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\begin{document}

\title{Achieving change readiness for health service innovations}



\author[1]{Reema Harrison}%
\author[1]{Ashfaq Chauhan}%
\author[2]{Huong Le-Dao}%
\author[2]{Amirali Minbashian}%
\author[2]{Ramesh Walpola}%
\author[3]{Sarah Fischer}%
\author[2]{Gavin Schwarz}%
\affil[1]{Macquarie University}%
\affil[2]{UNSW}%
\affil[3]{Clinical Excellence Commission}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
Continual innovation to address emerging population needs necessitates
health service ongoing redesign and transformation worldwide. Recent
examples include service transformations in response to covid-19.
Ensuring effective change management processes occur is central to
delivering these transformative changes yet notoriously challenging.
Recent evidence indicates that affective commitment to change amongst
healthcare staff may be an important contributor to gaining support for
change implementation but understudied in healthcare. Our analysis
sought to examine the association between affective commitment to change
and change readiness in projects across the New South Wales health
system in Australia. Our findings indicate that affective commitment to
change; healthcare worker's emotional and personal perception of the
value of the proposed change, is independently associated with
individual and collective change readiness. Given that achieving change
readiness is a central goal of change management strategies, this pilot
work provides valuable insight to inform change management practices in
healthcare contexts.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{introduction}}

Continual innovation to address emerging population needs necessitates
health service ongoing redesign and transformation worldwide. Recent
examples include service transformations in response to covid-19. The
pandemic has catalysed several changes to how healthcare is delivered,
particularly in the rapid acceleration of virtual and hybrid models of
care.(1) As work processes, systems and models of care shift in response
to health system needs, so too must individual and collective behaviours
of the workforce and its consumers.(2, 3) Ensuring effective change
management processes occur is therefore central to transformative
changes that deliver their intended outcomes and are sustained. Yet
change management is notoriously challenging in healthcare contexts,
with limited evidence available for healthcare managers to optimise
their implementation of current change management models.

Achieving `change readiness' amongst healthcare staff is identified as
an important precursor to whether staff accept and adopt a change
initiative. Change readiness is influenced by the extent to which staff
perceive that a given change is needed (their commitment to the change)
and that they have the required capability and support to work in a new
way (change self-efficacy).(1)(4, 5) Commitment to change arises for
three reasons: a) because there is a requirement to support the change
due to recognition of cost associated with failure to do so (continuance
commitment), b) because there is a sense of obligation to support the
change (normative commitment), and c) because an individual wants or
desires to support the change due to the benefits associated with it
(affective commitment).(6, 7)

Recent evidence indicates that affective commitment to change is an
important contributor to achieving change readiness but understudied in
relation to healthcare projects.(8-10) A systematic review of 38 studies
of healthcare change projects highlights that management approaches
rarely focus on the influence of affective commitment to change.(11) Our
analysis sought to address the evidence gap regarding the association
between affective commitment to change and change readiness in
healthcare by exploring change readiness amongst clinical and
non-clinical staff directly involved in one of four transformational
change projects in New South Wales, Australia.

\section*{Method}

{\label{method}}

\emph{Ethical approval:} This study was approved by Western New South
Wales Local Health District Human Research Ethics Committee (Approval
number 2020/ETH01247)

\emph{Design} : Cross sectional survey

\emph{Survey instrument:} A survey tool was developed by the research
team consisting of five elements (Supplementary File A). The responses
were measured on a 7-point Likert scale (from 1- strongly disagree to 7
- strongly agree). The four validated elements were: i) Individual
change readiness scale (4 items) , ii) collective change readiness scale
(4 items), iii) change self-efficacy scale (4 items), and iv) affective
commitment to change scale (3 items).(6, 13) A fifth element contained
purposively developed items to assess participants understanding and
awareness of the change being proposed.

\emph{Setting} : The study was conducted in partnership between academic
researchers, health agencies and two local health districts (LHDs) in
New South Wales, Australia. Two local health districts (LHDs) in New
South Wales participated in this study, one servicing a metropolitan
region and one servicing a rural/remote region. Within each district the
project partners identified two transformational change projects that
were at a suitable stage to address our aims. This meant that projects
were of a similar scale, at a similar point in their planning, but
implementation had not yet commenced. The four participating projects
were: virtual pharmacy project, in-home monitoring project, emergency
department expansion and an outpatient administration change project.

\emph{Recruitment and procedure} : Employees in any clinical or
non-clinical role who were directly affected by or involved in the
change/s proposed in each project were eligible to participate: a total
participant pool of 60 participants was available who met the
eligibility criteria in the participating projects. A minimum sample
size of 15 participants per site was sought to enable us to detect
significant changes in individual change readiness between sites.(14)
Participants were recruited via a study invitation email with an
embedded survey link. The email was distributed by the research team to
eligible potential participants at each site through the local study
partners. Written consent was obtained from individuals prior to their
participation.

\emph{Analysis} : Descriptive and inferential statistics for sample
characteristics and the levels of change readiness, change commitment,
and change self-efficacy were explored using SPSS (IBM Statistics,
Version 25). Pearson correlation coefficients were calculated to examine
the relationships between readiness for change (individual and
collective), change self-efficacy, and affective commitment to change.
Multiple regression analysis using ordinary least square estimation was
conducted to examine the independent effects of the two antecedents
(affective commitment to change and change self-efficacy) on individual
change readiness. Specifically, we conducted a simultaneous regression
in which change readiness was entered as the outcome variable and change
self-efficacy and affective commitment to change were entered as
predictors.

\section*{Results}

{\label{results}}

Thirty participants of the 47 invited (64\% response rate) completed the
survey. Table 1 provides a breakdown of participant characteristics by
site and overall.

\textless{}INSERT TABLE 1\textgreater{}

Participants from both sites scored highly on individual and group
readiness for change (Table 2). Readiness for change (individual and
collective), change self-efficacy, and affective commitment to change
were moderately to strongly correlated in a positive direction. Higher
affective commitment to change was associated with higher levels of
self-efficacy (r =.46, p\textless{}. 01) and individual readiness for
change (r=.75, p\textless{}.001). The correlation between self-efficacy
and individual change readiness was moderate in size (r =.32) but not
statistically significant (p=.08). Finally, collective readiness for
change was positively and significantly associated with higher levels of
change self-efficacy, affective commitment to change and individual
change readiness (change self-efficacy: r=.43, p =.02; affective
commitment: r=.69, p\textless{}.001; individual change readiness: r
=.39, p =.04).

\textless{}INSERT TABLE 2\textgreater{}

Regression analyses demonstrated that the effect of affective commitment
to change on change readiness continued to remain strong after
controlling for change self-efficacy (\selectlanguage{greek}β \selectlanguage{english}= .76, p \textless{}.001),
whereas the effect of change self-efficacy became negligible after
controlling for affective commitment to change (\selectlanguage{greek}β \selectlanguage{english}= -.03, p = .82).

Individual items in the fifth survey component (Table 3) indicated that
participants were aware of the change and its success measures. The
scores also indicated that most participants understood the criteria for
success, felt they had leaders that could drive the change and could get
the support they needed. Although most felt that they had sufficient
resources for change, this item had a slightly lower mean score overall
(4.8/7) and wider variation between respondents.

\section*{\textless{}INSERT TABLE 3\textgreater{}}

{\label{insert-table-3}}

\section*{Discussion}

{\label{discussion}}

Our findings indicate that affective commitment to change; healthcare
worker's emotional and personal perception of the value of the proposed
change, is independently associated with individual and collective
change readiness. Given that achieving change readiness is a central
goal of change management strategies, this pilot work provides valuable
insight to inform change management practices in healthcare contexts.
Larger scale replication of this analysis is warranted to explore these
findings across health systems and a wider range of change projects.

Many factors contribute to an employee's affective commitment to change,
which may warrant further exploration to underpin interventional
approaches that promote change readiness in healthcare. Factors that
contribute to an employee's affective commitment to change include
employees interpersonal workplace relationships with managers and with
colleagues, change frequency (more frequent change reduces commitment to
change), organisational communication about change, and employee's
participation or engagement in decisions about the change.(15)

Wider research literature indicates that employee engagement in
decisions about the change process have been linked with individuals
feeling more positive emotions towards change proposals and greater
understanding of the purpose of change proposals and the possible gains
to be made. These reactions, in turn, are associated with a greater
likelihood of employees making the behavioural changes required for
changes to be adopted and sustained.(16) When employees engage in
decision-making about changes and how change occurs, it also promotes
interpersonal trust, attachment to their organisation and their sense of
competence to achieve the changes needed.(17) Employee engagement in
decision-making about changes may also therefore be a factor to consider
in attempts to promote affective commitment to change.

Our findings must be considered in light of the limitations of the
research. As a pilot project, the results need to be treated cautiously
due to the small sample size and cross-sectional nature of this
research. Change readiness is not static and it is important to consider
in future analysis how the environmental factors (e.g. the extent to
which a health service environment has a culture that is conducive to
change, the level of resourcing and support for changes to be made
successfully and leadership) influence whether change readiness is
achieved and sustained. The sample was also made up largely of females
and of clinicians who consented to participate, which may have also
influenced the resulting data.

\section*{Conclusion}

{\label{conclusion}}

Our analysis provides novel insights into how health systems might seek
to address the challenge of bringing about change in health services
through a focus on value-based approaches to achieve staff investment in
change proposals. These findings offer opportunities for developing
service-level interventional approaches and avenues for research.

\section*{Acknowledgements}

{\label{acknowledgements}}

We wish to thank our partners of NSW Health who contributed to the
shaping of this research paper. Their dedication in gaining insight into
how change is implemented and managed at NSW Health for better patient
value and staff experience. We thank: Adrienne Stern of Hornsby
Ku-ring-gai Health Service; Ian Richards of NSW Clinical Excellence
Commission; Lea Kirkwood and Tricia Cummins of NSW Agency for Clinical
Innovation; and Harry Illingworth. The research team appreciate the NSW
Health staff and partners who contributed their time and advice in the
development and conduct of this project. Particularly, their time during
the global CoVID-19 pandemic.



\section*{References}

{\label{references}}

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3. Schwarz G, Bouckenooghe D. Improving our understanding of collective
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4. Rafferty AE, Jimmieson NL, Armenakis AA. Change Readiness: A
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5. Armenakis AA, Harris SG, Mossholder KW. Creating readiness for
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6. Herscovitch L, Meyer JP. Commitment to organizational change:
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7. Bouckenooghe D, Schwarz G, M., Minbashian A. Herscovitch and Meyer's
Three-Component model of commitment to change: Meta-analytic findings.
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8. Stevens GW. Toward a process-based approach of conceptualizing change
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10. Madsen SR, Miller D, John CR. Readiness for organizational change:
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11. Harrison R, Fischer S, Walpola RL, Chauhan A, Babalola T, Mears S,
et al. Where Do Models for Change Management, Improvement and
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12. Le-Dao H, Chauhan A, Walpola R, Fischer S, Schwarz G, Minbashian A,
et al. Managing Complex Healthcare Change: A Qualitative Exploration of
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13. Rafferty AE, Minbashian A. Cognitive beliefs and positive emotions
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change-supportive behaviors. Human Relations. 2018;72(10):1623-50.

14. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible
statistical power analysis program for the social, behavioral, and
biomedical sciences. Behavior Research Methods. 2007;39(2):175-91.

15. Foks M. Antecedents of commitment to change : a study about the
contribution of change related variables, individual variables,
communication variables and work-relationships to employees? commitment
to organizational change. 2015.

16. Bartunek JM, Rousseau DM, Rudolph JW, DePalma JA. On the Receiving
End: Sensemaking, Emotion, and Assessments of an Organizational Change
Initiated by Others. The Journal of Applied Behavioral Science.
2006;42(2):182-206.

17. Cummings TG, Worley CG. Organization development and change: Cengage
Learning; 2014.

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