explained that participation was voluntary; thus respondents were free to terminate the interviews at any stage of the research without any fear of a penalty (Gail, 1999). Anonymity and confidentiality were achieved only through nameless group analysis and reporting of data (Burns & Grove, 1997), as the researcher was continuously involved with the participants in the field. The researcher undertook to destroy the audiotapes as soon as the data analysis was completed, and this was in fact done.

DATA ANALYSIS AND FINDINGS

Data from in-depth interviews and focus group discussions were triangulated during the analysis, as the same questions were used for both interview methods. Despite the fact that data analysis took place concurrently with data collection in this inquiry, the researchers began with aggressive data analysis after official field work had been completed, using the open coding technique derived from grounded theory methods (Tesch, 1990; De Vos, 2002). Through this coding method, various categories were constructed. Table 2 shows detailed analysis of verbatim quotes and codes, categories and themes that emerged from detailed analysis.

The researchers illustrate the views of nurse managers regarding their reported strategies for facilitating the change process in the health sector in two main themes and seven categories in Table 2. Since it is impossible to report on all the codes, a minimal number of codes are included for the purpose of illustrating the process of data analysis. Numerous codes were involved in the construction of categories. The two themes clearly indicated the need for planning and strategising towards the creation of an environment that is conducive to an effective transformation process. This process requires strategic planning for the support and nurturing of cooperative interpersonal relations and also for dynamic participation by and the involvement of all role players.

The relevant literature control is integrated in the discussion that follows. The discussions are organised around the identified seven categories of two main themes, as indicated in Table 2. The seven categories are:  promote participation and involvement in the change process, communicate clear image of the future, reward behaviour in support of change, provide time and opportunities to “disengage”, develop human resource training, provide technical and financial support, and encourage social interaction.

The findings of the study indicated that despite the undisputed benefits of health sector reform, transformation is first and foremost about people and their caring and supportive participation. The researchers argue that, although policy makers may target the envisaged outcomes of policy, the essence of change is embodied in the way people communicate and help one another and thus give life to policy directives.

To begin with, when change (the restructuring process) was imminent and regarded as vital for the survival of the Ministry of Health, nurse managers did not understand the need for this exercise and as a result experienced a fear of the unknown. The following discussions centre around the suggestions by the nurse managers regarding the strategies required to facilitate a change process during the health sector reforms.

Participation and involvement in the change process

Inadequate involvement and participation were reported unanimously, and the respondents registered a need for involvement and participation in the change process right from the early stages. One participant commented.

"We need to be involved in whatever the decision that is taken. …for the ownership of the process.”

As a result of inadequate involvement and participation, the majority of the nurse managers were of the opinion that the ownership of the health sector reform lay only with the change agent (Ministry of Health) and not with them. Another comment on participation and involvement was:

“... Not many people were properly consulted as to what the restructuring exercise was all about...”

However, it is well documented that participation and involvement are important, particularly for ownership and full commitment to a change process (Eales-White, 2003; Williams, 2002; Haberberg & Rieple, 2001; Jones & George, 2000). Similarly, Chapman (2005-2006, p.3) argues that “Change must not be imposed on people. Instead, people need to be empowered to find their own solutions and responses, with facilitation and support from change managers”. In the opinion of the researchers, if people who are most likely to be affected by a change process are not adequately involved, it is almost the same as imposing change upon them, as they did not participate adequately and make their voices heard.

Communicate a clear image of the future

Despite the importance of good interpersonal relations before any change process is implemented in the health sector, the nurse managers in this research project claim that they did not have a clear understanding of the real need for the reform process. Consequently, the nurse managers pointed out how a vision of change needs to be communicated. One such comment was:

“Inform them (nurse managers) to understand  what exactly is changing, who will be affected, what will happen to those who will be affected, who will be the beneficiaries, and where is the organisation going and why.”

In line with the negative experiences of the nurse managers, the literature emphasises that those who are likely to be affected by any change need to be persuaded of the real need for such change if they are to support the envisaged change process (Chapman, 2005-2006;  Williams, 2002; McGhee, 2002).

Reward behaviour in support of change

According to some authors, effective change management requires an understanding and appreciation of how one person makes a change successfully. Their argument is that the ultimate success of the organisation lies with each employee doing his or her work differently, multiplied across all of the employees impacted by the change (Prosci, 1996-2008). Moreover, they claim that without an individual perspective, an organisation or change process will be left with activities but with no idea of the goal that the organisation or a change process is trying to achieve (Prosci, 1996-2008). In view of the above, the current study supports the argument that organisations do not change, but that individuals change the organisations. Furthermore, the researchers are of the opinion that whenever the environment is changing, people are knocked off balance. Thus internal and external motivation are important to counteract possible resistance. One participant echoed this:

“Give praise where it is due. Praise the people when they do well, because everybody wants to know whether you are progressing.”

Rewards and recognitions are morale boosters (Kimberling, 2002). Similarly, praise and congratulations in front of peers was hailed by some authors as one of the most powerful, simplest but most underutilised of the motivational techniques (Kouzes & Posner, 2003; Meridian Group Services, 2003). Another comment on motivation was:

…“Constant support and feedback are part of motivation. …People need to be motivated; otherwise they will be demoralised.”

Kouzes and Posner (2003) support the role of feedback in motivation by indicating that people produce best when they are given feedback. Furthermore, in the context of the current inquiry, adequate feedback could reduce stress and anxiety in the nurse managers, caused by fear of the “unknown”.

Provide time and opportunities to “disengage”

Despite the numerous advantages of health sector reform, the nurse managers who are subjected to a change process need sufficient time in advance to weigh the benefits of the envisaged change process. This will allow nurse managers to disengage from the previous way of doing things and have enough time to mourn for what they acknowledge as loss (Kimberling, 2002). The researchers believe that change needs to be gradually introduced to reduce resistance and enable the nurse managers to embrace the new order. The following comment bears this out:

 … “Change should be a gradual process … do not rush change… people need to be psychologically ready first.”

Chapman (2005-2006) supports the above views of nurse managers on the issue of not rushing a change process. He argues that a quick change precludes proper consultation and involvement, which leads to difficulties that require time to resolve.

Develop human resource training

According to Prosci (1996-2008, p.2), the resources for change management were rated as the “fourth overall greatest contributor to success”. The same study shows a correlation between how successful a change initiative proves is and how well the people were managed for the change initiative. In the context of the current study, however, the nurse managers were not adequately prepared for the envisaged change process.  Therefore they were experiencing negative reactions during the change process. It was against this background that the researchers argue that the skills should first be developed among the nurse managers who are most likely to be affected by the proposed change. This will ensure the availability of motivated nurse managers who are needed to meet the present and future needs of the health sector. The following comments were made by some participants:

“You can’t just bring the change. You must develop your managers, because they are powerful if they have the knowledge and skills. People are the ones who allow you to change the whole set-up of the organisation.”…

Another similar comment was received:  

“Educate people, communicate the change and, I think, that it is for me important to change their set values. I think it is about education and communication, getting trust from the people.  Then they can support you in what you think should be changed....”

There is abundant evidence in the literature on the importance of training and management development in the organisation before a change process is implemented (Griffin & Moorhead, 2007; Marquis & Huston, 2003; Loose, Dainty, Lingard, 2003; Williams, 2002).

Provide technical and financial resources

While involvement and skilled human resources were hailed by the nurse managers as being vital during the change process, obviously, it was clear that change may not be effective without technical and financial resources. This calls for clear vision and proper planning by the change agent before such a comprehensive reform process is embarked on. The issue of lack of technical and financial resources was also seen by some of the nurse managers as a serious shortcoming.  One participant commented:

“… the environment could be sufficiently conducive, people well motivated or committed, but without the technical support, change process will not be effective… practical and easy to implement…”

In support of the above findings, various authors voice the importance of sufficient technical back-up for the change process (Williams, 2002; Cisco Systems, 2003; Services Industrial Professional & Technical Union, 2003).

Encourage social interaction

The researchers argue that even if there are adequate resources and the vision is clearly communicated, there are still some components of social interaction lacking for coping with the challenges of a changing environment. The respondents raised the issue of the non-supportive behaviour of leaders during the change process. They suggested that social interaction could assist them to cope better with the challenges of a changing organisation. This social interaction was needed within different levels of management, such as middle nurse management and the operational levels. Interaction with the top management of the changing organisation was also required. The following were some of the comments made and suggestions provided:

“Reforms can be stressful… The factors that are causing stress should be identified and strategies worked out to support people. You barely recovered from one change and new change is coming. You have not even clearly seen whether your previous programme was successful, and now the new one has come”.

“Manager Support groups are needed to boost the morale of the managers when they are being stressed out. We are thinking actually to have a support system in place. We are really under pressure.”

In support of the above views of the nurse managers, Griffin and Moorhead (2007) also emphasised the importance of stress management programmes for helping employees, particularly executives, to cope with organisational change.

The key component in the effective management of change is the creation of a climate for change, characterised by mutual trust and respect, awareness creation prior to the change process, and adequate communication and negotiation (Hogan, 1997).

Leadership is viewed by some authors as crucial in creating a supportive climate of this kind during a changing environment. Jooste and Minnaar (2003, p. 297) emphasised that leaders should understand the characteristics of a changing environment and identify strategies for dealing with it in the health sector. Furthermore, visionary leadership is regarded as crucial for setting the direction and priorities in a changing organisation by influencing others to accomplish a mission, task or objectives (Robbins & DeCenzo, 2001; Daft, 2004).

Conclusions

The Namibian health sector reforms were aimed at redressing many administrative issues that had been skewed (MoHSS, 1995). The ultimate aim was to balance the available resources in order to meet the contemporary demands for quality health care (ICN, 1996).

However, before embarking on any change process of this magnitude, the change agent should assess the meaning of the change for people who are likely to be affected and plan appropriate strategies to prevent negative emotions. It is obvious that people subjected to a change process will experience the change differently and attach their own meanings to the changes.  If the envisaged changes are perceived as beneficial to them, then their outlook will more likely be positive, and they will approach the change with optimism. The contrary situation is also found, however.  Some people may perceive similar positive changes with antagonism and most probably resist them.  

This inquiry aimed to gain in-depth insight into strategies for facilitating a change process by nurse managers during the Namibian health sector reform. Obviously, the responses of the nurse managers reflect expectations and subsequent dissatisfaction that were deeply rooted in the meaning they attached to the reform process in the Namibian health sector. Most probably, for the same reason, the Namibian nurse managers suggested the strategies they regarded as necessary for facilitating a change process during health sector reform as follows: supportive environment, characterised by adequate participation and involvement in the change process, clear communication of the vision, appreciation in support of change, adequate time and opportunities to detach  from the old behaviour, development of human resource training and provision of technical and financial support, and encouragement of social interaction.

Given the complexity of adaptation to change in the health sector, the change manager has to carry out a thorough and accurate assessment of the extent and nature of the change, identify factors causing stress and work out strategies for supporting the nurse managers to facilitate the change process effectively.

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