Between a rock and a hard place: Nurse managers' experiences of large-scale organizational change in the public health service.

BACKGROUND: Nurse managers are often at the forefront of implementing organizational changes. Studies suggest that conflicting pressures and stress are high during such times, though little is known of how nurse managers experience the continuing run of change initiatives. AIMS: To explore nurse managers' experience of large-scale organizational changes and its impact on their working lives and conditions.
DESIGN: A qualitative phenomenological hermeneutical study utilizing a Ricœur-inspired method of interpretation.
METHODS: Semi-structured interviews were conducted with 12 nurse managers at a public sector university hospital that had recently undergone large-scale organizational changes. Interviews were conducted in 2021 during the covid-19 pandemic. The analysis is based on the three-stage Ricœur-inspired analysis method by Pedersen and Dreyer.
RESULTS: Three themes emerged outlining the nurse managers experiences of large-scale organizational change: The need for support structures to be incorporated in the change process, The need for a guiding star, and The challenge of the values embedded in the Nurse Manager mindset. These themes were consistent across both predominantly positive as well as mainly negative experiences.
CONCLUSION: This study reveals the potential that receiving support from management, staff and peers has to positively influence the experiences of nurse managers during large-scale organizational changes. However, lacking a clear vision for the process negatively influences their ability to support high-level quality care within their wards, potentially increasing their feelings of stress and conflicting pressure. IMPACT: Participants offered important insight into the sparsely explored subject of nurse managers' experiences of organizational change, the complexity they face and the potentially high personal costs. The study highlights the detrimental effects of not providing support to all managers in organizations undergoing change, and the parallels to the covid-19 pandemic. No Patient or Public Contribution was required for this study due to its aim.

INTRODUCTION

Healthcare systems today have seen repeated often extensive reforms, all with a significant impact on the sector and its employees (Andreasson et al., 2016; Vallgårda & Krasnik, 2016). While the effects of organizational change on nurses, the skills needed by nurse managers (NM) to implement the change, or what is expected of NMs by their staff during times of change are subjects often explored in literature, little research has focused on NMs' experience of change (Andreasson et al., 2016). When linked to the worldwide nursing shortages that, according to the World Health Organization, are predicted to increase (WHO, 2022), understanding NMs experiences of this aspect of their work could allow us to better retain and support NMs. This study will focus on Danish NMs' experiences of organizational change as they are often at the forefront of implementing the planned changes in the public health service.

BACKGROUND

Since the 1980s, the health sector has experienced continuing reforms and organizational changes which have led some studies to question whether the public health service is suffering from ‘repetitive reform injury’ or ‘reform fatigue’ (Day et al., 2017; Worrall & Cooper, 2009; Wynen et al., 2019). This strain is further compounded by the fact that most decisions concerning the direction and goals of the public health service are made by politicians which, unlike private organizations undergoing change, leaves the employees to implement actions over which they have had limited influence (Worrall & Cooper, 2009). While studies argue that NMs take on this role of implementing change initiatives big and small, they have also found that the continuous organizational changes come at a cost to the NMs, e.g. in the form of a skewed work/life balance, increased work‐related stress, lower motivation and occasionally alienation from their staff (Day et al., 2017; Skakon, 2010; Whitehead et al., 2021; Worrall & Cooper, 2009), all of which can be assumed to have a negative impact on their working conditions.

Many organizational changes have come about due to the prevailing public administration paradigms. Public administration paradigms are the basic principles, assumptions and norms that together provide a frame for what are considered legitimate points of view, theories, methods, problems and acceptable solutions to these at any given time (Lerborg, 2017). Public administration paradigms can be viewed as representations of the political ideal of how the public administration should be run and structured to achieve certain goals (Bøgh Andersen et al., 2017).

The emergence of the New Public Management (NPM) administration paradigm in the 1980s resulted in an increase in reforms and changes in the public sector (Bøgh Andersen et al., 2017; Lerborg, 2017). The ideals of NPM are rooted in the corporate world of business with a focus on cost‐effectiveness and quality control measures. The aim of NPM is to create a highly functioning public sector that provides public consumers with choice and financial incentives for the providers to reach politically defined targets (Andreasson et al., 2016; Bøgh Andersen et al., 2017; Lerborg, 2017). According to Bøgh Andersen et al. (2017), the area of the public sector whose organizational structure was impacted most by the implementation of NPM was the secondary health service (Bøgh Andersen et al., 2017). A new paradigm is now emerging to replace NPM, often called New Public Governance (NPG) (Bøgh Andersen et al., 2017). A central element in NPG is the ideal of creating a ‘good society’ (Bøgh Andersen et al., 2017). To achieve this, all members of society must actively participate in finding the creative solutions required to overcome the problems society is facing. NPG is based on democratic values, such as representational government and actively involved citizens working together to create something of value for the benefit of all (Bøgh Andersen et al., 2017). The emergence of the NPG paradigm once again changes expectations and requirements for the health sector and its employees.

The Danish healthcare system is similar to the British National Health Service (NHS) in that it is funded primarily through taxation and provides universal access to healthcare for all citizens, and like many others, it has seen a multitude of change initiatives over recent years (Vallgårda & Krasnik, 2016). Between 1999 and 2018, hospitals in Denmark were subject to a yearly politically negotiated demand to increase efficiency initially by 1.5% and later by 2%. In the course of the first decade, this resulted in an increase in efficiency of almost 20% (Bech, 2017a, 2017b; Sundhedskartellet et al., 2010). While it is hard to argue that there was no room to achieve this increase, these targets became resented by employees as they were continually required to do more with less. According to the Danish Nursing Council (DSR), the efficiency demands were reflected in poorer working conditions for staff and overall reduced quality as experienced by patients. The basis for this statement by the DSR was the 73% increase in activity in the primary and secondary health sector over 15 years, while staff numbers had only risen by 48% and 20% for doctors and nurses, respectively (Bech, 2017a, 2017b).

One of the most comprehensive and large‐scale recent reforms was introduced in 2007. The main purpose of the planned changes was to improve the quality of the healthcare provided by taking advantage of specialization and ensuring resources were utilized most effectively (Health, 2005). To achieve this, it was decided to reduce the overall number of hospitals in Denmark, and to build six large ‘super‐hospitals’, merging and restructuring some existing hospitals into one. Organizational change of this magnitude provides a different set of challenges than e.g. implementation of an IT system in a ward.

Since the time of Florence Nightingale, nurses have overseen nurses and this essential part of the professional paradigm has not changed with the emergence of subsequent paradigms or reforms. However, the role of what being an NM entails has expanded from one focusing on clinical nursing to one focusing on management (Andreasson et al., 2016).

Today, NMs work at all levels of the hospital hierarchy, from chief nurse executive officer to clinical NM. During times of organizational change, NMs often find themselves at the forefront of the change implementation process. However, studies describe how they have had little influence over the politically mandated changes taking place, while at the same time lacking information regarding the vision behind them and their own role in the process (Boyal & Hewison, 2016). Organizational changes can create a feeling of uncertainty amongst staff, due to worries about job security, changes to current duties, increases in workload and the expectations of continuing high levels of service for patients in potentially tumultuous circumstances (Salmela et al., 2013; Wynen et al., 2019). Moreover, during times of organizational change, a study shows that despite the occurring changes, NMs must maintain and support “nursing's caring tradition” as a main priority, adding further complexity to the everyday work of NMs (Salmela et al., 2013).

For NMs, the many demands may result in stress, as NMs may find themselves caught between conflicting forces. Research suggests they might experience pressure from above to deliver the change initiatives while maintaining the productivity of the ward, and pressure from their staff due to the feelings and struggles they experience (Salmela et al., 2013; Whitehead et al., 2021). Skakon (2010) further reports that leader stress tends to infect the staff within their span of control with a potentially huge negative impact on the organization. Many studies report that NMs lack options for supervision and mentorship, and that they feel an opportunity for this would be of great assistance in their early years as an NM, but especially during times of change (Penconek et al., 2021; Saifman & Sherman, 2019; Salmela et al., 2013).

It is apparent that NMs are at the forefront when organizational changes are implemented, and that organizational changes have been, and will likely continue to be, a significant aspect of their everyday working lives as societal and political foci change over time. Modern‐day NMs no longer have the luxury of focussing solely on the core aspect of professional nursing care, they have a broad and varied portfolio of responsibilities and must move between different roles depending on the situation. However, NMs are not just managers they are also employees, and they often find themselves caught by contradictory forces emanating from senior management level regarding operational demands and the expectations of bedside staff, further complicating what they must negotiate on a daily basis. Therefore, understanding how organizational changes are experienced by NMs and how it affects their everyday working lives is necessary if we are to support NMs of the future.

THE STUDY

Aim

The purpose of the study was to examine NMs' experiences of large‐scale organizational change in the Danish public health service and its impact on their working conditions, aiming to positively influence NMs' working conditions and aide in the understanding of the conflicting pressures that literature suggests they may experience during such times.

In this paper, we have chosen to classify the amalgamation of the four Aarhus hospital sites into one, as a large‐scale organizational change.

Design

A qualitative exploratory design using a phenomenological hermeneutical approach employing a Ricœur‐inspired method of interpretation (Pedersen & Dreyer, 2018). The choice of a phenomenological hermeneutical approach was deemed essential to achieve a depth of understanding of the phenomena of how large‐scale organizational changes impact on NMs. The chosen Ricœur‐inspired method combines the aspects of allowing the participants to relate their experiences and setting forth a structured approach to the analysis of these experiences. Thereby gaining the depth of understanding needed due to the aim of this study.

Sample/participants

In this study, an NM is defined as the nurse overseeing the running of a ward or unit. They are ultimately responsible for maintaining high professional and clinical standards and for the delivery of high‐quality patient care within a given budget. Simultaneously, they are responsible for the hiring of new nursing staff, rostering, staff development, the working environment, student training and any ongoing development or research projects.

Participants were required to be NMs and to have held that position for a minimum of 3 years, preferably at Aarhus University Hospital (AUH). This minimum time limit was set to ensure that the participant was established in their role, as there is a compounding effect of the challenge of transitioning to the new role of NM while at the same time ‘learning the ropes’ (Saifman & Sherman, 2019). A 3‐year requirement also corresponds with the beginning of the physical amalgamation of the four Aarhus hospitals into one site, which ensured participating NMs had relevant experience of large‐scale organizational change.

Participants were recruited in two ways during February and March 2021. Initially, contact was made to an NM to gauge their interest in the possibility of this study and ask for their help in recruiting other NMs at AUH. This NM contacted their superiors and was granted approval for NMs to participate if so inclined. A short email containing information regarding the purpose of the study and an attached document giving further information and asking for consent to participate in the study was sent to four NMs identified as possible participants. All four agreed to participate and dates for individual interviews were set.

A further 8 participants were recruited via an email sent to all 118 NMs at AUH, using the hospital NM e‐mailing list. All respondents to this email were included, resulting in a total of 12 participants for individual semi‐structured interviews. Of these 12, one participant was known prior to interview by the first author. While this could constitute a bias, due to the sample size, we find this possibility to be minimal. see table 1: demographics

Data collection

12 semi‐structured interviews were conducted by the first author during March 2021. A study‐specific interview guide with open‐ended questions was developed. This contained six themes of relevance to the experience of organizational change by NMs as revealed through an extensive literature search. The guide contained suggested phrasings such as “Would you tell me about a typical working day for you as a NM?” and “Do you remember the last time you experienced organisational change in the ward? Can you tell me about it?”. These were the results of the literature search and discussions between the authors. The interview guide was used as a structural support tool to ensure all themes were covered in each individual interview and to allow participants to tell of their experiences freely according to the principals set forth by Brinkmann and Kvale (2018). Pilot testing was not conducted.

Of the 12 interviews, 11 were conducted in a face‐to‐face setting of the participant's choosing at AUH during working hours, keeping within the governments COVID‐19 guidelines. The final interview was, at the participant's choosing, conducted using encrypted video conferencing facilities. The interviews lasted between 45 and 60 min each.

Once the interview was finished, the researcher followed Kvale and Brinkmann's suggestion of taking time to reflect on the interview (Brinkmann & Kvale, 2018). These reflections were recorded in written notes with the purpose of providing insight into the context at the later analysis stage.

All 12 interviews were recorded and transcribed verbatim by the first author, with the exception of the use of fillers and repetitions, resulting in 131 pages of text (103.313 words). To further ensure the anonymity of the participants, identifying names of people and departments were replaced with a letter in the transcripts.

Ethical considerations

All participants received oral and written information about the study prior to providing their written informed consent to participate. The planning and execution of this study have occurred in accordance with the ethical guidelines for nursing research in the Nordic countries as stated by the Northern Nurses' Federation, which are based on the Declaration of Human Rights and the Helsinki Declaration (Oterholt et al., 2003). Approval from the Danish National Committee on Health Research Ethics was not required under Danish law (NVK, 2020).

Data analysis

To ensure the openness towards the phenomena, as advocated by the method, each author clarified their own understanding and experiences of organizational change prior to the data collection (Pedersen & Dreyer, 2018). This ensured an openness during the data collection phase and the later dialectical process between explanation and understanding during the critical analysis phase. The Ricœur‐inspired method of interpretation is a dialectic process that contains three levels of interpretation: a naïve reading, a structural analysis and a critical analysis & discussion (Pedersen & Dreyer, 2018). In accordance with the method, we read the transcriptions repeatedly with an open approach to obtain a unified understanding of the data material thus gaining an impression and understanding of what the text is about. At this first level of analysis, a dichotomy of the NMs experiences of large‐scale organizational change emerged.

Then, we proceeded to the second stage, the structural analysis, to reach a deeper understanding of the NMs experiences. We used a schematic to divide the text into units of meaning. Quotations that illuminated the NMs experiences served as viewpoints (what is said). This was followed by collating the viewpoints into units of significance (what the texts talk about) resulting in a dialectical process between the two (Pedersen & Dreyer, 2018). Finally, these were structured into themes and subthemes (Table 1).

TABLE 2

An example of the structural analysis

Viewpoint (what is said)	Units of significance (what is talked about)	Theme	Subtheme
“That is what happens when your span of control becomes so big, you end up removed from the praxis you are a part of” (NM12) “70 members of staff are way too many and I knew this when I applied for the position, that's the most grotesque part!” (NM11) “It was the number of staff. I wouldn't be able to cope, because I want to know my staff and I want them to be able to come to my office… I can cope with this number; I wouldn't be able to cope with that many… I don't even want to try” (NM3)	12) Their span of control has a significant impact on NMs' ability to know their staff and feel like they can perform their best on behalf of their staff to reduce the risk of losing staff members	The challenge of the values embedded in the Nurse Manager mindset (based on the following units of significance: 1, 3, 11, 12, 19 and 21)	Maintaining professional standards The focus on staff management The personal costs of change for Nurse Managers

At the final level of the analysis, the critical analysis and discussion, the themes identified through the structural analysis were illuminated and discussed using theory and other research to further nuance our understanding and interpretation (Pedersen & Dreyer, 2018).

As the Ricœur‐inspired method requires reading the data material as a collected whole, we estimated that data saturation had been reached based on the post‐interview notes, this estimation was confirmed in the analysis.

Rigour

The validity of phenomenological hermeneutical research is reliant on the variation of the phenomena being studied (Brinkmann & Kvale, 2018). To prevent a skewed sampling, we included 12 participants with variation in characteristic as described in Table 2. We particularly wanted to ensure variation in NMs' departments and number of years as an NM (Table 2).

TABLE 1

Demographics of participants

Nurse Managers at AUH interviewed	12 of 118 (10,2%)
Gender, female (%)	12 (100%)
Bachelor of Nursing a , n (%)	0 (0%)
Advanced Degree, n (%)
Leadership degree (unspecified)	12 (100%)
Diploma of leadership	10 (83%)
Master's degree	4 (33%)
Currently enrolled in study n (%)	1 (8%)
Number of years in nursing, mean (range)	32 (19; 40)
Number of years as a Nurse Manager, mean (range)	14 (3; 31)
Age when first appointed Nurse Manager, mean (range)	42 (34; 48)
Number of wards/departments managed in their career, mean (range)	2 (1; 4)
Span of control, nursing staff, mean (range)	50 (35; 70)
Ward/department type, n
Treatment b wards	6
Bed wards	6

Bachelor of Nursing was implemented in Denmark in 2001.

Wards such as intensive care, clinics, theatres, and recovery.

We strove to establish transparency by clearly setting out and stringently following the Ricœur‐inspired method of interpretation (Pedersen & Dreyer, 2018) and by providing an example of the structural analysis schematic (Table 1).

The first author collected and transcribed the data, and during the analysis, the findings were continually discussed with the second author leading to a refinement of the themes as they emerged and also ensuring an openness towards the material as advocated (Pedersen & Dreyer, 2018). Criteria for Reporting Qualitative Research (COREQ) was used to ensure accurate and complete reporting (Tong et al., 2007).

FINDINGS

The naïve reading revealed a dichotomy in the NMs experiences of large‐scale organizational change. The NMs with many years of experience often felt abandoned throughout the process but also felt that the several years of experience on the job was the only reason they survived the period of organizational change. This contrasted with the NMs with fewer years of experience who felt supported by both their managers and peers. Both groups felt the pressure to maintain or increase productivity.

Through the structural analysis, we identified three themes; The need for support structures to be incorporated in the change process, The need for a guiding star and The challenge of the values embedded in the nurse manager mindset. The themes showcase the experiences that influence the work of NMs during largescale organizational change. See Table 1 for an example of the structural analysis schematic and Table 3 for further supporting quotations.

TABLE 3

Supporting quotations

Subthemes	Quotations
1st theme: The need for support to be incorporated in the change process
Quotations describing how NMs experienced being left to their own devices	“It felt like you were shouting at a closed door” (NM7)
	“I felt under pressure, because there was no help to be found, we just had to fix it ourselves, and that's why jobs that never should have landed on a nurse manager's desk landed on my desk… because there was no one else” (NM11)
	“Of course there was a pressure from staff, they just thought ‘this is S**t! When's it going to end?’, couldn't I just tell the leaders that we can't do this? I understand why, but it was so much pressure to be under” (NM2)
	“The staff knew how I felt about the management. That doesn't sound very nice, but I believe they knew. I tried to be loyal, but I might have slipped sometimes, because there was no support” (NM1)
	“If you describe the right issues, then I think you get heard” (NM8)
Quotations describing the NMs need for a visible and engaged management	“I remember one of my nurses saying ‘Who is it you're talking about when you talk about the management, is it God in heaven?’ They're so far away!” (NM5)
	“At one time we were so short staffed that I wasn't able to sleep, I'd been pushed so far…I couldn't see how we could run the department, and no one listened!” (NM12)
	“Not an unfair pressure no, more like a continuing clarification regarding where we were and what help we needed (NM9)
	“It helped when the staff started making noise too and we had that report made. I think that if the management we had at the time, didn't understand what was in that report… then I don't know how we would have made them sit up and pay attention” (NM5)
	“It was one of those things where I thought, now I'm not just angry, now I'm beyond furious! But I had nowhere to go with this!” (NM12)
	“I'm baffled that it was me that was meant to have the overview! That there wasn't someone, in such a huge moving process, that had that job” (NM10).
	“I have a team of nurses with special positions that help me in my management, and that's why I think it's possible” (NM6)
Quotations describing how NMs experienced the usefulness of peers	“I've definitely used them, if they hadn't been there then it wouldn't have worked, not with those challenges!” (NM9)
	“I was in a conflict of loyalties… I couldn't just go and tell how things were in our department, because the others are employed at AUH as well, and I didn't want them to start talking” (NM12)
	“I felt there was no one I could call on” (NM7)
	“It was really difficult moving to Aarhus, I hadn't worked at Skejby before, I didn't have a professional or collegial network to call on” (NM4)
	“I have more colleagues with a job like mine now, I didn't have that before…I think that's one of the good things that's come out if the way we're organised now, having a management network” (NM5)
2nd theme: The need for a guiding star
Quotations describing how NMs experienced the never‐ending rounds of organizational change	“I've had so many meetings due to the move and the new structure, and then a new structure again” (NM5)
	“The big organisational change was when we moved. The ward was made… split. Parts of it were going to this area, another part to a different one. It was the sort of thing that came about almost overnight, I think” (NM1)
	“We had to hire 9 nurses in one go, which is a lot to onboard. On top of everything else it added an enormous pressure on the regular staff, and that might have been the cause of further resignations” (NM2)
	“We've been running around like crazy… productivity is everything” (NM3)
	“It does make sense that we're together with the ones we have a similar ward as…at least it's more efficient, and that's what counts these days” (NM6)
Quotations describing the NMs need for a set course	“We've been lacking the visions and goals, there hasn't been anything to steer towards. I haven't really known what was expected of me… should I steer in this direction? Should I stay put? It would have been nice to know, especially as everything keeps changing all the time” (NM3)
	“It's been difficult to set a course, simply because I haven't known which way we were heading. It's something we've asked for repeatedly, and we've only, maybe, been told just recently” (NM3)
Quotations describing how NMs experienced similarities between the COVID‐19 pandemic and largescale organizational change	“We had to solve a massive task and it resulted in me arriving in the ward a bit off kilter… we weren't able to continue with the nurse manager development process we were doing” (NM11)
	“This covid business has caused a lot of bad stuff… you don't get to see each other, you miss having professional discussions, you miss professional development” (NM3)
	“Luckily, I had 7 years of prior experience, that counts for something!” (NM4)
3rd theme: The challenge of the values embedded in the nurse manager mindset
Quotations describing the NMs need for maintaining professional standards	“I would like to have as competent a ward as possible, where things work well professionally, socially, organisationally… but that requires that staff has access to development, if not they end up standing still” (NM3)
	“Sometimes I'm asked what visions I have for how we're going to develop nursing in the unit… and I become speechless, because the focus has just been on productivity” (NM5)
	“I've always firmly believed that us nurses, we thrive if we're allowed to deliver high quality of care, and when we're not… that's when we burn out” (NM4)
Quotations describing the NMs need to focus on staff management	“It's extremely important to me that they're okay sitting here saying ‘I just need a break from such and such’” (NM7)
	“If my staff had come and said ‘we're leaving, we're calling in sick from tomorrow’ I don't know what I'd have done, it was what I feared, because I was there myself… I had 5 people crying in my office daily” (NM1)
	“They need a present manager, that sees them, recognises them, and can get them to sign up to all the decisions and developments being made. It's paramount that you have a closeness to and a relationship with your staff, if you're going to be successful with a task, and that was where I was challenged” (NM11)
	“As a nurse manager we must have 51% of our attention on the whole of the unit when dealing with a staff issue and 49% on the individual, ensuring we're doing all we can to help them become strong so they can return to the flock” (NM8)
	“It was the number. I wouldn't be able to deal with it, because I want to know my staff, for them to be able to come in… I wouldn't be able to deal with that many, I don't even want to try” (NM3)
Quotations describing how NMs experienced the personal costs of change	“I felt unsafe, I couldn't concentrate, I had signs of stress… cognitively, I slept badly, had stress dreams, felt nauseated on my way to work and at work sometimes, felt like I couldn't breathe, heart palpitations… I was in a horrible mood at home, cried a lot” (NM12)
	“My colleague who's a bit older than me, she chose to retire. I don't think it's something she'd have chosen if we weren't in that situation” (NM5)

The need for support structures to be incorporated in the change process

This theme is based on 7 units of significance and shows how the participants experienced being left to their own devices, lacked the support of a visible and engaged management, and had mixed experiences of attaining and utilizing peer support.

An overall feeling of being left to their own devices was present for the NMs during the process. While practical help was given with regards to the physical move, NMs experienced considerable distance to their superiors and often struggled to make their concerns and requests for help heard at a higher level within the organization: “It was a feeling of you're on your own and you better be sure to have control of everything, because there is no one who'll catch you” (NM12). These experiences left the NMs feeling powerless and stressed—for themselves but also for the ward. The lack of support added to the experience of being abandoned and at times left them to deal with overwhelming tasks that from an NM perspective was not within their remit. Furthermore, it provided a foundation for experiences of conflicting loyalties to grow amongst the NMs, as they had to show loyalty to the organization and the process it was undergoing, but often found themselves having to defend and explain decisions over which they had little influence or disagreed with.

“You just feel completely squashed. Like you almost can't breathe, it comes from below, and from above you're just told you have to do it… it can also come from the sides, because you have people at the same level that you might completely disagree with” (NM3).

However, not all managers felt that support was lacking from their superiors. This was often experienced by the NMs with fewer years of experience prior to the organizational change occurring. They still felt a level of pressure, but they did not experience it as excessively.

The lack of support experienced by the NMs had a physical location aspect and an emotional aspect. The physical aspect of the distance to superiors increased feelings of abandonment that manifested themselves amongst many NMs: “They didn't visit us; they didn't come here. Really… it's not that far, grab a bike!” (NM1).

The emotional aspect of the distance experienced came to the fore when the NMs felt that their concerns and worries were ignored, which further compounded feelings of abandonment. Contrary to the NM's experience of a lack of visibility from their own managers, they attempted to stay clearly visible in their own department. They saw distributed management as something that benefited both parties. When it worked well, it helped them with overseeing specific parts of the running of the ward as well as freeing up some of their own time. The NMs saw delegation as an essential aspect of their role:

“It's just so important that when they do something, that they're seen, heard and recognised for the jobs that they do. And when they meet a bump in the road, then I can help move things along” (NM8).

Being able to delegate allowed a sense of normality to return to their working day but also potentially highlighted what they were missing from their own managers.

The usefulness of peers during times of organizational change was highly valued by the NMs. Although, being able to use their peers for support or as sounding boards for problems encountered varied greatly and they lacked a structure to support achieving this: “We were all struggling so much, it was difficult to find anyone with a mental surplus… it was impossible, because we'd all moved” (NM1). Hence, the majority of the NMs felt the opportunities to use their peers were non‐existent and that they faced a potential conflict of loyalty with regards to how their department was perceived.

The inability to utilize their peers for support led to feelings of isolation, again potentially further exacerbating their feelings of abandonment.

The need for a guiding star

This theme is based on 11 units of significance. The central element of this theme is the need stated by the NMs for a direction, which they can steer towards during the tumultuous times of change and use as an aid to assist them as they make long‐term plans for their wards. With the intensity of the never‐ending rounds of organizational change NMs felt they were lacking a course consisting of information on the vision and purpose of the change process. This element of experiencing a missing course was described by the NMs as having many similarities with their experiences of the COVID‐19 pandemic which started less than 2 years after the amalgamation of AUH commenced. NMs experiences of large‐scale organizational change was helpful during the pandemic but also a reminder that elements of their job that they finally had the surplus energy to focus on again, such as forums for professional discussions and opportunities for professional development, disappeared into an uncertain future once more.

Organizational change was not new for the NMs, but this change (the physical amalgamation of the four Aarhus hospitals into one site) was on a scale and level of complexity unlike any they had previously known. One NM described the never‐ending rounds of organizational changes as if “they follow each other like pearls on a string” (NM8). Preparatory efforts started early but were often in vain as plans were changed overnight, which was also the case during the pandemic, often without input from the affected parties:

“You almost wanted to run away screaming… because it was impossible to accommodate all the changes, and how was it going to change tomorrow? And trying to bring my staff along. It was so difficult!” (NM3).

The NMs repeatedly asked for clarification on the vision and purpose of the change process, but they felt continually let down as they did not receive the needed clarification from their superiors:

“Maybe the future is something we won't know for another 4–5 years, but what future is the system expecting us to work towards? If it even knows… if not, we could take part in the process of finding something to steer towards” (NM10).

A vision or goal to steer towards would, according to the NMs have provided a stable element throughout the many changes making the process easier to manage and allowing them to spend time on what they viewed as the most important part of their job; staff management. This was often also the aspect of their job that they found the most enjoyable, but they felt that the opportunity to be the type of manager they preferred was limited by the organization's focus on productivity, which was the only thing that seemed consistent to the NMs in the continuing chaos of change.

Instead, NMs' experienced that the organization's rigid focus on productivity had a negative impact on their ability to lead their staff, and many lost significant numbers of staff: “I've been privileged in that I haven't experienced an exodus of staff, but it's contagious, and I kept thinking: How long? When is it going to break all around me?” (NM5).

Merging departments together was one way to meet the simultaneous demands for increased productivity and a reduction in overheads. The NMs experienced an expectation that they would instantly become a collective “one” in their large new departments:

“It's been awful for the staff, and we're not there yet. We're from all four hospitals, four different wards, and suddenly we had to be “one”, without even knowing each other. It's been extreme!” (NM10).

Having to create new working relationships and agree across many wards on issues that were previously solved within individual units added a further layer of complexity and drudgery to an already demanding situation. Still, some NMs experienced how the external pressures helped create a feeling of togetherness; a ‘we can do this’ attitude:

“When we get new staff, when they want to hear a bit about the ward… that's the story they're told. That it was completely, utterly awful, but that it became great, awesome… yes, it did” (NM1).

This helped build a positive platform for the unit and demonstrated that something good could come from something generally experienced as bad.

With the onset of the COVID‐19 pandemic, similarly during the large‐scale organizational changes, the NMs again faced an extremely disruptive period characterized by limited preparatory efforts, enormous tasks to overcome, and uncertainty and repeated changes to guidelines. Moreover, COVID‐19 affected the collegial togetherness that was being rebuilt after the changes as well as options for professional development activities, much to the NMs' disappointment: “Things can happen quite fast. It's been the same during Corona. One day I was told to do things this way, the next it's forget everything we said yesterday” (NM9). Hence, the arrival of the COVID‐19 pandemic soon after two stressful years dealing with change processes felt like a knock back for some NMs, as some of the aspects of their job that they were ready to grab hold of again slipped out of reach once more.

The challenge of the values embedded in the nurse manager mindset

This theme is based on six units of significance. It focuses on the role of the NM, how the values of maintaining professional standards and of being able to carry out staff management were an integral part of the nurse manager mindset. This mindset also related to the personal costs for some of the NMs, which have been high.

Maintaining professional standards in their unit and supporting their staff to achieve and set high standards is seen by many NMs as one of the central aspects of their job. They view it as fulfilling a duty to patients and staff and a way to create a ward where staff thrive: “I believe that as a nurse manager, you must drive professional competence, and as we know professionalism for nurses is extremely important” (NM11). During the change process, their options to work towards this was often limited as superiors focused mainly on the productivity of the unit and reductions in overheads. This left some NMs struggling with ways to reconcile the values and beliefs central to their role and the organization's expectations: “It was the most difficult part of it all, feeling that to succeed in your job you had to compromise on your own core values” (NM4).

A main aspect of a NMs' job is staff management. It was important to the managers that they were available to their staff, and many saw it as a pat on the back when staff included them not just in ward business but also in their personal lives, as both can affect staffs' work performance: “My door is always open. I've just gotten a busy sign, because if the door is closed, they're wondering what that's all about. And I think that's a good sign” (NM9).

The NMs see this availability as a way to care for their staff, and in the longer term the running of the ward and maintaining high professional competencies within the unit. They continued this during the change process:

“The move was completely awful, by which I mean that my main issue was to take care of my staff, because we must look after our professional strengths to ensure a high standard of care, and that became truly difficult” (NM12).

Another issue affecting their availability to their staff is their span of control. The span of control varies, but all felt that it had an impact on their staff management options and that their span of control had grown and was at the upper limit, if not over, to allow them to be the type of manager their staff needed:

“If I had a smaller span of control, the presence I could give them as a manager… they would have noticed a different type of manager, probably truer to the type of manager I am” (NM11).

The above aspects that NMs value as essential parts of their job and that help them achieve a ward where staff thrive run the risk of being forgotten. Especially when they experience that the focus is firmly on maintaining productivity during times of change.

The organizational change at AUH was felt over a protracted period, with some NMs saying that 3 years down the line they still did not feel it was over. This prolonged period clashed with the integral values of the profession and the NM mindset and resulted in considerable personal costs to many, with some questioning whether they wanted to remain in the organization. The stress and pressure the NMs were under were felt by themselves but also by their families:

“It was so bad that my grown (!) children were worried about me. They're in their 20's and I don't think they've ever worried about me before. It makes me really uneasy that they could see how affected I was” (NM4).

At the same time, several NMs expressed how, despite the effect on their personal lives, they kept going as they did not want the hospital to break them: “I couldn't leave a sinking ship… I wanted it to succeed. It's a stubbornness and I didn't want them to break me or the staff!” (NM3).

DISCUSSION

In this study with NMs, we found that NMs in their experience of large organizational changes expressed a need for support structures to be incorporated in the change process, a need for a guiding star, and that the nurse manager mindset was a challenge to hold on to during the change process. At the same time, NMs with many years of experience often felt abandoned throughout the process but also felt that the several years of experience on the job was the only reason they survived the period of organizational change which contrasted with the NMs with fewer years of experience. Still, all NMs felt the pressure to maintain or increase productivity.

The importance of support structures

In our study, support was often experienced as missing during the organizational change making it difficult for the NMs to lead their staff with the professional nursing focus they wanted and were expected to deliver. This is similar to the findings in a study on the differences in experiences amongst healthcare leaders (45 nurses leaders) between the first and the second wave of COVID‐19, which also showed a lack of support during both periods (Hølge‐Hazelton et al., 2021). Skakon et al. describe how stress in an organization can be contagious, and how a significant amount of stress experienced by managers is a result of a lack of support from their superiors and of finding themselves caught by conflicting pressures emanating from superiors and staff (Bossen, 2017; Skakon, 2010). She defines conflicting pressure as:

a condition where a person is affected socially or psychologically by opposing forces.

According to Skakon, a final significant work‐related stressor is when managers lack the time to be present with their staff due to general managerial and administrative tasks (Bossen, 2017; Skakon, 2010). Therefore, it could be expected that different types of support could potentially lessen the work‐related stress and feelings of conflicting pressures for NMs during tumultuous periods of change. Furthermore, it may help ensure a work environment more conducive to the implementation of changes.

While it would be easy to place the blame on the NM for not being able to cope with the change occurring, it could be argued that the cards are stacked against them given the environment they work within. This is supported by other studies on how the environment impacts NMs' ability to cope (Day et al., 2017; Udod et al., 2017). Skakon also makes the point that leader stress is a taboo, and that there is an expectation that managers can cope with whatever is thrown at them (Bossen, 2017; Skakon, 2010). Still, NMs are employees of the organization and therefore in need of support during times of organizational change and the multitude of challenges and unusual tasks it brings. Support during such times has been shown to improve NMs' job satisfaction, which in turn improves their ability to support their own staff, facilitate change and lead staff through the change (Kirchhoff & Karlsson, 2019; Penconek et al., 2021; Udod et al., 2017). This highlights the need to focus on support across all levels to avoid NMs becoming ill due to stress or resigning as approximate ½ of the participants in this study seriously considered. Resignations would have disrupted the continued implementation of the changes in their unit.

Even without ongoing organizational changes, a lack of support is still a major factor in NMs experiencing work‐related stress and this has been shown to have a negative impact on productivity and efficiency with the added negative of stress being contagious (Bossen, 2017; Hølge‐Hazelton et al., 2021; Udod et al., 2017). Hence, studies on how different kinds of support structures could have a positive impact on experiences and levels of stress would be important. This is especially relevant in today's healthcare systems where organizational changes are a persistent feature coupled with the wish to maintain high levels of productivity.

Our study revealed that NMs experienced a need for direction, something towards which they could steer during the turbulent times of change. The never‐ending rounds of organizational change often left wards in a state of chaos due to a lack of an overall plan guiding the process. The only plan the NMs experienced appeared to be the requirement for continued productivity. Thereby, leaving them with little time to focus on other aspects of their role such as professional competence and staff management.

Kotter, a noted thought leader in change management and creator of a widely used eight‐step change model, points out that a change process must have a vision and a strategy for the realization of it to lead to the proposed change and that it must be communicated clearly and often, or it has the potential to become an immense barrier (Knærkegaard & Steenstrup, 2012). The NMs in this study actively sought clarification of the vision guiding the organizational change but did not receive an answer. Thus, while many of the NMs were excited about the move and the challenges ahead at the beginning, it can be assumed that the lack of a clearly communicated vision, despite repeated requests, had a negative impact on their view of the change process which potentially created barriers.

Voxted suggests that Kotter's model is missing a ninth step if it is to be useful in overcoming barriers associated with change occurring in the public service sector. This ninth step specifies that any successful change must be rooted in the professional context, unlike Kotter's previous eight steps that focus on the goals of the organization (Voxted, 2016). Voxted argues that for the change to be successful in the public service sector, it is necessary that professional leadership is practised by frontline leaders as this is where the organization's plans and visions are translated into actionable value‐adding activities (Voxted, 2016). Without the changes being anchored in the professional context, it is likely the change will be viewed as a negative that clashes with the profession's ability to keep up professional standards (Voxted, 2016).

In the healthcare sector, the pace of organizational changes and reforms have been rampant. Changing governments, budgets and public administration paradigms have all influenced these changes (Vallgårda & Krasnik, 2016), and it may be assumed that this has only heightened the need for a clear actionable vision for the organization as part of the latest round of organizational change experienced by the NMs in our study. Without a communicated vision for the ongoing change, getting staff to buy into a process that potentially affects their ability to keep up professional standards would have been difficult for the NMs as is shown in this study.

Research shows the important role NMs play in ensuring the quality of care delivered to patients and in keeping up professional standards. It also shows how NPM has increased the pressure on NMs through a disregard for their professional background in favour of a managerial outlook (Hansell, 2018; Kirchhoff & Karlsson, 2019; Penconek et al., 2021; Udod et al., 2017). If, as Voxted suggests, the change should be anchored in the professional context, the rising paradigm of NPG has the potential to allow the professional practice to come to the forefront once again. This in turn may allow more influence on and participation in the change by NMs. The experiences of the participants in this study vary greatly, from those achieving restructuring of the newbuilt physical space to better suit ward needs, to those losing staff members due to e.g. shift changes despite repeated protest against such measures. The energy and buy‐in from the whole ward when able to influence outcomes was enormous, whereas negativity towards the change process spread when not. The possibility of participating in the process could further help the NMs know of and transform the vision at ward level, thereby ensuring a continued anchoring in the professional context as suggested by Voxted and enabling them to focus on professional standards and quality of care.

Nursing values

In relation to the role of the NM, the aspects and values they view as an integral part of their job, the NMs in our study often had to compromise on these to get the job done and doing so came with personal costs for some of the NMs.

According to Hewison (2012), the values embedded in the nursing profession are retained by NMs after they make the move from bedside to office (Hewison, 2012). The international Council of Nurses (ICN) code of ethics states that nurses and managers should be active in developing and sustaining a core of professional values (p. 3) and establish standards of care and a work setting that promotes quality of care (p. 8). (ICN, 2012).

Through this, the ICN puts responsibility on nurses at all levels to uphold the core professional values. For the NMs, this involves setting the tone in the unit, supporting their staff and being able to focus on delivering a high standard of care (Penconek et al., 2021; Udod et al., 2017). When they are able to work on such matters, research shows that they experience increased job satisfaction often leading to reduced levels of stress and increased rates of job retention (Andreasson et al., 2016; Penconek et al., 2021; Udod et al., 2017).

It is these practices and values that have been under threat by the NPM paradigm of the last 30 years (Kaspersen & Nørgaard, 2015). The Danish philosopher Morten Dige describes the three ‘au's’ of professional values: authorisation, autonomy and authenticity, with each ‘au’ referring to central elements of a profession such as nursing. These professional values are threatened by the competitive focus of NPM with increased outsourcing, standard operating procedures and expected hierarchical loyalty to the leadership and not the citizens requiring the profession's assistance (Kaspersen & Nørgaard, 2015). This clash between the values of the profession and the way NPM influences how public organizations are run has caused difficulties and mistrust to build on both sides (Kaspersen & Nørgaard, 2015). The NMs in our study have a mean of 32 years in the nursing profession (see Table 1), meaning they started their careers during a different paradigm where the values of the profession were at the forefront, and it is likely that the same code of ethics continues to be an integral part of their professional core values and identity today. However, the circumstances in which they must live up to these deep‐rooted ideals differ, further increasing the rift between the professional values of the NMs and the organization.

Being caught by the conflicting pressures of internalized professional values and external expectations of what their role entails has had a significant effect on the NMs' experiences of the organizational change and their personal lives.

A comparable effect was shown in a systematic review from 2013 which found that difficulty combining the NM role's conditions and expectations as well as personal and organizational values had a significant negative influence on their intention to stay (Brown et al., 2013). This is supported by Udod et al. (2017) who found stressors such as being pulled in different dictions, organizational change and limited recourses, had a negative impact on the NM role. They further found that job satisfaction was influenced by workload, span of control, organizational support and recognition (Udod et al., 2017). This study found that the same aspects influence the NMs' experience of organizational change, suggesting that while these aspects are known, not much has been done to affect a positive outcome related to these. Further studies could explore how such knowledge could be viewed as a potentially untapped resource and guide efforts to improve working conditions for NMs prior to and after organizational change. The outcome of such interventions could focus on the NMs experience of being included and engaged in the process, as well as striving to align the professional values and those of the hospital potentially benefiting staff, patients and the change process.

LIMITATIONS

While qualitative studies are not concerned with reproducibility, recognisability is of relevance (Brinkmann & Kvale, 2018). It could be considered a limitation that both authors are nurses, and as such, presumably, have internalized the values of the profession, which could impact their ability to question the validity of these. A further limitation could be that both authors were employed at AUH during the lead up to and during the amalgamation. However, it helped create a sense of trust and understanding in the interview setting that the participants knew that the first author had her own experience of AUH during this time. A further limitation of the study could be that only 12 of 118 possible participants chose to take part. Several possible reasons for this exist such as a lack of follow‐up request, the personal character of the subject matter and the time required for interview. Nevertheless, as participants include both those with predominantly positive and negative experiences, we believe the number of participants is not a significant limitation.

The values embedded in the nursing profession, such as described by the ICN codes of ethics (ICN, 2012), can be assumed to be comparable across many nations similar to Denmark. Further, many western countries have experienced a comparable development in public administration paradigms (Bøgh Andersen et al., 2017). Thus, the findings from this study may not only be useful in a Danish context, where further moves to newly built hospitals are scheduled but also in the wider western public hospital world. This supposition is supported by research from other countries that have found a lack of support, rapid flow of changes, increased span of control, conflicting pressures and increases in stress amongst NMs (Andreasson et al., 2016; Hansell, 2018; Kirchhoff & Karlsson, 2019; Udod et al., 2017; Whitehead et al., 2021).

Further research into how organizational culture and organizational change in the public health service impact NMs would provide further knowledge in this area and highlight potential solutions.

CONCLUSION

Our study shows that support structures, a guiding star to lead you and being able to maintain your professional values have an impact on NMs' experience of large‐scale organizational changes. It adds to the knowledge on how to handle large‐scale organizational changes and should not be ignored or pushed to the side as other aspects of the change process become the focus of the hospital management, namely productivity. Ignoring these aspects risks leaving NMs caught between a rock and a hard place during times of organizational change and runs the further risk of the organization losing the very people they need to help implement these changes, thereby endangering the very changes the hospital management is trying to achieve.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.