Out 2

UNDERSTANDING THE IDEAL INPATIENT UNIT ENVIRONMENT WHERE
PROFESSIONAL TEAMS AND EMPLOYEES PROVIDE PATIENT-CENTERED CARE
By
CEC1LE A. MARVILLE-WILLIAMS
RN, BScN, Ryerson University, 2005
A thesis submitted in partial fulfillment of
the requirements for the degree of
MASTER OF ARTS in LEADERSHIP
We accept this proposal as conforming
to the required standard
Project Sponsor, Patti Cochrane, MHSc
Faculty Project Supervisor, David Reagan, EdD
Committee Chair, P. Gerry Nixon, PhD
ROYAL ROADS UNIVERSITY
August, 2007
© Cecile Marville-Williams, 2007

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Ideal Unit Environment for Patient-Centered Care ii
ABSTRACT
This action research project examined how health system managers at Trillium Health
Centre (THC) can evolve their role to foster innovative, healthy work environments
for nursing teams, interdisciplinary health professionals, and employees. Data were
gathered through interviews, focus groups, and a survey. Participants included health
system managers, frontline nurses, allied professionals, and pilot unit employees.
Findings were that involving patients as participants enables an ideal experience;
communication, cooperation, coordination, and teamwork are essential; recognition,
respect, and accountability are fundamental; several factors impact managers'
abilities to coach and mentor; a change in mindset is necessary to sustain patient-
centered care; and manager role redesign is imperative to build leadership capacity. I
conclude that professionals and employees are committed but need further education;
communication and teamwork are vital; there is a desire for standards of behaviour
and accountability; managers want the clinical leader role developed; and health
system managers can build leadership capacity.

Ideal Unit Environment for Patient-Centered Care iii
ACKNOWLEDGEMENTS
I am grateful for the support and guidance of the many people who have supported
me in completing this master's thesis. First, I must thank my organizational sponsors, Patti
Cochrane, vice president of patient services, and Lina Rinaldi, director of the medicine and
emergency health system, for their support on this journey. You enabled me to fulfill my
dream.
To my husband Paul Williams, you encouraged and supported me every step of the
way. Thank you. To my daughters Chloe and Bria Williams—there are few words that can
convey my gratitude for your unconditional love and support over the last 2 years. Thank you
all for always believing in me.
To Dr. David Reagan, my project supervisor, you are awesome and amazing. I thank
you for your guidance, constant upbeat enthusiasm, support, and encouragement on this
journey; "Upwards and onward." Karen Crosby and Erin Seatter of Documedic, thanks for
your superior editing.
In addition, I could not have succeeded without the support of my critical friends.
Sandra Smith, thanks for your confidence, commitment, and determination; you got me to the
finish line early. Roger Gougeon, thanks for your calm and focused approach. And Carol
Laberge, thanks for your genuine, caring, and unselfish friendship. You are all my friends for
life. I am also thankful to my MAL Health 2005 cohort and all the staff at Trillium Health
Centre who participated as my research team and participants in the interviews, focus groups,
and survey. And finally, this thesis is dedicated to my mom Claudette, my brother Michael,
and my sisters Ellen and Che, who always told me I had the power to achieve anything I
wanted to in life. This is for you and me.

Ideal Unit Environment for Patient-Centered Care iv
TABLE OF CONTENTS
ABSTRACT ii
ACKNOWLEDGEMENTS iii
TABLE OF CONTENTS iv
LIST OF TABLES vii
LIST OF FIGURES vii
CHAPTER 1: FOCUS AND FRAMING 8
The Opportunity and Its Significance 10
Systems Analysis of the Opportunity 13
Organizational Context 15
CHAPTER 2: REVIEW OF THE LITERATURE 23
Topic 1: Patient-Centered Care 23
Definition 23
Collaborative Approach to Patient-Centered Care 25
Communication, Patient-Centered Care, and Culture 27
Future of Patient-Centered Care in the Microsystem and Organization 29
Topic 2: Ideal Unit Environment 30
Characteristics 31
The Role of Health System Managers 33
Topic 3: Leadership 34
Leadership and Management 34
Leadership and Span of Influence 38
Leadership Style 39
Topic 4: Organizational Culture and Change 42
Vision and Change 43
Communication and Change 44
Leadership and Change 44
Subcultures and Change 45
Summary 46
CHAPTER 3: RESEARCH APPROACH METHODOLOGY 48
Research Approach 48
Project Participants 50
Research Methods and Tools 51
Pilot Test 51
Interviews 52
Focus Groups 53
Survey 55
Study Conduct 56
Data Analysis 58
Ethical Issues 62
Respect for Human Dignity 63
Respect for Free and Informed Consent 63
Respect for Vulnerable Persons 63
Respect for Privacy and Confidentiality 64
Respect for Justice and Inclusiveness 64
Ideal Unit Environment for Patient-Centered Care v
Balancing Harms and Benefits 65

Minimizing Harm 65
Maximizing Benefit 65
Conclusion 66
CHAPTER 4: ACTION RESEARCH PROJECT RESULTS AND CONCLUSIONS 68
Study Findings 68
Finding 1: Involving Patients as Participants Enables the Ideal Patient Experience 69
Finding 2: Communication, Cooperation, Coordination, and Teamwork Are Essential.... 71
Finding 3: Recognition, Respect, and Accountability Are Fundamental 73
Finding 4: Several Factors Impact the Manager's Ability to Coach and Mentor 75
Finding 5: A Cultural Change in Mindset Is Necessary to Sustain Patient-Centered Care 79
Finding 6: Manager Role Redesign Is Imperative to Build Leadership Capacity 80
Conclusions 81
Conclusion 1: Professionals and Employees Are Committed but Need Further Education82
Conclusion 2: Communication and Teamwork Are Vital 84
Conclusion 3: There Is a Desire for Standards of Behaviour and Accountability 86
Conclusion 4: Managers Want the Clinical Leader Role Developed 88
Conclusion 5: Health System Managers Can Build Leadership Capacity 89
Scope and Limitations of the Research 91
Conclusion 93
CHAPTER 5: RESEARCH IMPLICATIONS 94
Study Recommendations 94
Recommendation 1: Redesigning the Manager Role Will Provide Clarity 95
Recommendation 2: Restructure the Clinical Leader Role to Provide Leadership Supports
98
Recommendation 3: Develop a Model of Care 100
Recommendation 4: Develop Communities of Practice to Support the Model of Care... 102
Recommendation 5: Implement the Organization's Standard of Behaviour 104
Recommendation 6: Transition Retired Nurses to Mentor and Coach the Units 106
Study Recommendations Conclusion 106
Organizational Implications 107
Three-Step Implementation Process 108
Step 1: August 2007-December 2007 108
Step 2: September 2007-January 2008 109
Step 3: September 2007-September 2008 109
Implications for Future Research 110
Conclusion 110
CHAPTER 6: LESSONS LEARNED 111
Trust the Process—The Leadership Challenge Ill
Enlist Critical Friends—Creating a Supportive Organizational Culture 112
Choose An Engaging Supervisor—A Research Team Approach 112
Exercise Personal Leadership—Self-Awareness, Timing, Resources, and Balance 113
Envision the Future—The Key to Leadership 114
REFERENCES 116
APPENDIX A: MODEL FOR DEVELOPING AND SUSTAINING LEADERSHIP 125
APPENDIX B: LETTER OF INTRODUCTION AND RESEARCH CONSENT FORM . 126
Ideal Unit Environment for Patient-Centered Care vi
APPENDIX C: PILOT TEST INTERVIEW QUESTIONS 128

APPENDIX D: FOCUS GROUP FACILITATOR QUESTIONS 129
APPENDIX E: SURVEY QUESTIONS 130
Ideal Unit Environment for Patient-Centered Care vii
LIST OF TABLES
Table 1. Summary of Participants by Data Gathering Tool 56
Table 2. Survey Responses to Question, "Does the Manager's Span of Influence Impact Your
Role?" 77
Table 3. Survey Responses to Statement, "In My Current Role I Spend Time Developing
Leadership Ability in Frontline Staff by Mentoring and Coaching in the Current Unit
Environment." 78
LIST OF FIGURES
Figure 1. THC's strategic framework 18

CHAPTER 1: FOCUS AND FRAMING
"Leadership is about articulating the visions, embodying values, and creating the
environment within which things can be accomplished" (Richard & Engle, as cited in Yukl,
2006, p. 3).
Health system managers strive to create innovative, healthy work environments so their
teams can provide care focused on the patient. In a public organization, the effective and
efficient use of human resources is a key enabler in meeting the needs of patients and the
organization. Health care organizations are "clinical microsystems,. . . the small, functional,
front-line units that provide most health care to most people" (Nelson, as cited in Godfrey,
Nelson, Wasson, Mohr, & Batalden, 2003, p. 474).
Much of the relevant literature tries to prove that, in order to manage specialized,
knowledgeable, team-based individuals, managers need to develop high-performance teams that
bring interdisciplinary professionals and employees together to accomplish specific results.
Buckingham (2005) writes that managers need to be able to discover what is unique about each
person and capitalize on that special ability.
Drucker (1994) defines the knowledge worker as someone whose role relies on his or her
ability to find and use knowledge. People cannot manage change; they can only try to stay just
ahead of it. Drucker stresses that leadership is a key element in successful change. Senge, Ross,
Smith, Roberts, and Kleiner (1994) speak of building learning organizations, whose "members
are continually focused on enhancing and expanding their collective awareness and capabilities"
(p. 4). Today, the skill set necessary for professional teams to manage capably within altered
work environments is changing at a fast pace. Clinical shifts in patient conditions are happening
quickly, and innovative, emerging models of care require patients' transitions through the health
Ideal Unit Environment for Patient-Centered Care 9
care system to occur at a rapid pace. Demand is increasing for staff to constantly learn to
effectively manage and lead change to achieve a desired future state.
In a rapidly changing health care environment, it is imperative that staff at all levels
acquire the requisite leadership skills to adapt. I am new to the role of medical health system
manager at Trillium Health Centre (THC) and the accompanying span of influence over the
General Medicine Unit, Respirology Unit, Clinical Access and Support Unit (CASU), and the
large off-site ambulatory clinic at the West Toronto location. As a researcher and health system
manager, I must identify what is an ideal unit environment for professional teams and
employees. Teams can then develop the knowledge, skills, and attributes that will enable them to
respond effectively in a patient-centered environment.
During organizational Vision Days on creating the ideal patient experience, staff
members identified some of the challenges they face today. These include clinical innovation,
limited resources, staffing shortages, rapidly changing technology, and more knowledgeable
patients (Trillium Health Centre [THC], 2006a). Nurses, who form by far the largest number of
professional teams in the inpatient units, are very task oriented. The current role of health system
managers and their clinical leaders is to develop nurses who demonstrate clinical skills and
patient advocacy combined with advanced critical-thinking, creative problem-solving, and sound
decision-making skills. The environment that health system managers and teams create and the
way they relate to each other are crucial elements in organizational viability.
My research question is, "What can the health system manager do to contribute to the
creation of the ideal unit environment for professional teams and employees who are dedicated to
providing patient-centered care?" I have four subquestions:

1. What are the characteristics of patient-centered care, and what do these characteristics
require professional teams and employees to contribute to patient-centered care?
2. What are the characteristics of an ideal unit environment?
3. What are some of the challenges and parameters that define the potential scope of
influence that health system managers can have on the ideal unit environment?
4. How can health system managers evolve their role to achieve the ideal unit environment?
The Opportunity and Its Significance
As one of Canada's leading community hospitals, TCH is a two-site facility that serves a
population of over one million residents in Mississauga, West Toronto, and the surrounding
region. The Mississauga site houses over 750 inpatient beds, and the West Toronto site houses a
freestanding day-surgery facility.
Since the Ministry of Health mandated the merger of the Queensway General and the
Mississauga Hospital in 1998, THC has prided itself on its ability to break new ground in the
delivery of health care. Throughout its early years, the organization demonstrated an ability for
innovation by nurturing an organization-wide culture that invited inquiry and embraced change.
In 2005, THC poised itself to lead the transformation of the health care system. The new mission
of "transforming the health care experience" (THC, 2005, p. 2) underlies THC's desire to
provide patients and their families with an extraordinary health care experience, free of the
traditional silos, barriers, and frustrations all too common in today's health care environment. It
is a mission that moves far past simply fine-tuning the system. The approach is about moving
from a provider-driven system to one that is coordinated around the patient's needs and
expectations. It is about exploring new and innovative ways of providing patient-centered care in
a collaborative environment.
I became interested in pursuing this action research project for personal and professional
reasons. This study provided an opportunity for me, as researcher and manager, to focus on what
factors create the ideal patient unit. This work was aligned with the organization's mission, in
which teamwork and the needs of patients and staff are the focus. As an agent of change, I
wanted to create the best possible environment for myself and for the teams I lead. One outcome
of this project will be an environment that contributes positively to the greater success of the
organization's goals.
I also pursued this action research project because of its relevance to the initiatives in
leadership development that were taking place at THC and because of its related impact on my
managerial role. I am committed to creating an environment that provides teams with an
increased understanding of their leadership potential and scope of influence and with the tools to
develop their skills as leaders so they can be empowered to realize their potential. Shared
leadership duties, through participation in interdisciplinary councils, have encouraged leadership
competency at the nursing unit level. There are opportunities to facilitate the development of
leadership competencies in frontline staff. THC uses a distributive leadership model, which is a
priority for the organization's Leadership Executive Team. Its goal is to develop more than 2,001
leaders in the organization, thus enhancing leadership capacity.
My leadership stretch involved working with professional teams and employees to
identify the ideal unit environment at THC. Typically at THC, teams spend a lot of energy
developing business cases and project profiles to implement best-practice initiatives. This
journey saw us work towards the organization's vision as we endeavoured to achieve the ideal
patient experience. To realize the objective of transforming the health care experience, managers
need to facilitate and support the leadership development of professional teams and employees.
In partnership with patients, these teams can ultimately lead to the creation of the ideal patient
experience.
THC is redefining the role of its management. As part of this initiative, it conducted a
study on time use to examine and understand how its managers were performing, what activities
they were engaged in, and what challenges they faced in carrying out their responsibilities. Up to
81% of THC's managers reported that they spent 57.2% of their time on activities related to
meetings, staff issues, special projects, communication, voice mail, and e-mail. They indicated
that in the future, they would like to spend more time on leading and coaching the teams in their
units (THC, 2006a).
THC's strategic direction for the next 5 years reflects an agenda with a strong focus on
transforming the heath care experience and creating a healthy workplace. This project sought to
enhance the organization's ability to be successful in fulfilling this mission for patients and
health care providers. I believe the organization's success in meeting its mission of transforming
the health care experience requires teams to create the ideal unit environment. The unit
environment is the foundation of the health system. It is the place where teams and patients
interact. The unit is a microcosm of the larger organization. Leaders need to cultivate, develop,
and create a work environment that supports the leadership capacity of teams through shared
growth and responsibility. Leaders must support the contributions and creativity of teams and
ensure that teams are aligned with the vision and have a shared purpose.
Kouzes and Posner (2002) note, "Leadership is a relationship between those who aspire
to lead and those who choose to follow" (p. 20). Similarly, Hooper and Potter (as cited in
Bratton, Grint, & Nelson, 2005) observe that "transformational leadership involves four
elements: vision, values, communication, and behavior" (p. 217). The primary goal of this
project is to create the ideal unit where professional teams and employees can flourish in an
environment that promotes empowerment. If THC is successful in creating an ideal unit
environment, that will enhance the health care experience and outcomes for patients and their
families.
Systems Analysis of the Opportunity
Mendelson and Divinsky (2002) believe that "Canada's health care system is among the
most egalitarian on the globe" (p. 3). Undoubtedly, globalization is having an impact on how
Canada sustains its health care system and on the environment in which knowledge workers
practice. THC has restructured itself, placing emphasis on fiscal accountability, efficiency, and
quality. The organization implemented its healthy workplace initiative to create a quality
environment that retains people and attracts new and experienced professionals and employees,
thereby minimizing the risk of shortages that could endanger patient care.
The health care delivery environment has changed dramatically and rapidly, amidst a
constantly evolving health care landscape spurred by an aging population and workforce, new
technologies, and health care reforms. Exacerbating the challenges to the Canadian work
environment is the nationwide shortage of nurses and allied health professionals. The need for
adequately trained health care professionals is a global phenomenon. The Canadian Nurses
Association (2002a) contends that, if left unchecked, current shortages will escalate into a
regional, provincial, and international health care crisis. The factors of supply and demand have
contributed to the problem of an insufficient availability of professional workers to care for the
rising needs of the Canadian public. Supply in all disciplines has seen continued growth;
however, consumer demand outpaces such growth.

A new paradigm is envisioned for health care organizations and the manner in which
professional teams work within them. Porter-O'Grady, Alexander, Blaylock, Minkara, and Surel
(2006) believe that the paradigm for health care organizations involves multidisciplinary groups
of health care providers functioning in integrated systems, networked to provide a seamless
continuum of care. Consumers, the stakeholders of health care, now expect to be active
participants and demand to have input. They want to participate in creating health care policy for
the iuture. Typically, they want to become more involved in their own and their family's health
care. Bennett (2005) explains:
In order to ensure the benefits of globalization reach as many people as possible, we must
begin that process [of implementing the new paradigm] from the perspective of the
patient. . . . The role of hospitals will have to be part of the seamless continuum of
prevention and care that cannot be planned without all players at the table, (p. 55)
Professional teams and employees are routinely adjusting their roles in their
organizations and communities as they respond to the growing needs of the patient. There is a
growing acknowledgement that a meaningful and sustainable relationship between professional
teams, employees, patients, and families yields benefits to the organization. It is imperative that
micro-systems plan and design processes and services to match the needs of patients. The goal is
to ensure that the sustained processes and outcomes associated with these initiatives are fully
integrated within the organization, with accountability shifting to the managers and clinical
leaders of the functioning units.
The health care discipline sees cascading responsibility and accountability for quality
improvements, healthy workplace issues, patient safety, and the safety of health care teams
throughout the management structure. Wheatley (1999) states,
Seeing the interplay between system dynamics and individuals is a dance of discovery
that requires several iterations between the whole and its parts. We expand our vision to
see the whole, then narrow our gaze to peer intently into individual moments. . .. If we
hold awareness of the whole as we study the part, and understand the part in its
relationship to the whole, profound new insights become available, (p. 143)
This evolution requires an environment of shared inquiry, openness, and curiosity. One of
the important elements of THC's foundation is the creation of a new operational model that
emphasizes quality care and service to patients, staff, and the community. This research provided
an opportunity to examine how managers can create an ideal unit environment that maximizes
the health and well-being of professional teams and employees who contribute to quality patient
outcomes and organizational performance.
Organizational Context
THC continues to expand in response to the growing health care needs of the more than 1
million residents who reside within Mississauga, West Toronto, and the surrounding region.
Currently a regional centre for stroke, neurosurgery, and domestic violence and sexual assault,
and a provincial centre for cardiac services, THC is also home to the busiest emergency
department in Canada and is the largest freestanding day-surgery facility in North America.
THC's two-site model facilitates the delivery of comprehensive services for inpatient and
ambulatory care, with its Mississauga and West Toronto locations only five kilometres apart.
THC serves this huge, vital patient base under the umbrella of eight health systems:
Cardiac, Diagnostic, Emergency, Medicine, Mental Health, Neuroscience/Musculoskeletal,
Surgery, and Women's and Children's Health. Three Strategic Business Units (SBUs) promote
health care services through exemplary leadership of best practice and innovation. These services
include Decision Support, People Support, and Operations Support.
THC is guided by the "The Trillium Way" (THC, 2004, p. 1), a roadmap that represents
an unparalleled commitment to innovation, collaboration, and cutting-edge patient care. THC's

vision is, "Together . . . Leaders in Health Innovation" (THC, 2004, p. 1), and its core purpose is,
"In partnership with many others, we positively impact the health of the individuals, families and
communities we serve" (THC, 2004, p. 1). THC seeks to enhance the experience of care, using
the following six values.
1. Excellence—We strive to set the standard for health service delivery and will be
courageous, innovative and evidence-based in our efforts to improve the quality of our
services.
2. Service—We nurture a service culture that is focused on meeting the needs of our
patients and clients. We value the unique contribution of each and every person directly
or indirectly involved in the provision of care.
3. Teamwork—We work cooperatively and collaboratively with each other, those we serve
and our external partners.
4. Integrity—We are honest and accountable for our actions and attitudes in order to be
trustworthy in our relationships.
5. Balance—We support and encourage the physical, emotional, intellectual and spiritual
well-being of our staff and those we serve.
6. Learning—We encourage and support personal and professional development and
growth. (THC, 2004, p. 1)
In 2005, THC set course on a journey that would transform its delivery of health care. Its
new mission became one of "transforming the healthcare experience" (THC, 2005, p. 3), which
underscores its caring and passionate desire to provide patients and their families with an
extraordinary health care experience. THC chief executive officer Ken White (as cited in THC,
2005) observes:
It is an ambitious but realistic mission, one currently unparalleled by any other individual
health care organization in this country. Saving Medicare in Canada is just as much
Trillium's issue as anyone else's. Transformation of this magnitude begins with . . .
change, and that change has to start right here at home. (p. 3)
Reflecting on the health centre's distributed leadership model and more than 2,001
leaders, White (as cited in THC, 2005) describes this new mission as a persuasive one with
personal and organizational meaning:
This is an opportunity for everyone in this organization to move beyond their day job by
doing something they're really passionate about, and would really like to have an impact
on. It's an opportunity to jointly create a preferred future, (p. 3)
White (2003) attributes the exceptional depth of THC's teams to a strong commitment to
distributed leadership, enabling decision making at the point of care and cultivating an
environment that supports and encourages ongoing learning. THC's strategic framework has
provided the context and direction for the organization's development. It clearly articulates roles
and responsibilities, along with inputs and outputs, as shown in Figure 1.

Figure 1. THC's strategic framework.
Note. From What's It All About. .. Phase 2 and the 6 Strategic Initiatives Tool Kit, by Trillium Health Centre,
2005, p. 12. Copyright 2006 by Trillium Health Centre. Adapted with permission of the author.
Over the past few months, THC has developed a road map of six initiatives, the stepping
stones for the transformation, which are called (a) patient centered, (b) integrated care, (c)
leadership, (d) sustainable value, (e) innovation, and (f) Transforming Healthcare into Integrated
Networks of Knowledge (THINK). These strategic initiatives serve as the lenses through which
THC views everything it does. These lenses frame the important questions to be asked and
provide the focus and guidance required to support the transformation agenda. They provide a
context for planning and a filter for collective decision making. The work required to transform
the health care experience will be delivered through the functional goals and objectives of larger
health system priorities, which include (a) a healthy workplace, (b) accreditation, (c) site renewal
and redevelopment, (d) key process redesign, (e) ambulatory and primary care, (f) seniors'
health, (g) enterprise risk management, and (h) academic partnerships.
As the teams work toward creating an ideal patient experience, they are also on a journey
toward creating an ideal staff experience. Working to create the ideal patient experience
contributes to the evolution of a healthy workplace. Wheatley (1999) states,
No one can hope to lead any organization by standing outside or ignoring the web of
relationships through which all work is accomplished. Leaders are being called to step
forward as helpmates, supported by our willingness to have them lead us. (p. 165)
The partnerships councils are designed to practice, live, grow, and develop the concept of
shared decision making and shared accountability. It is where interdisciplinary integration of
practice occurs; a place where management, practice, and education are linked and decisions are
made by the team. This infrastructure was developed to create a place to develop informal
leaders, tap individual gifts and collective capacity, enhance relationships, have meaningful
conversations, improve care and service, achieve the shared mission and vision, and improve the
quality of work life. The councils have management representation; however, these groups are
chaired by and primarily comprised of staff. Each council member is accountable for connecting
with five others to share dialogue and discussion at meetings.
The impact of the councils has been measured through THC's Healthy Workplace
survey. Much of the councils' work provides job enrichment and a sense of empowerment. In
March 2006, the Clinical Practice Model Resource Centre awarded THC the Canadian Practice
Model (CPM) Sustainability Award, titled "Interdisciplinary Integration at the Point of Care:
Patient Centeredness" at the Clinical Practice Model Resource Centre's 16th Annual
International Conference in Irvine, California. This award is the result of the organization's and
councils' commitment to cocreating healthy, integrated work cultures that positively influence
the health and health care of patients and families on what mattered most to them. The award
clearly indicated that the work of the councils is to create a healthy workplace. This aligns with
THC's message to staff members of creating an environment where they will look forward to
coming to work.
THC launched the most significant of its strategic initiatives, patient centered, at its Back
to School event in September 2005. There were 6 leadership days to engage informal and formal
leadership teams throughout the organization and to bring the patient-centered initiative to staff.
The primary objective of these days was to fully engage all participants in a full-spectrum
understanding of the meaning and behavioural aspects of being patient centered. THC designed
sessions to produce the following outcomes: a description and vision of the ideal patient
experience, a list of barriers to the ideal patient experience, and a list of personal commitments
and commitments representative of the units.
Continuous messaging through an array of mediums has significantly contributed to the
successful implementation of the ideal patient experience throughout the organization. THC
developed a comprehensive tool kit to assist in communicating and incorporating this initiative
amongst knowledge workers within units and teams. The knowledge from these workshops has
contributed to the development of THC's 2007-2008 operating plan, specifically pertaining to
the barriers identified in these sessions. As part of the operating plan, each health system and
SBU is accountable for considering how to reduce or eliminate the barriers within their units
when constructing their goals and objectives.

THC's mission of transforming the health care experience is foremost about the patients.
It is about professional teams and employees using their special skills, with the patient as the
most significant member of the health care team. It's about the community and environment
collaboratively shaping and contributing to the health and well-being of patients and families.
The critical success factor on this journey is THC's ability to demonstrate accountability to
patients and ultimately deliver an experience designed by the patient in collaboration with
knowledge workers. This experience will be timely and effective, produce superior outcomes,
and exceed the expectations of the patient and family. This framework must also respond to the
specific needs and aspirations of the professional teams and employees, ensuring that their work,
tools, environment, and professional and personal growth maintain healthy workplace vitality.
As its first step towards transforming the health care experience, THC embarked on a
comprehensive process to develop a philosophy of care. This process involved extensive
consultation with patients and staff. THC's philosophy of care forms the foundation for all it will
do and be for its patients as it moves forward on its journey:
You told us that your health, well being,/ and how you are treated/ are what matter most,/
and we can best meet your expectations by:/ Providing access to excellent care/ Sharing
meaningful information with you, to help you make decisions/ Involving you and those
most important to you in your care/ Listening and responding to your unique needs/
Caring for you with respect, compassion and dignity/ Keeping you comfortable in a safe
environment. (THC, 2005, p. 6)
Many processes are in place, responsible for determining and meeting patients' needs. An
important foundation for THC's strategic initiative of patient centeredness is the new philosophy
of care. It shapes the way professional teams and employees support and interact on a daily basis
with patients and their families. THC instituted a very broad stakeholder-engagement process
with the goal of understanding the needs of patients and their families, using focus groups
comprised of patients, volunteers, staff, and community partners. As a result of this study, THC
determined several recommendations and allocated resources for improvements in processes and
practices within the organization. Health systems and SBUs are frequently engaged in formal
best-practice projects that focus on improving clinical and service processes as identified through
key performance measures. Teams are encouraged to be innovative and to utilize best practices
not only from within the health care industry, but also from other industries.
THC will move on to the next stage of its journey towards redefining management. I have
had the opportunity to observe, mentor, champion, and integrate the transformational journey
into my major project of fostering an ideal unit environment where professional teams and
employees provide exceptional patient-centered care.

CHAPTER 2: REVIEW OF THE LITERATURE
"Healthy work environments are supportive of the whole human being, are patient-
focused, and are joyful workplaces" (Shirey, 2006, p. 258).
The research question for this project asks what the health system manager can do to
contribute to the creation of the ideal unit environment for professional teams and employees
who are dedicated to providing patient-centered care. First, I will define patient-centered care
and discuss its characteristics and what these characteristics require of professional teams and
employees in terms of their contributions. Second, I will review the literature on the ideal unit
environment in which nurses, professionals, and employees can provide patient-centered care.
Next, I will look at leadership and review some of the challenges and parameters that define the
potential scope of influence that health system managers can have on this ideal work
environment. Finally, I will review organizational change and culture and discuss how health
system managers can evolve their role to achieve the ideal unit environment.
As Glesne (2006) suggests, I will commence the literature review with a broad view of
patient-centered care and relate it to the change in organizational culture that must happen for it
to be successful.
Topic 1: Patient-Centered Care
Definition
A variety of definitions surround the concept of patient-centered care in the literature,
with various terms being transposable including customer-centered or client-centered care.
Patient-centered care is not a new concept; however, organizations and the health care profession
have been slow to employ this philosophy within a collaborative interdisciplinary team approach
(The Picker Institute, 2004). Frampton, Gilpin, and Channel (2003) note, "We have lost sight of
the reason patients come to see us. They come not just for medical care.... They come to be
heard, to be helped. .. . We spend too little time listening and answering questions" (p. xxvi).
Applying practices that reflect the opinions of patients within a partnership with the patients is a
challenge in the current health care environment.
THC defines patient-centered care as, "Moving the health centre away from a provider-
centred model to one focused on meeting the needs of patients who are central to everything we
do" (THC, 2005, p. 19). The organization's philosophy is that patient-centered care is the
ultimate show of respect for patients as individuals. It's about engaging patients as essential
members of the health care team and supporting their role as active decision-makers in the
direction of their care.
The Registered Nurses' Association of Ontario (RNAO) (2006a), in its Client Centred
Care guideline, notes that clients are the experts regarding their own lives and recommends that
clients be provided the opportunity to lead their care as much as they choose. From a patient-
centered perspective, this method encompasses the relationship and personal experience of the
patient.
Godfrey et al. (2003) purport that planned, patient-centered care "results in productive
patient-provider communication and improved patient self-management. The natural synergy
between planned services and planned care results is doing it right the first time for every single
patient" (p. 227). The microsystems goal at THC is to make the delivery of health care as
seamless as possible, while respecting the patient's perspective on what matters most and then
tailoring care to enhance the patient-client experience (THC, 2005). Professionals and employees
aim to be respectful and responsive to individual patients' preferences, needs, and values, and to
establish a partnership among patients and their families. Ultimately, they want to solicit
patients' input on the education and support they need to make decisions and participate in their
own care.
Collaborative Approach to Patient-Centered Care
Linden (2003) describes collaborative leadership as "the art of pulling people
together from different units or organizations to accomplish a task" (p. 42). When
implementing a culture to support these changes, Linden suggests that there is a need to
remove administrative and organizational barriers to collaboration; offer training in the

key collaboration skill; recognize and support collaborative leaders; learn and publicize
best practices from other partnerships and alliances; provide experienced mentors; and
tell the stories of successful collaborative leaders. (2003, p. 46)
Teamwork and shared decision making among health care professionals, employees, patients,
and families will facilitate the development of a collaborative approach to providing patient-
centered care.
The research available surrounding collaborative patient-centered care is limited, but
Health Canada (2003) notes:
Collaborative patient-centred practice is designed to promote the active participation of

several health care disciplines and professions. It enhances patient-, family-, and
community-centred goals and values, provides mechanisms for continuous
communication among health care providers, optimizes staff participation in clinical
decision-making (within and across disciplines), and fosters respect for the contributions
of all providers. (Collaborative patient-centred practice section, % 1)
Health Canada (2003) also notes that from a patient-centered perspective, using this approach to
care has a significant impact along the continuum of care.
Collaboration and partnership are seen through the lens of "the seven C's of strategic
collaboration" (Austin, 2000, p. 173). Austin asks people to be cognizant of the fact that there are
no rigid steps that can be followed to create strategic alliances; rather, they must recognize that
"effective collaboration . . . involves jointly tailoring a garment that fits the unique characteristic
and needs of the partners" (2000, p. 173).
The synergistic effect of collaboration is achieved through keeping the team or
organization focused on the mission and having the right people at the table. Hall (2004) notes
that L'no one provider can meet all the multifaceted needs of a patient and family" (p. 191).
Today, patients are living longer, and the complexity of their health care issues requires a
collaborative approach across the continuum for improved population health and satisfaction
among patients and health care providers.
Linden (2003) states that collaborative leadership is used to pull diverse people and ideas
together to accomplish a common task or goal. Austin (2000) further elaborates that
collaboration has become a 21st-century trend. He has even developed seven steps for strategic
collaboration, beginning with connection of purpose and people. A collaborative approach
concept contributes to "improved population health and patient care, improved access to health
care, improved recruitment and retention of health care providers, improved patient safety and
communication among health care providers, and more efficient and effective employment of
health human resources" (The Picker Institute, 2004, p. 10).
As organizations evolve to capture the essence of providing patient-centered care, the
complexity of the environment continues to impact how professionals and employees engage
patients in setting attainable goals for their care. This philosophy can only be embraced and
implemented through a consistent approach used by professionals, employees, patients, and
families in a collaborative model.

Communication, Patient-Centered Care, and Culture
Providing patients with information and knowledge regarding their care can be
empowering; however, navigating the health care system requires caution, care, and effort on the
part of the patient. According to the Advisory Board Company (2007), managers believe patient-
centered care requires a "cultural change throughout based on restoring patient power and
diminishing power from health care professionals that are less patient-centric" (p. 6).
In order to become a full partner in treatment decisions with health care professionals and
employees, patients need to be encouraged and have the opportunity to ask questions and
comprehend answers. The patient must be given all relevant information for informed decision
making. However, communication of all the pertinent facts from the health care professionals to
the patient in a comprehensible medium is not always easily achieved. This is especially true for
the mental health patient population.
How can employees support and embrace patient-centered care? Kouzes and Posner
(2002) suggest that motivation, commitment, and behaviour will change significantly if the
vision is shared and understood by professionals and employees. Sharing the organization's
vision, values, and commitment will assist in developing trusting relationships with other
members within the microsystems and organization.
Gertis, Edgman-Levitan, Daley, and Delbanco (1993) encourage professionals to support
family involvement with patients' personal and nonmedical care whenever possible, to provide
whiteboards at bedsides where patients and families can post questions or comments, and to
encourage patients and families to express their own goals and expectations for care. Employees
who provide services such as communication, environmental cleaning, food services, and patient
transportation can also impact patients' care. The Advisory Board Company (2007) found that
these employees have an equal effect on the patient stay in hospital. Universal findings are that,
although clinical factors are significant to patients, cleanliness and quality of food are other
factors that influence patients' choice of hospital.
Lee (2004) agrees that patients' perceptions of how they are treated as individuals, not
clinical competencies, are the top drivers of patient satisfaction. The Picker Institute (2004)
shares this belief, noting that clinically-competent staff do not necessarily ensure that patient
values are respected, and those values should guide all clinical decisions. The Advisory Board
Company (2007) says that clerical, housekeeping, and food service employees who directly
interact with patients and families have the ability to influence patient care through their actions
and behaviours.
As leaders, health system managers must embrace patient-centered care as a priority and
assist their teams to make a cultural shift using best practice initiatives, education, and training
on the benefits of patient-centered care. As professionals and employees undergo training in
patient-centered care, they will realize that their actions have the ability to strongly influence
patient care. "Managers believe that PCC [patient-centered care] is a serious undertaking and
thus its application must be taken seriously" (The Advisory Board Company, 2007, p. 10).
Similarly, a recent study of four hospitals in the United States found that clinical staff and
employees must feel like their actions and behaviours truly affect the care of the patient (Studer,
2003).
The changing demands of the environment require health professionals and employees to
be committed to the organization's philosophy and remain accountable to sustain this initiative.
The synergistic effect of collaborating with the patient and family is achieved through keeping
the team or organization focused on the mission. Professionals and employees in clinical and
nonclinical roles must participate in organizational orientation and training, with an ongoing
sharing of information on how best to provide patient-centered care to patients and families.
As for the sustainability of this initiative, the onus lies with maintaining the
organization's distributed leadership model to ensure professionals and employees are
accountable to develop and promote measures to involve patients and families in their care and
respect the patients' needs, values, and preferences.
Future of Patient-Centered Care in the Microsystem and Organization
Health Canada (2004) says that the Canadian health care system is slowly transitioning
from a medically-driven health care approach to one that is geared toward the patient or client.
The Advisory Board Company (2007) states that health care professionals currently perceive
good patient care as generally provider focused, not patient centered.
A significant concern and challenge facing organizations and policy makers is
redesigning existing processes of care to improve the delivery of a patient-centered care
philosophy. Wasson, Godfrey, Nelson, Mohr, and Batalden (2003) state that "microsystem
awareness of the 'four P's'—the patients, people, processes, and patterns—can result in greater
efficiency" (p. 227). Health care professionals, employees, and patients must engage in shared
decision making to develop a plan of care that best meets the needs of the patient in a timely,
effective manner and in a language that the patient and family can comprehend. As baby
boomers become increasingly knowledgeable about their care, wishes, and needs, they are
demanding to take more accountability and responsibility in shared decision making about their
care.
The changing demands in health care call for a focus on quality as THC transforms the
health care experience for its patients and families (THC, 2005). Wasson et al. (2003) contend
that as each microsystem addresses the issue of quality, the premise is that understanding the
patient's perspective and creating a more patient-centered environment will enhance the
individual quality of care and increase patient satisfaction. The current literature suggests that
patients who are active participants in their care experience better outcomes than those who are
not equally engaged (The Picker Institute, 2004; Registered Nurses' Association of Ontario
[RNAO], 2006b). Nevertheless, approaches to totally engage all individuals as comanagers of
their health and health care are still in the early years and have yet to be broadly adopted.
The Institute of Medicine (2001) recommends that the concept of patient-centered care be
expanded from the interactions that occur within the margins of a clinical encounter to include
shared decision making between patients and health care professionals. This includes customized
information, communication, education, coordination, and integration of care across conditions
and settings that include the patient and family.
Frampton et al. (2003) urge people to transform the future of health care through
providing patient-centered care: "It is an approach that has proven successful for hospitals
committed to it. It has the potential to transform an organization's culture.... It is a journey of
recommitting ourselves to looking at our beliefs and behaviors from the patient's perspective" (p.
306). The Picker Institute (2004) concurs that clinicians and organizations that seek to champion
patient-centered care will improve the patient experience and achieve quality health care through
a partnership that informs and respects patients and their families as members of the health care
team.
Topic 2: Ideal Unit Environment
In the past decade a great deal of research has been done on work environments in
Canada and the United Sates. While various studies look at the relationship between employee
satisfaction and productivity and patient outcomes, few address registered nurses as knowledge
workers in health care and their work environment.
The diversity of terminology used in current research to describe healthy work
environments is extensive. Scholars use quality, workplace, work, healing, and practice
environment to refer to the work environment. In striving to create an ideal unit environment for
professional teams, it is necessary to first examine the definition of a healthy work environment.
O'Brien-Pallas, Bauman, and Villeneuve (as cited in Canadian Nurses Association, 2001) define
a quality professional environment as
one in which the needs and goals of the individual nurse are met at the same time as the
patient or client is assisted to reach his or her individual health goals, within the costs and
quality framework mandated by the organization where the care is provided, (pp. 14-16)
For the purpose of this research, I will use the RNAO's (2006b) definition of healthy
work environments for nurses: "practice settings that maximize the health and well-being of the
nurse, quality patient/client outcomes, organizational performance and societal outcomes" (p.
12).
Characteristics
What are the characteristics of a healthy work environment? McClure, Poulin, Sovie, and
Wandelt (2002) believe that key attributes include respect, autonomy, leadership, and maximized
scopes of practice for nurses in all roles and settings. McGillis Hall (2004) notes that the
attributes of a quality setting for nursing are those that stress workplace safety, personal
satisfaction, teamwork, a reasonable workload, and adequate physical surroundings.
A number of factors impact the work environment of nurses. The work environment for
the practice of nursing has long been cited by Canadian researchers (Baumann et al., 2001;
Canadian Nursing Advisory Committee, 2002) as one of the most demanding across all types of
work settings. Numerous studies (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar, 2002;
Shamian, Kerr, Thomson, & Laschinger, 2002) provide some evidence regarding nurses who rate
their work environment as positive and have lower incidences of absenteeism due to illness.
Studies on Ontario teaching hospitals (Aiken, Havens, & Sloane, 2000; Baumann et al., 2001)
found a direct correlation between job satisfaction, work production, recruitment and retention,
the quality of care, and ultimately patient-client outcomes.
Subsequent research (McGillis Hall, Baker, & Irvine, 2001) has also shown that patients'
satisfaction is directly linked to nurses' job satisfaction. According to Clarke et al. (2001), "The
most important characteristics predictive of nurses' emotional exhaustion and satisfaction with
their jobs are nurses having control over their work environment, including having sufficient
resources, and having effective nursing leadership" (p. 54). All the preceding studies attest to the
importance of a healthy work environment.
A review of current literature on healthy work environments suggests that the nursing
workforce is experiencing a critical time. Magnet hospital studies (Aiken et al., 2000;
Laschinger, Shamian, & Thomson, 2001) found the work environment to be a major factor in
recruitment and retention and successful patient outcomes. Aiken et al. showed that nurses are
attracted to hospital work environments that foster autonomy, offer influence, and promote good
nurse-physician relationships. Not surprisingly, according to McClure et al. (2002), these
environments facilitate professional nursing practice and have lower levels of burnout and
greater levels of job satisfaction than nurses in nonmagnet hospitals.
Furthermore, research has shown that hospitals with these characteristics have better
patient outcomes, including lower mortality rates (Aiken et al., 2000; Lowe, 2004; Ontario
Ministry of Health, Report of the Nursing Task Force, 1999; Registered Nurses' Association of
Ontario and Registered Practical Nurses Association of Ontario, 2000). How can today's health
system managers ensure that these characteristics are evident in their work environments?
McClure et al. (2002) found that nurses wish to be consulted, have their opinions
solicited and recommendations followed, and have real control over professional practice
decisions. For nurses to exercise influence over practice, employers need to provide
environments with opportunities for nurses to have meaningful involvement in decision making
from the point of service through to the corporate and even regional level. These perspectives
provide a sense of understanding the concept of a healthy work environment.
The Role of Health System Managers
According to RNAO (2006b), the conceptual model for developing and sustaining
leadership practices to achieve a healthy work environment includes five transformational
leadership practices (see Appendix A), which serve as the foundation to transform nurses' work
environments. They include building relationships and trust, creating an empowering work
environment, creating an environment that supports knowledge development and integration,
leading and sustaining change, and balancing competing values and priorities. This conceptual
model provides a framework for understanding organizational support, leadership practices, and
personal resources that facilitate leadership practices for a healthy work environment.
From this review of the literature one can conclude that healthy work environments are
needed in today's complex health care systems. Additional empirical work is necessary to
understand how professional teams and employees who consist of nurses, allied health
professionals, and support workers contribute to the woven fabric that sustains and maintains
healthy work environments for practice in acute care. The ripple effects of the importance of
healthy work environments may not only need to be understood for successful patient outcomes,
but also for the survival of the health care profession and health human resource strategies as we
move beyond the 21st century in health care.
Topic 3: Leadership
Kouzes and Posner (2002) explain that true leaders challenge the process, inspire a shared
vision, enable others to act, model the way, and encourage the heart. Concepts of modern
leadership training are based on the belief that individuals can be educated and developed to be
leaders. "People first follow the person, then the plan" (Kouzes & Posner, 2002, p. 15). To
develop supportive leadership relationships with staff, health systems managers need to examine
the relationships between leadership and management, span of influence, and leadership style.
This section of the literature review defines the differences between leadership and management,
looks at the impact of span of influence on leadership abilities, and examines leadership style
within the organization.
Leadership and Management
Leadership and management are two concepts that are often confused but are not the
same. Typically in health care, the dimensions of leadership and management are combined.
Kouzes and Posner (2002) distinguish between leadership and management by explaining that
managers convey order, compliance, and consistency, whereas leaders create direction by
developing a vision and inspiring people to follow.
As a student in the Masters of Arts Leadership program, I am usually asked to explain the
differences between leadership and management. Yukl (2006), like many other researchers,
describes evidence that leadership and management are two separate paradigms. Bennis and
Nanus (as cited in Yukl) have examined a number of theories on leadership and management and
provide a broad definition:

Managers value stability, order, and efficiency, whereas leaders value flexibility,
innovation, and adaptation. Managers are concerned with how things get done, and then
try to get people to perform better. Leaders are concerned with what things mean to
people, and they try to get people to agree about the most important things to be done.
(2006, p. 4)
Bennis (as cited in Yukl, 2006), a professor of business management, suggests, "The
concept of leadership eludes us or turns up in another form to taunt us again with its slipperiness
and complexity.. . . We have invented an endless proliferation of terms . . . and still the concept
is not sufficiently defined" (p. 2). With the emergence of current leadership theory, managers
today are much more comfortable in incorporating leadership into their practices.
Vaill (1996) notes:
Managerial leadership itself is primarily learning. There is nothing static about it, nothing
fixed, nothing constant from person to person or from situation to situation. Instead it is a
moment-to-moment process of learning the needs and opportunities for influence that are
found in situations and learning what purposeful things can be done. (p. 148)
Like Vaill (1996), Senge et al. (1994) believe that "[encouraging] learning is the primary
task of leadership, and perhaps the only way that a leader can genuinely influence or inspire
others" (p. 65). Kouzes and Posner (2002) note that the word leader refers to a position or place
within an organization. Similarly, Senge et al. (1994) propose that the word is frequently linked
with personal authority and used as a synonym for top managers in an organization.
O'Toole (1996) promotes \alues-based leadership, which is about ideas, values, and
understanding the diverse needs of followers to pursue goals other than what they ever thought
possible. He posits that leadership must entail such factors as integrity, trust, authenticity, and
hope. How then do health system managers incorporate leadership within their management
role? Manson (2006) eloquently notes that leadership is "subtle but recognizable . . . [in] driving
new ideas and forcing the pace of change.... Leadership may also be the people who orchestrate
the way a clinical team works, drawing on everyone's strength" (p. 20). Leaders do not lead in
isolation. They are but leaders of leaders. Leaders' effectiveness is measured by their followers'
success.
Cooke (2001) says that unsustainable workloads and lack of organizational support
influence a manager's ability to provide effective leadership. In years past, according to the
Advisory Board Company (2007), the nurse manager's role was pivotal to a hospital's
performance and high-quality patient care. With the flattening of organizational structures, the
manager's role in health care has seen an expansion in turbulent times. It has become
increasingly hard for managers to lead and support teams while developing leadership
competencies of professionals and employees. Bratton et al. (2005) assert that "if work
organizations are to survive, managers must be able to lead as well as manage" (p. 8). Not only
leadership in the boardroom, but also leadership at the frontline, provides opportunities for
organizations to effectively address challenges and achieve goals.
Mintzberg (1999) argues, "The best managing of all may well be silent. Followers can
say, 'We did it ourselves,' because we did" (p. 30). Clawson (2003) shares this belief, stating,
"Leaders of the future will have to place a greater value on listening than on talking" (p. 19).
Schein (2004) notes that leadership is "the ability to step outside the culture . . . to start
evolutionary change processes that are more adaptive" (p. 2). Yukl (2006) explains that
management and leadership both involve doing what needs to be done, while creating networks
of people to accomplish the agenda, and ensuring the work actually gets done. Their work is
complementary, but each system of action goes about the tasks in a different way.
Similarly, Kotter (1996) asserts that leadership is the engine that drives redirection,
reengineering, and restrategizing in agile organizations. Therefore, understanding how to

incorporate leadership competencies such as mastering change, systems thinking, shared vision,
and continuous quality improvement are essential antecedents of management competencies. If
managers lead only from a purely managerial mindset, they will inevitably fail to actively engage
followers.
In applying his theory of management and leadership, Kotter (1996) suggests that
"managers promote stability while leaders press for change, and the only organizations that
embrace both sides of that contradiction can thrive in turbulent times" (p. 85). These two
distinctive and complementary systems of action leadership and management are a requisite skill
set for health system managers if they are to maintain a viable nursing workforce and provide a
safe and successful health care environment in an increasingly complex and volatile
environment.
In order for organizations to effectively support staff, the benefits of promoting
leadership development must be considered. Kouzes and Posner (2002) assert, "It's not the
absence of leadership potential that inhibits the development of more leaders; it's the persistence
of the myth that leadership can't be learned" (p. 386). From an organizational perspective,
developing existing leadership capacity in professionals and employees and providing the
requisite support is vital.
Yukl (2006) notes, "Leadership is the process of influencing others to understand and
agree about what needs to be done and how to do it, and the process of facilitating individual and
collective efforts to accomplish shared objectives" (p. 7). Success comes to leaders who support
followers by opening doors, removing barriers, rewarding successes, and mentoring when
challenges occur, while managing in permanent white water.

Leadership and Span of Influence
Management span of influence is not a new term in health care. Routinely, managers are
responsible for many units on different floors and across multiple sites. The term span of
influence (or span of control) is defined as the number of people (direct reports) who report to
one manager, supervisor, or leader (Cathcart et al., 2004; Densten & Gray, 1998; McCutcheon,
2004; Mintzberg; 1999; Simons, 2005). McGillis Hall et al. (2001) contend that "nurse managers
who are directly responsible for maintaining standards of care and developing staff are less able
to provide nurses with the traditional mentoring and coaching; individual support and
encouragement" (p. 6).
Equally, McCutcheon (2004) notes that managers cannot lead, mentor, oversee multiple
direct reports, and facilitate the day-to-day operations of multiple professionals and employees
effectively. There is a need to develop organizational consultant expertise such as finance,
human resource, and administrative clerical to free up managers so they can effectively supervise
and lead.
When surveying the field, McGillis Hall et al. (2001) note that frontline managers have
taken on tasks that were previously performed by other senior managers. The Advisory Board
Company (2007) lists the scope of accountability for frontline managers as clinical-technical
specialty, recruitment, staffing and scheduling, managing current staff, daily operations, budget
activity, staff development, program development, and hospital-wide initiatives.
Saint-Onge and Armstrong (2004) state, "Organizations that recognize the need to move
to a new leadership agenda are creating environments in which leadership capabilities can be
exercised by all employees" (p. 203). As the role of the health system manager evolves and the
environment in which health care is provided increases in complexity, there is ongoing debate
with regard to the scope and function of management and leadership roles within health care and
agreement of how organizational factors such as size and culture influence and impact nurse
managers' abilities and work environment.
The Canadian Nursing Advisory Committee (2002) recommends that employers examine
the span of influence of managers to be successful; managers need to be visible on units to meet
the needs of teams and patients. Mintzberg (1999) notes that leadership is exercised at an
individual, group, and organizational level: "At the individual level, leaders mentor, coach, and
motivate; at the group level, they build teams and resolve conflicts; at the organizational level,
leaders build culture" (p. 6). As organizations are struggling with identifying the right
composition to balance the needs of strategy, people, and process management, the Ontario
Hospital Association (1998) reports that clinical managers are the most difficult to recruit.
What is the number of direct reports that a health system manager should be responsible
for? Clinical nurse managers are typically accountable for spans of influence of up to 100.
Cathcart et al. (2004) postulate that the tipping point for span of control is when work size
exceeds 40 employees. Similarly, Henricks' (2001) rule of thumb is, "Managers in flat re-
engineered organizations can supervise up to forty people" (p. 2). McCutcheon (2004) notes that
there still needs to be additional empirical research completed on the span of influence of nurse
managers to explore the effects of span of influence, the ability of health system mangers to
effectively lead, and the impact on staff, staff turnover, and patient satisfaction.
Leadership Style
The role of health system managers, as described by Upenieks (2003) and Ward (2002),
encompasses more than managing; leadership is a key enabler of a healthy work environment.
Perra (2000) notes that the leadership style of healthy system managers contributes to the success
of the organization. How does leadership style impact the outcome of a healthy work
environment? What leadership style supports health system managers with large spans of
influence?
Many leadership experts believe that a transformational leadership style is the best
method to cultivate an empowered environment. Burns (as cited in Covey, 2004) first described
the concept of transformational leadership: "[Transformational] leadership occurs when one or
more persons engage with others in such a way that leaders and followers raise one another to
higher levels of motivation and morality" (p. 362). Likewise, Yukl (2006) notes that
transformational leadership "develops follower skills and confidence to prepare them to assume
responsibility" (p. 151). "With transformational leadership, the followers feel trust, admiration,
loyalty and respect towards the leader, and are motivated to do more than they originally
expected to do" (Yukl, 2006, p. 135). Kouzes and Posner (2002) explain that it is the leader's
role to interact, stimulate, and inspire the team to work collaboratively towards a common
mission and vision.
A transformational leadership style is a method to cultivate empowered nurses, where
leaders can drive followers to take action and become leaders and change agents. Nurse leaders
play a major role in influencing the development of potential leaders within the profession.
Creating environments where nurses can develop skills and expertise needed to be successful
leaders will ensure successful nursing leaders for today and tomorrow (Canadian Nurses
Association, 2001; Canadian Nursing Advisory Committee, 2002).
Doran et al. (2004) describe how a transformational leadership style provides positive
effects on nurses' job satisfaction while a large span of influence decreases the encouraging
effects of a transformational leadership style. They succinctly purport,

The moderating influence of span of control on the effects of leadership on nurses' job
satisfaction demonstrates that no leadership style can overcome a wide span of control. It
is not humanly possible to consistently provide positive leadership to a very large number
of staff, while at the same time ensuring the effective and efficient operation of a large
unit on a daily basis. Thus there is a need to develop guidelines regarding the number of
staff a nurse manager can effectively supervise and lead. (Doran et al., 2004, p. iv)
The role of the health system manager has become overwhelming; it is at the point where
health system mangers struggle to focus their energies on strategic initiatives, recruitment, and
retention while developing and leading their teams (Ontario Ministry of Health, Report of the
Nursing Task Force, 1999).
How do health system managers attempt to lead with a large span of influence? THC is
using a distributed leadership model, which to date has been successful. Distributed leadership is
the sharing of leadership among two or more individuals. This type of leadership has many
names, as Lambert (2002) says, such as shared, relationship, ox participatory leadership.
According to Spillane, Halverson, and Diamond (2001), a distributive model framework
approaches the learning of leadership with the idea that leadership is distributed across diverse
groups of people within a particular environment.
Gronn (2002) purports that distributed leadership "enables organizations to capitalize on
a range of strengths, individuals to strengthen their skill and abilities, and also aids bonding.
These advantages amount to an overall widening of the net of intelligence and organizational
resourcefulness" (p. 37).
Likewise, McGehee (2001) believes that the ultimate challenge for a leader is to shift
from the traditional command-and-control model to a distributed model that encourages
agility, creativity, innovation, and collaboration. This model recognizes the significance of
subgroups or taskforces, which are called upon to realize the organization's missions and
outcomes. It is a powerful organizational strategy and one that makes excellent use of the human,
physical, and financial resources of an organization (THC, 2005).
Topic 4: Organizational Culture and Change
Sanchez (2004) says that diverse scholars define culture as how an organization goes
about meeting its goals and missions and solving problems, or how deeply entrenched values
shape the behaviour of individuals within the group. Kotter (1996) and Schein (2004) define
organizational culture as the deep-rooted beliefs, values, and assumptions widely shared by
organizational members that powerfully shape the identity and behavioral norms of a group. It is
"a pattern of shared basic assumptions that was learned by a group as it solved its problems of
external adaptation and internal integration, that has worked well enough to be considered valid
and, therefore, to be taught to new members" (Schein, 2004, p. 17). Organizational change
requires professional teams and employees to come together in teams within microsystems for
the purpose of leveraging their specialization to deliver organizational priorities. This section
looks at the how professional teams and employees integrate patient-centered care into the
organizational culture and adapt to new structures within the unit to deliver on the goals,
mission, and vision of the organization.
Each organization has its own distinctive culture. It is a combination of the impact of
founding leaders, past history, events, successes, crises, and current leadership. These routines
and rituals reflect the "way we do things" (Kotter, 1996, p. 14). These rituals impact individual
behaviour within the organization. As organizations transition to deal effectively with change,
they need to rely on teams to shift their mindsets. "[Organizational] culture is to organizations as
mindset is to individuals" (Anderson & Ackerman Anderson, 2001, p. 98).

An organization's transition through the task of considering the need for change and
subsequent undertaking to implement change requires support from leaders within the team to
champion the change and be committed, while providing any needed resources to support and
anchor the change. Change leaders institute a coalition to include "the necessary skills,
experience and chemistry" (Kotter, 1998, p. 6) to assure meaningful change.
Kotter (1996) stresses that to implement change, the leadership effort must have support
from many people who assist the leadership agenda within their sphere of activity. Kotter (1996)
advises those who implement change to foster a sense of urgency within the organization: "A
higher rate of urgency does not imply ever-present panic, anxiety, or fear. It means a state in
which complacency is virtually absent" (p. 162).
Vision and Change
Anderson and Ackerman Anderson (2001) purport that leadership and organizational
culture are tightly intertwined. Many theorists (Anderson & Ackerman Anderson; 2001; Kotter;
1996; Kouzes & Posner, 2002) note that only when leaders engage at the inception of change
with teams, share the vision, and role model the behaviour of the required change, can the culture
adapt. Schein (2004) maintains that leaders must have a deep understanding of the identity and
impact of the organizational culture in order to communicate and implement new visions and
inspire follower commitment to the vision.
Yukl (2006) contends that the leader's responsibility is to create supportive environments
to inspire followers by paying attention and aligning the organization's mission to the vision,
values, and priorities of the change. In the same way, Kouzes and Posner (2002) suggest that
leaders empower followers to take risk and challenge the status quo without laying blame.
Communication and Change
Kotter (1996) suggests that leaders should be able to communicate their vision, so that
people can perceive the change as important. "The real power of a vision is unleashed only when
most of those involved in an enterprise or activity have a common understanding of its goals and
direction" (Kotter, 1996, p. 85).
Several scholars (Kotter, 1998; Senge, 2006; Yukl, 2006) advise that leaders are
organizational role models who set examples with actions and words by "walking the talk."
Keeping open the lines of communication with employees gives leaders an opportunity to engage
in dialogue and evaluate people's understanding of the change. Leaders build partnerships and
teams by "doing real work together, sharing a vision, and building commitment to a goal"
(Kotter, 1998, p. 7).
Kouzes and Posner (2002) note that telling stories is an effective way of communicating
important change. Similarly, Kotter (1996) agrees that people at all skill levels can relate to
stories and metaphors that are clear and simple. He proposes that leaders use every existing
communication channel and opportunity. This methodology gives the message a better chance of
being understood. Only when the change has been communicated to a critical mass, and
employees take ownership and responsibility for the change, can the change be sustainable.
Leadership and Change
To understanding how leaders impact change, one must take into account the individuals
within the microsystem and the organization. Without taking into consideration those involved,
lasting change will not be impossible. Fullan (2001) states that "leading in a culture of change is
about unlocking the mysteries of living organizations" (p. 46). Fullan furthers this view by
recognizing that a "culture of change consists of great rapidity and nonlinearity on the one hand
and equally great potential for creative breakthrough on the other. The paradox is that
transformation would not be possible without accompanying messiness" (2001, p. 31). In the
current environment of rapid change, leaders need to be flexible, take risks, and try different
approaches while using multiple leadership styles in each situation.
Subcultures and Change
All organizations exhibit a dominant culture. Jordan (2003) notes that this culture is
taught to new employees through formal orientation, but also through informal methods such as
stories, myths, rituals, and shared behaviour. Kotter (1996) and Schein (2004) point out that each
culture contains fragments of additional cultures in the form of subcultures and that cultural
norms impact individual behaviour.
Any culture can be functional or dysfunctional. Therefore, key aspects of culture are
mainly the result of behavioural patterns of the leader. For an organization's culture to change, a
cultural shift of mindset is needed (Anderson & Anderson Ackerman, 2001). O'Toole (1996)
notes that for change to be successful, it is imperative that "leaders always include the people
affected in the change process" (p. 37). Maximizing the leadership abilities of professionals and
employees augments organizational capacity by enabling contributions from every individual
voice.
Clawson (2003) posits that the successes of thriving organizations are characterized by
structures that recognize the value of inclusiveness of all members within an organization. In
addition, he comments on the ever-changing responsibilities of leaders, stating that leaders learn
to value "cooperation more than competition; talent, more than title; teamwork, more than
individual effort and glory" (Clawson, 2003, p. 19).

McGehee (2001) notes that when an organization pursues and builds on the strengths of
its people, creates opportunities, and looks inward, it will never miss out on the potential
creativity and innovation within the organization. As well, De Pree (2001) remarks that creativity
and innovation must be engaged and supported. He stresses the significance of creativity and
innovation as an experience in which change is not only accepted as a reality, but also is sought
after and implemented.
Summary
To answer the research question, the literature review for this research project examined
the four topics of patient-centered care, the ideal unit environment, leadership, and
organizational culture and change. Hence, I have provided a lens that increases the understanding
of how this project can affect the microsystem and organization.
Based on the review of literature on patient-centered care, the microsystems and
organization's strategic focus must start with the design and sustainability of this initiative using
the four P's: patient, people, process, and patterns. It is critical that health care leaders implement
a culture to support these changes, while engaging all staff to understand that individuals
(patients) are the comanagers of their health and health care. When professionals and employees
collaborate together and gather knowledge of the patient, people, process, and patterns, they
acquire useful information to assist them in providing patient-centered care.
The literature review supports the work environment as a major factor in the recruitment,
retention, and job satisfaction of nurses and successful patient outcomes. Organizations offering
high-quality physician-nurse relationships that are respectful, and that emphasize workplace
safety, teamwork, a reasonable workload, and adequate physical surroundings are able to retain
nurses, allied professionals, and employees. This section of the literature review provided
valuable solutions that could be implemented to improve the quality of the unit environment.
In reviewing the literature on leadership, I found that health system managers must use a
style of distributed or shared leadership if their span of influence exceeds 40 direct reports.
Consequently, there is a need to develop organizational consultant proficiency in areas such as
finance, human resources, and administrative clerical to support managers so they can effectively
mentor, coach, and lead in a high-performance organization.
Finally, the literature review examined how professionals and employees integrate
patient-centered care into the organization's culture and adapt to new structures within
microsystems to deliver on the goals, mission, and vision of the organization. From the review of
the literature, I learned that in order for leaders to be successful in implementing change into an
organization's culture, leaders must be focused, constantly respond to changes in people and the
environment, look for opportunities to engage the energy of the team, and award control to the
affected stakeholders to move the change forward.

CHAPTER 3: RESEARCH APPROACH METHODOLOGY
Research Approach
I designed this action research project to gain insights into what constitutes an ideal unit
environment in which professional teams and employees at THC can deliver the ideal patient
experience. Action research is a tool used to look for change. The aim of my action research
project was to improve my and the participants' awareness of the environment under
investigation and to facilitate change.
According to Berg (2007), "Action research focuses on methods and techniques of
investigation that take into account a study's population, history, culture, interactive activities
and emotional lives, [and] collaborates with the very people it seeks to study" (p. 224).
Community action research has been described as "a collaborative approach to inquiry and
investigation that provides people with the means to take systematic action to resolve specific
problems" (Stringer, 1999, p. 17). Qualitative research involves inquiry into the environment and
practice of the participants, and boasts several benefits for health care professionals and
employees (Berg, 2007; Glesne, 2006).
While planning cycles for improvement, I incorporated Stringer's (1999) interacting
spiral of look, think, act. This is similar to Kirby and McKenna's (1989) model of plan, act,
observe, and reflect. Stringer (1999) explains that this cyclic process allows the researcher and
participants to repeat, revise, or make sweeping changes of the data based on the results of each
cycle.
Creswell (2002) says that mixed method research entails qualitative and quantitative
approaches to exploring phenomena. Polit and Beck (2004) describe this appraoch as
triangulation. Using multiple methods of inquiry to triangulate data increases their

trustworthiness and authenticity. The triangulation design of this project included a process of
inquiry, participation, and dialogue through qualitative interviews, focus group discussions, and
a quantitative survey. Glesne (2006) describes the advantage of triangulation: "The more sources
tapped for understanding, the richer the data and the more believable to findings" (p. 36). Glesne
also notes that the "purpose for methods triangulation is not the simple combination of different
kinds of data, but the attempt to relate them so as to counteract the threats to validity identified in
each" (2006, p. 36)
Historically, as Palys (2003) and Stringer (1999) describe, quantitative research inquiry
has included research that is scientific, replicable, numerical, and thorough. Polit and Beck
explain that scientific experimental research has the ability to manipulate and measure one or
more independent or dependent variables through a comparison approach. Using this
methodology enabled me to employ flexible and creative methods of experimental and
nonexperimental approaches to capture key concepts that provided an impetus for change in the
current environment.
A qualitative and quantitative research design approach combines an investigation of
participant perceptions and inquiry into the environment with collection of factual and
measurable data about participants' practices and boasts several benefits for health care
professionals and employees (Berg, 2007; Glesne, 2006; Palys, 2003). The insights provided
from this study provided valid information to health system managers, allied health
professionals, and employees to generate solutions and build on the existing work being done
within THC as it embarks on its quest to transform the health care experience through providing
patient-centered care.
Project Participants
The main goal of this action research project was to discover and understand how
professionals and employees at THC can create an environment that enables the delivery of
patient-centered care. In exploring the environment of the unit, it was essential that all
interdisciplinary members of the team be heard to achieve an understanding of the unit
environment. Stringer (1999) states, "It is imperative that all stakeholder groups feel that
someone is speaking for their interest and is in a position to inform them what's going on" (p.
49). He notes that action research aims to "envisage a collaborative approach to investigation
that seeks to engage 'subjects' as equal and full participants in the research process" (Stringer,
1999, p. 9).
My research advisory team consisted of me as the researcher, the major project
supervisor, project sponsor, a clinical educator from the pilot unit, a consultant from the
Organizational Development department, and a unit clerical associate for transcription and
assistance with data collection. I informed the project supervisor and project sponsors of all
aspects of the research process to ensure that my bias did not influence the results of the research
process.
As suggested by Palys (2003), I used a purposive sampling technique. I recruited
participants from four subgroups that included (a) health system managers, (b) frontline nurses,
(c) allied professionals, and (d) employees of the pilot unit. The participants shared their
perspectives, experiences of the environment, and viewpoints of the phenomena investigated.
Palys contends that this process allows the researcher to study a specific set of like teams who
"are intentionally sought because they meet some criteria for inclusion in the study" (2003, p.
142). I selected participants to achieve a sample inclusive of all members of professionals and
employees who collaborate daily to provide a patient-centered experience for patients and
families.
I invited participants in person and via e-mail and gave them a formal letter of
introduction with an attached consent form to participate in the study (see Appendix B). Among
other things, the invitations outlined the purpose of the research, the time commitment, and the
fact that if people chose to not take part in the study their employment would not be jeopardized.
I followed the guiding principles of Royal Roads University's (RRU's) (2006) Research Ethics
Policy and THC's (2006c) Research Principle #5000.
Research Methods and Tools
I used multiple interactive tools to collect data for the action research project. Action
research is a collaborative, holistic approach to problem solving, rather than a single method for
collecting and analyzing data (Berg, 2007; Glesne, 2006; Stringer, 1999). This methodology
allowed me to employ several different types of research tools while the project progressed,
including unstructured interviews, focus groups, and a survey. Palys (2003) asserts that the
authenticity and trustworthiness of a research study relates to the extent to which the research
findings are genuine with accurate interpretations of information provided by participants.
Pilot Test
First, I sent out letters by e-mail inviting health system managers, staff, and employees to
attend the Nursing Advisory Council and the Medical Health System Council, forums in the
organization where decisions are reviewed and made and best practice initiatives are developed
in consultation with members, to discuss the research project. Stringer (1999) classifies this
process of information sharing as part of the action research interacting spiral of "look, think,
act" (p. 19). In the look phase I provided an executive summary to quickly highlight the study,
expectations of the group, and timelines to assist prospective participants in their decision to
engage (or not) in the project.
Glesne (2006) says that a key step in the development of questions used in an interview is
to pilot test the interview questions prior to the actual interviews. I pilot tested the interview
questions (see Appendix C) and refined them based on the feedback from the pilot test
participants in the Nursing Advisory Council and Medical Health System Council. Palys (2003)
summarizes the challenge of developing effective interview guides as "designing thoughtful,
interesting and appropriate questions; providing an ethical context in which respondents will be
most likely to give insightful and candid responses; and understanding just what we have at the
end of the process" (p. 150). I took extreme care in formulating the questions, so that all
stakeholders could engage comfortably.
Interviews
In the second step, I conducted individual interviews with health system managers from
like units at the Mississauga site using semistandardized interview questions. Berg (2007) says
that semistandardized interview guided tools "can be located somewhere between the extremes
of the completely standardized and the completely unstandardized interviewing structures" (p.
95). This format allowed me to add or remove probes to interviews between subjects. Because
the research is based on the health systems manager's role, it was critical that I understood their
perspectives. Their diversity created a base to garner further knowledge on the research question.
Glesne (2006) suggests that a researcher "might interview in search of opinions,
perceptions and attitudes toward some topic" (p. 80). There are a number of reasons for using an
individual interview process as the look phase of this action research study. Stringer (1999) states
that "the interview process not only provides a record of their [the participants'] views and
perspectives but also symbolically recognizes the legitimacy of their views" (p. 68).
The aim of the individual interviews was to explore and drill down to the central
concerns, opinions, perceptions, and attitudes of the participants. Palys (2003) notes, "Face-to-
face contact typically provides two things: higher response rates and the chance to both clarify
ambiguities or misunderstandings and monitor the conditions for completion" (p. 151).
Understanding health systems managers' experiences and perceptions was vital to develop a
deeper understanding of the issue. Data from the managers' interviews helped to build additional
questions for the focus groups of frontline nurses, allied health professionals, and employees.
This information created the foundation of knowledge transfer while providing a meaning-
making journey for the action research cycle.
Focus Groups
Next, I conducted three interactive focus groups. The first focus group included frontline
nurses, the second included allied health professionals, and the third included a blend of
employees (clerical, hospitality, and environment associates). According to Stringer's (1999)
action research interacting spiral, this was the think stage of the research study.
Palys (2003) notes that focus groups "provide provocative and/or insightful information
to the exploratory researcher who is looking for unanticipated consequences to organizational
interventions" (p. 162). The focus groups gave me an opportunity to identify themes, inquire into
insights, and generate ideas on what participants can do to improve the environment. The focus
group questions (see Appendix D) allowed lively interactive discussion about the unit
environment, roles of employees and professionals, and the barriers or challenges to providing
patient-centered care in the current environment.

The organizational consultant from the People Support SBU assisted me as cofacilitator
in the focus groups. In the focus groups, the organizational consultant observed the interaction
between me as researcher and the participants. This process allowed me the freedom to prompt
participants for follow-up questions and richer discussions, as suggested by Berg (2007). I taped
the sessions using two recorders. The unit clerical associate transcribed the tapes and notes from
the focus groups, which I shared with the participants for verification and accuracy and to
prevent researcher bias. Stringer (1999) describes this process as member checking.
In the focus group with nurses, I limited participation to a cross section of 8 full-time and
part-time nurses who ranged from novice to expert in terms of years of experience. This
purposive method was used to ensure a cross-generational selection of nurses, who are the
largest discipline of staff within the organization. Previous research (Baumann et al., 2001;
McGillis Hall, 2005; RNAO, 2006b) has found that novice and experienced nurses view the
work environment quite differently. Benner (1984) maintains that professionals move through a
developmental continuum in which they progress from novice to expert. According to Benner,
expert nurses have a unique awareness of the patient and family experience, in contrast to novice
nurses who have little experience with real situations and rely on their education. Expert nurses
are more comfortable in challenging the status quo and are able to help others to see situations
from various perspectives.
The allied professionals and employees focus groups were limited to 7 members. Berg
(2007) notes that for complex topics, focus groups should not exceed 7 participants. Having a
large group of participants can provide a bounty of information-rich data; however, I was
cognizant of the time commitment required by all members of the research team to sort,
interpret, and transcribe the data.

Survey
Finally, to widen the scope of inquiry, I sent a survey (see Appendix E) made with the
online Survey Monkey® tool to all clinical leaders and clinical educators within the organization.
Clinical leaders and educators are critical in the development and implementation of best
practice at THC.
Polit and Beck (2004) surmise that the objective of this type of research is to "produce an
impetus that is directly used to make improvements through education and sociopolitical action"
(p. 266). I selected a survey to glean valuable insights into the practice of professional teams and
employees to determine what was needed in the environment to provide patient-centered care.
The goal of this study was for participants and I to identify and discover more about the current
reality of the environment and what supports are needed at THC to provide patient-centered care.
The use of multiple research approaches such as interviews, focus groups, surveys,
observation, peer debriefing, and member checks authenticated the data with participants and
demonstrated credibility through triangulation (Glesne, 2006; Polit & Beck, 2004). Schuman (as
cited in Glesne, 2006) "advocates interviews as the validity check of the responses given to
questionnaire items" (p. 80). Utilizing these tools and process added to the validity and reliability
of the project.
Table 1 shows the number of participants for each data gathering tool.
Table 1. Summary of Participants by Data Gathering Tool
Data gathering tool Participants TV value
Interviews In-patient managers 6
Focus group #1 Frontline nurses 7
Focus group #2 Allied professionals 7
Focus group #3 Employees 7
Survey Clinical educators and clinical leaders 56
Study Conduct
In the first stage of the research cycle, I sent online invitations to health system managers
selected from each of the inpatient units at THC's acute care site, inviting them to participate in
the research study. I attached a written consent form to the invitations. I also sent invitations to
professionals and employees of the pilot unit by interoffice department mail. I excluded the
Critical Care, Emergency, and the Operating Room departments from the survey as the patient
ratios are different in this environment. I obtained signed informed consent prior to engaging
each participant in the study.
I conducted interviews with 6 health system managers from the inpatient units at the
Mississauga site to collect baseline data on the environment's current state. I used the questions
from the manager interviews to develop the interview guide for the focus groups with nurses,
allied professionals, and employees. I recorded the focus group sessions so that I could document
key themes. A secretary transcribed the tape recordings from the interviews and focus group and
the field notes.

Utilizing broad stakeholder engagement across health system managers provided a deeper
understanding of the managers' perceptions and identified themes related to their perception of
an ideal unit environment and how this could be accomplished at THC. The environment in
which I chose to conduct the interviews and focus groups with different stakeholders was
significant. 1 used my office to create an environment that was safe, welcoming, and conducive
to open dialogue.
During the data collection it was important to analyze, explore, share, and be open to
findings synthesized from the data collection and inquiry as themes and patterns unfolded. I
continued to keep the lines of communication open between the research team and participants to
verify the data and update the findings.
In the second stage, I used data obtained from the health system managers in the
interviews to develop four questions for the focus groups. Palys (2003) believes that a great deal
of qualitative data can be collected when participants share their experiences, annotations, and
perspectives. In order to present action research in the most concise and useable way possible,
data must be well organized. My research team formulated the four open-ended research
questions for the focus groups to capture perceptions and to validate and look for commonalities
and threads.
I invited all members who have contact with patients to participate in the research on the
pilot unit. These members represented the culture of a typical team involved in providing care to
patients and families throughout the inpatient units at THC. This group provided a diverse lens to
support and augment the data collection, while enabling me to develop a deeper understanding of
the stakeholders' insights and perceptions of what constitutes a patient-centered work
environment.
Stringer (1999) notes that participatory action research enhances the capacity of different
stakeholders to represent their interests on the issue under investigation. The findings represented
data from professional and indirect caregivers and examined their experiences and viewpoints.
In the third stage, act, the research team used Stringer's (1999) action research interacting
spiral, to collect data, interpret the data, and turn interpretations into action plans. These were
revised through analysis, action planning, and evaluation after each cycle. The research team was
my guide in exploring, discussing, and reviewing the data.
Data Analysis
Polit and Beck (2004) suggests that in order to analyze data, they must be categorized and
synthesized; look for patterns and then interpret the findings from the patterns. Similarly, Morse
and Field (as cited in Polit & Beck, 2004) describe qualitative analysis as a "process of fitting
data together, of making invisible obvious, of linking and attributing consequences to
antecedents. It is a process of conjecture and verification, of correction and modification, of
suggestion and defense" (p. 572). Palys (2003) suggests that the research team can glean themes
from the text using an inductive approach. An inductive approach starts with observation and
then moves to theory. Hence, researchers observe, stimulate empirical generalizations based on
observations, and then, through analytic induction, endeavour to develop a theory that reflects
the observed reality (Palys, 2003; Polit & Beck, 2004).
Kirby and McKenna (1989) provided the structure that I followed in this research to
analyze qualitative data. To manage qualitative data and identify themes, I started a content-and-
process file. The files housed the raw data as the categories and themes emerged. Kirby and
McKenna note that "the expansion of the file structure is to order the data, not to change the
nature of the data" (1989, p. 131). I categorized and synthesized data from the interviews, focus
groups, and survey to look for patterns, and then the research team interpreted these findings
from the patterns in order to develop the emerging theory. This type of research from the
margins requires that "all data . . . be given equal voice to speak in the analysis.... [It] makes
sense that if we are to fully understand the data and effect change, we must try to understand
contextual patterns as they are sustained and controlled" (Kirby & McKenna, 1989, p. 129).
I used bibbits to code the data from the interviews, focus groups, and survey. Kirby and
McKenna (1989) describe a bibbit as
a passage from a transcript, a piece of information from the field notes, a section of a
document or snippet of a conversation recorded on scrap paper that can stand on its own
or, when necessary, can be relocated in its original context, (p. 135)
I used cross-referencing procedures as recommended by Kirby and McKenna (1989) in
an attempt to develop themes and look for patterns that "went together" to make categories. I
coded each bibbit according to its category. I colour coded the bibbits and numbered them for
ease in identification and relocation. I copied them in case they fit into more than one category. I
found that, as Kirby and McKenna suggest, analysis and coding of the research requires that "I
step back, reflect on the analysis, live with it, and rework the analysis as necessary" (1989, p.
150).
Following Kirby and McKenna's (1989) advice, I conducted interviews with the
assistance of the research team through a systematic method to ensure all data collected had a
voice in the analysis. As researcher, I engrossed myself in the data analysis and reflected on the
data from verbatim transcribed notes, observations, and audiotapes to "simultaneously live with
the data and make sense of the data" (Kirby & McKenna, 1989, p. 128). I conducted this process
collaboratively with members of the research team to discover differences and similarities in the
data collected. It was critical that transcriptions were accurate and reflected the participants'
experiences. To check for accuracy, participants reviewed transcripts for accuracy at the end of
the interview. Using member checks encouraged participants to "support, contradict, or modify
the thematic analysis" (Polit & Beck, 2004, p. 580).
The research team examined the transcripts for common threads, and all identifying
information such as name and role were deleted. Analysis and reflection of the information
occurred before the data collection had ended as it allowed for preliminary findings to guide
subsequent data collection. Writing short thoughts, comments, or questions while reviewing the
transcripts developed my observation notes and transcribed interviews.
Themes that materialized from the interviews built the four questions for the focus
groups. The approach for the focus groups mirrored the interviews; however, I invited a few
members from the research team as moderators to code participants and to take detailed field
notes of the nonverbal behaviour.
At the end of a focus group session, I immediately debriefed the data with participants to
ensure that the identified themes fit the focus group's viewpoints. I then colour coded bibbits
using an approach that involved looking for similar words or phrases mentioned by the
interviewees. I numbered the bibbits for easy identification and retrieval, copied and categorized
them, and then converted them to manageable segments for review and retrieval, as suggested by
Kirby and McKenna (1989). Next, with the research team in attendance, I analyzed the data and
segmented and compared them with data gathered from the interviews.
Palys (2003) says that quantitative research is examined critically to assess the likelihood
of it being reliable and valid. A 5-point Likert-scale and categorical questions generated ordinal-
level data for the statistical analysis portion of the research. Using the online survey, I collected
data using open-ended and closed questions. The closed questions reflected a quantitative
methodology using a numerical Likert scale. As Polit and Beck (2004) explain, this well-planned
methodology was an effective structured tool that collected rich data and generated statistical
measurement of participants' attitudes and opinions.
Once all data were gathered and collated, the research team, as Polit and Beck (2004)
expected, recognized a sequence of patterns in the information that emerged within and across
the diverse sources of information. The research team reflected on the patterns in relation to the
environment identified in the research question. Immersion in the data aided the team in asking
the interpretive questions of "who, what, when, how, and why?" that Berg (2004) and Stringer
(1999) call for. Asking the interpretive question of "why?" provided a starting point for
developing interventions and opportunities to implement change. Investigation of the "what" and
"how" helped to further catalogue issues linked to the purpose of the research. Asking "who,
where, and when" provided specific information to refine the phenomena and provided a
collaborative approach to problem solving.
The literature review, interviews, focus groups, and survey aided the credibility and
reliability of the research. Lincoln and Guba (as cited in Stringer, 1999) assert that establishing
credibility, validity, reliability, and confirmability is a process that is significant in the
assessment of trustworthiness of data analysis. Stringer (1999) describes this as "rigor . . . . A
procedure and process of inquiry having minimized the possibility that the investigation was
superficial, biased or insubstantial" (p. 176).
The project achieved validity through spending time with the participants, as
recommended by Palys (2003) and Stringer (1999), and using a method of member-checking
interviews and focus groups to review the data analysis for accuracy. Reliability for this project
was established through concise wording and clarity in the survey. This method increased the
probability of obtaining the same results if the questions were repeated. Confirmability was
demonstrated by confirming and corroborating with the research team and participants when
reviewing, checking, and rechecking the data throughout the study.
Ethical Issues
Ethical approval is a requirement to commence any research project that involves human
participants. In all circumstances, I as the researcher considered the ethical implications for
participants in the research. Throughout the process, it was my responsibility as researcher to
ensure decisions and actions were ethical. Palys (2003) describes ethics in research as "principles
that guide the way we interact with research participants and the commitment to safeguard their
rights and interests" (p. 80).
Glesne (2006) notes, "Ethics is not something that you can forget once you satisfy the
demands of institutional review boards and other gatekeepers of research conduct" (p. 129).
While conducting participatory action research in my workplace, I developed relationships with
participants and adopted a collaborative process of critical inquiry. These relationships were
essential to the success of this mixed method research study.
Ethical approval of this project's intent and process was obtained through the research
ethics board of THC and RRU. This project adhered to THC's (2006b) Research Applications
and Reporting Requirements Protocol #5010 and RRU's (2006) Research Ethics Policy, which
includes the eight ethical principles of the Tri-Council Policy Statement on Ethical Conduct for
Research Involving Humans: (a) respect for human dignity, (b) respect for free and informed
consent, (c) respect for vulnerable persons, (d) respect for privacy and confidentiality, (e) respect
for justice and inclusiveness, (f) balancing harms and benefits, (g) minimizing harm, and (h)
maximizing benefit.
Respect for Human Dignity
All participants are autonomous individuals and have the "right to make informed,
voluntary decisions about study participation" (Polit & Beck, 2004, p. 147). It was imperative to
protect the anonymity of the participants and have the informed consent of those within the
organization. I informed participants that refusal to participate would not jeopardize their current
work situation, and at any time during the focus groups or interviews they could stop answering
certain questions or withdraw from the study.
Respect for Free and Informed Consent
Polit and Beck (2004) advise that guidelines and care must be exercised when humans are
used as study participants. "When subjects volunteer information, the researcher has an
obligation not to share the information with others unless there is free and informed consent"
(Royal Roads University [RRU], 2006, p. 11). In an effort to conduct my research ethically, I
ensured participants in writing and verbally at the beginning of each interaction and in the letter
of invitation of the nature of informed consent.
Diener and Crandall (as cited in Glesne, 2006) note,
Through informed consent, potential study participants are made aware that participation
is voluntary, any aspects of the research that might affect their well being [are disclosed,
and] they may freely choose to stop participation at any point in the study, (p. 132)
Participants signed a consent form that highlighted the adherence to voluntary and
informed participation. I coded the data to ensure that it was not possible to relate a particular set
of data back to any given participant and destroyed all data at the end of the study.
Respect for Vulnerable Persons
All participants were treated with respect. I was the researcher participating in the
participatory action research, but I was also the manager of the pilot unit. This presented the
potential for a power imbalance or conflict of interest. To minimize vulnerability, I
communicated that participation was voluntary at the beginning of each session and informed
participants that I was guided by RRU's ethical policies and THC's ethical research board and
onsite ethicist, who was available if I needed guidance. I provided the contact numbers of the
project sponsor and supervisor in case the participants needed to contact them.
Respect for Privacy and Confidentiality
When developing relationships with participants, "researchers must consciously consider
and protect the rights of participants to privacy" (Glesne, 2006, p. 138). Furthermore, a
researcher must respect the confidentiality of participants by not discussing with anyone the
specifics of what was said and done. I had an obligation to provide confidentiality and anonymity
throughout the research study. I reviewed exactly what I meant by anonymity and confidentiality
for the research participants in advance of the research taking place.
I clarified the steps that I took to ensure the protection of participants' identities, because
the outcomes of the research were to be communicated and shared in my thesis and in the
organization. Throughout the research process, I kept the data in a secure locked cabinet in my
office. I gave the participants pseudonyms and destroyed tapes, transcriptions, notes, and surveys
relating to participants upon withdrawal and at the end of the project.
Respect for Justice and Inclusiveness
Polit and Beck (2004) explain that justice, the fair selection and impartial treatment of
participants, is important before, during, and after the research process. Researcher bias was not
tolerated when selecting subjects to participate in the research. It is unethical to deny access to
certain groups of participants because their beliefs are not aligned with the researcher. Some
examples of fair treatment in this project included full access, as all participants had equal access
to take part in the research, and no prejudicial behaviour toward those who refused to participate
in the research. Participants had the opportunity to provide input into the research and full access
to all research findings. My research team was committed to the dissemination of the study
findings and the participants received an executive summary of the research findings with
implications for practice.
Balancing Harms and Benefits
I and the advisory team made every effort to not expose participants or the organization
to any harm or discomfort during the action research project. The aim of the research was to
enhance the knowledge of participants and contribute to the organization's mission of
transforming the health care experience of patients and families.
Minimizing Harm
Polit and Beck (2004) define beneficence as "the most fundamental principle in research,
which encompasses the maxim: Above all, do no harm" (p. 143). I was cognizant that in
establishing relationships with participants while conducting critical inquiry, there is a potential
to cause distress to all parties "when the power differential is high" (Palys, 2003, p. 85). I made
every effort to minimize the potential risk my role of manager and researcher could cause
participants. Hence, I was careful in phrasing questions for the focus groups, interviews, and
survey. I encouraged the participants to ask questions, voice concerns, and debrief with the
research team after each session.
Maximizing Benefit
The benefits to the microsystem and organization are abundant. Nurses, allied health
professionals, and employees had the opportunity to challenge their mental models and articulate
their issues and concerns, while participating in a collaborative process of planning, studying,
and facilitating change. This research study was innovation from the front lines. From the
knowledge revealed within this study, the team was able to examine the setting, process, and
leadership required to explore what is needed at the microsystem and organizational level for
managers to evolve and assist teams in the creation of the ideal unit environment where teams
provide patient-centered care.
Conclusion
The research team and I gained a greater understanding of how to conduct a mixed
method research study that included qualitative and quantitative methodology. The team
collaborated together as we progressed through the stages of the action research cycle. The team
developed the questions that I used for the manager interviews and assisted me with the pilot
test. Pilot testing the questions with the Nursing Advisory Council and Medical Health System
Council enabled me to develop the right questions to garner the managers' perspectives of the
ideal unit environment.
Once the manager interviews were completed, the team met and collaboratively
developed questions, building on the perspectives from the manager interviews for the three
focus groups with frontline nurses, allied professionals, and employees. Once the focus groups
were completed, the team met and analyzed and synthesized the data, looking for themes,
patterns, anomalies, and trends. Finally, we developed the questions for the survey, which was
administered online using the SurveyMonkey® tool. The surveys collected information-rich data,
evidently engaging participants.
When the research team reviewed the data from the manager interviews, we had the
opportunity to compile the health system managers' experiences, perspectives, and

recommendations on how to evolve their role to assist the teams they lead to create a healthy unit
environment while providing patient-centered care.
The focus groups with cross-generational frontline nurses, allied professionals, and
employees built on the perspectives of the interviews with the managers. The focus groups
allowed individuals within the group to share personal and collaborative experiences on what
they considered the ideal unit environment in which to provide patient-centered care. The focus
groups widened the net of inquiry to the research questions.
The survey engaged the clinical leaders' and educators' perspectives on how to construct
a best practice approach to involve professionals and employees to evolve the environment and
patient-centered care. This research approach has been successful in challenging the team's
mental models on what is a healthy unit environment and the effect allied professionals and
employees have in enabling patients to drive their care.
By using interviews, focus groups, and the survey, this participatory action research
allowed the research team to continue Stringer's (1999) spiral activity of look, think, act to gain
insight and knowledge into the research question. As the team analyzed, interpreted, and
reflected on the data at each cycle, we were able to propose recommendations for change to
managers, professionals, and employees in the organization in developing an ideal unit
environment to provide patient-centered care.

CHAPTER 4: ACTION RESEARCH PROJECT RESULTS AND CONCLUSIONS
Study Findings
The purpose of this research was to answer the research question, "What can the health
system manager do to contribute to the creation of the ideal unit environment for professional
teams and employees who are dedicated to providing patient-centered care?" To provide further
perspective on the research question and to support this knowledge inquiry, I identified the
following subquestions:
1. What are the characteristics of patient-centered care, and what do these characteristics
require professional teams and employees to contribute to patient centered-care?
2. What are the characteristics of an ideal unit environment?
3. What are some of the challenges and parameters that define the potential scope of
influence that health system managers can have on the ideal unit environment?
4. How can health system managers evolve their role to achieve the ideal unit environment?
From the data collection process of six manager interviews, three focus groups, and the
electronic survey, six major findings evolved:
1. Involving patients as participants enables the ideal patient experience;
2. Communication, cooperation, coordination, and teamwork are essential;
3. Recognition, respect, and accountability are fundamental;
4. Several factors impact the manager's ability to coach and mentor;
5. A cultural change in mindset is necessary to sustain patient-centered care; and
6. Manager role redesign is imperative to build leadership capacity.
Now I will present my findings and integrate data and comments to support the themes
identified through the interviews, focus groups, and survey responses. I will substantiate each
finding with sample comments collected from the data, followed by examples. To maintain the
anonymity of all research participants, I recorded the interviews, focus groups, and survey data
without using participant identifiers. In this chapter, I identify comments from the interviews
with "(I)," comments from the focus groups with "(FG)," and comments from the survey with
"(S)." Even though data from the interviews, focus groups, and survey were collected and
analyzed separately, a great deal of congruency exists among the comments. Therefore, findings
include comments from all three data sources.
Finding 1: Involving Patients as Participants Enables the Ideal Patient Experience
All participants felt passionately about the organization's mission to transform the health
care experience through providing patient-centered care. However, most believed that they were
already practicing patient-centered care. I asked all participants to describe the characteristics of
patient-centered care, and what these characteristics require each person to contribute to the
patient-centered-care initiative. One participant wrote,
As a team we believe we are patient centered from a medical model and are eager to
focus on transforming. We can evolve to provide care collaboratively with all disciplines
by placing the patient at the centre of how care is provided. (S)
Another participant expressed this view:
The team demonstrates being patient centered when it respects the patients and enables
them to direct their own care if competent and supports patients to meet their daily goals,
which are posted on the whiteboards at the bedside so members of the team have an
opportunity to participate in meeting the patient's goals. (I)
Other participants commented, "When [our] teams can communicate the plan of care to
the patient and family, we are being patient centered" (FG) and "[In a patient-centered
environment,] teams share information and knowledge [and] maintain patient privacy in a quiet,
healing environment" (FG). Others, from novice to expert in years of experience, noted, "In this
environment, the patient is the centre of our care . .. [and] of all we do" (FG) and "You assist
them [the patient and family] to actively participate in their care if they are able" (FG). Another
participant stated, "It is also about supporting and educating the family to assist the patients in
their plan of care" (I).
One participant wrote,
I would like to support an environment of personal transformation as opposed to just

telling nurses things to do to be patient centred. I don't believe it is all about the things
we do; it is about how patients are treated. How can we support nurses by providing
training around conflict and dealing with complex patients and families?. (S)
Similarly, in a focus group, one individual said, "I want the manager to find a way [for us
to] deal with families that are abusive to staff."
Another participant noted,
I would like to see increased training and insight into my interactions with others.
Although I think I behave one way, I don't know if others perceive me that way. Also, I
always want to please everyone and need to deal with the fact that I can't. I want the
entire team to take ownership of the patient-centered approach, not just nursing. I would
like to see serious team-building sessions, done by professionals. (S)
All participants discussed time as a challenge to supporting the patient-centered initiative.
An inputter said,
T i m e . . . . We get so busy about our day that we forget to keep engaging our patients....
We need to encourage each other.... When we take the time to listen and truly put the
patient in the center of care, there will be good outcomes all around. (S)
Taking the issue of time further, another participant reported the need for focused time: "There
are so many things going on. We try to include a patient-centred care approach to everything, as
well as excellence in clinical care and improved patient safety" (S).

A consistent theme throughout the data was asking the patient and family how they
would like to be treated. A key concept of perception was highlighted in these data regarding
how patients perceive their experience.
Finding 2: Communication, Cooperation, Coordination, and Teamwork Are Essential
As an organization, THC encourages every member to support the ideal patient
experience, whether the individual conducts direct patient care or plays a supporting role. All
participants were passionate in discussing how they could create an ideal unit environment to
provide patient-centered care. One participant described this environment as demonstrating the 3
C's: "Communication, cooperation, and coordination of care" (FG).
All participants interviewed unanimously agreed that "in an ideal environment, you
would see teams take ownership to create the ideal patient experience." Another participant said,
"[In the ideal environment,] I personalize the patient, provide physical and emotional care, [and
a] comfortable environment; the patient's questions are answered. [I] respect the patient's values
and the patient feels I am paying attention to [him or her]" (FG). Another participant depicted
patient support as "active listening to what the patient is saying, being focused on the patient, and
involving the patient to be a part of [his or her] healing" (FG). Another participant elaborated:
Our purpose, our number one focus of why we are here, is . . . the patient. When it all
comes together in a coordinated fashion, you see everyone working together to care for
the patients hand in hand. It is a feeling of accomplishment and the patient has a good
outcome. (FG)
Another employee in the focus group described at what point the ideal environment is
achieved: "When patients are well cared for and feel comfortable and safe, see caring people and
satisfied caregivers; [when] their rooms are clean and their orders in their chart are processed in a
timely manner" (FG).

Many commonalities surfaced in the discussions when study participants were asked
what they needed in their current roles to support the creation of the ideal patient experience.
Some voiced "a desire to do daily walk rounds with the interdisciplinary team and physicians to
see patients and develop a plan of care" (FG). One participant expressed a wish for "direct, open
communication between all disciplines and employees" (FG). Professionals wanted expanded
communication: "We need the physicians to communicate with us in developing a plan of care
which is communicated to the patient" (FG). Another participant took it further by listing
barriers to creating the ideal patient experience:
Not having clear goals or practice expectations to guide practice, lack of leadership to
establish standardized processes for key functions or roles on the units,... [and a]
disconnect between the unit goals and expectations and the organization's goals and
expectation of care.... [These are] commonly associated with poor communication
between leadership and team. (S)
One survey question asked the participants to describe what was needed in their current
roles to assist them to be patient centered. A participant stated,
Time and nonclinical work are two major barriers in the ability to provide support to staff
so they can provide patient-centered care. In our current reality, there is a difference in
the care we provide Monday to Friday.... We are still operating on the principles of
trying to provide care 5 days a week, 7 hours a day. Care does not stop on weekends. (I)
A survey respondent wrote,
[We need] more time to do education with frontline staff to encourage more innovative
ideas from them about what they would like to see happen in the unit to provide patient-
centered care. Staff often verbalize wanting to do more for patients, but have limited time
to accomplish this.
One overwhelming reaction from professionals and employees was articulated by a
participant thus: "Effective teamwork is critical if this initiative is to be realized and sustained"
(FG).
One participant asked the following:

How many times do you see the unit end up in chaos if the team does not work as a team?
It all comes down to communication and teamwork. If the manager or physician comes
on the unit and ignores everyone and doesn't communicate with you,. . . nothing gets
done. It's also about respect for each other's roles. (FG)
Another participant said,
When you work as a team, you use each person's gifts.... Everyone is engaged. The unit
can be busy but you will see everyone is relaxed going about their work. It helps us to
move toward a patient-centered vision. (FG)
A facility (patient care unit) that is adequately staffed, with enough physical and human
resources, is the ideal environment to enable teams to provide patient-centered care. Three
consistent themes emerged from the data regarding this finding:
1. Communication, coordination, and cooperation should be consistently demonstrated by
the team regarding the patient plan of care.
2. Teamwork and trust in collaborative relationships amongst health care professionals,
employees, and physicians are essential for success.
3. Time and nonclinical work are barriers to staff to provide patient-centered care.
These themes demonstrate a need for a systems approach in working together to build the ideal
patient experience. Coordination, communication, and cooperation are key components of a
high-performing team.
Finding 3: Recognition, Respect, and Accountability Are Fundamental
When the facilitator asked the focus group participants what they needed from other
members of the team (including the manager) to support them on their journey, participants
quietly reflected and made comments such as, "I would like my manager to acknowledge me and
let know me that I have done a good job." This was a typical comment made by all professionals
and employees; a desire for a simple acknowledgement like "You did a good job" was
articulated by all. Verbal recognition was noted as the most meaningful show of appreciation.
More than one manager interviewed expressed the idea that "the manager and clinical
leader are not the only ones accountable; I want to see professionals take ownership and
accountability for their actions."
Another survey participant wrote,
I believe that the most important influence on the degree of patient centeredness in a unit
is the unit culture. I think the most influential factors in shaping the unit culture are the
attitudes and behaviours of the clinical leaders. In a great unit, the clinical leader would
model respect for patients' rights, values, and autonomy in their own behaviour. They
would also make clear the expectations and standards of care and address instances when
these standards and expectations are not met. I think that upholding standards conveys
that the patient is our priority. Clinical leaders, however, require the support of managers,
both at the unit and senior level, in order to do this.
Another participant said, "I need a leader who respects the team, actively communicates,
and listens to the opinions of the team" (FG). Others agreed and furthered the discussion by
making statements like, "Management and senior leadership in the organization need to hold
professionals, employees, and physicians accountable for their actions" (FG).
One focus group participant said, "I would like nurses to listen to me when I observe
something with a patient... or when patients tell me they need care when I'm in their room."
One participant stated, "I want my manager to have her finger on the pulse of what is happening
on the unit and hold people accountable" (FG). Another participant noted, "[The] entire team
must take ownership and accountability of care of patients in the environment" (S). Another said,
"There is a level of expectation that everyone who interacts with the patients treat them with
courtesy and dignity, taking into consideration the patients' individual needs" (FG).
Participants in the interviews, focus groups, and survey were asked what their role would
be in the ideal environment to support the ideal patient experience. Participants were very
passionate about this question and were not at a loss for words on their perspectives of what their
ideal role would look like. Participants in the interviews iterated that they would like to see
professionals, employees, and physicians engaged and satisfied at work, behaving in a
professional manner, and always remembering to keep the patient at the centre of what they do.
A focus group participant stated,
[Ideally,] the unit goals and objectives would be aligned with the organization's mission.
The facility—physical environment—would have state-of-the-art equipment and
surroundings. [There would be] knowledgeable teams where care is not solely based on
discharge planning [and] no blame environments where professionals are accountable.
[People would not be] covering two to three units on a single day [and there would no
longer be] limited time, limited assistant support, inadequate space and design of the unit,
and inability to reach physicians for consults. (FG)
Another participant added, "The environment [would be] clean, decluttered, and well maintained
with minimal chaos" (FG).
A survey participant wrote,
Academic education and preparedness (or lack of) around communication is different
among health care team members. Communication between physicians, RNs, and other
team members is forever strained if we are not talking the same language. We can't
expect patients and families to have respect for RNs and the health care team if
physicians are disrespectful and demeaning at the patient bedside. Each individual health
care professional (MDs, RNs, and allied health) has to understand that it is not an
intervention or privilege for patients and families to have patient-centered care.
Finding 4: Several Factors Impact the Manager's Ability to Coach and Mentor
Health system managers at THC are considered formal leaders and have leadership
competencies to support this role. It is the expectation that managers, as leaders, develop and
build capacity through coaching and mentoring staff. To enhance my literature review and
develop a greater awareness of the literature and the current reality of managers' portfolios at
THC, I interviewed 6 clinical managers whose span of influence ranged from 80 to 160 direct
reports. I asked them if their span of influence impacted their ability to coach and mentor staff.
All managers unanimously noted time and competing priorities as constraints in their inability to
coach and mentor staff. Here is a sample of their responses.
I have too many units, too many people, and not enough time. I spend my time dealing
with availability of staff; patient and family concerns; Risk Pro reports on falls, errors, or
near misses; [acting as] staff advocate to physicians; [the] hiring [of] staff; paperwork; e-
mail; and meetings where everyone uses the manager as a filter to push information out
to staff. (I)
One manager stated,
I don't feel I'm there often [enough] to really know everyone. Their perception is I'm
always too busy . . . involved in other things. I try to coach staff around council initiatives
and projects but I hardly have time [for] leadership development. This impacts my ability
to encourage them [to take advantage of] opportunities within the organization because I
don't know their desires. I'm hoping to get to do all of their performance reviews where I
can assess their skill ability and desires. (I)
Another manager discussed these issues:
I end up spending my time putting out fires and dealing with staff [members who are] not
performing. There are just so many competing priorities. I have portfolios at different
sites. The perception is [I'm] not visible, [I'm] not there. Staff want [me] to stay closely
connected,... supporting them.... [People want me to] show [I] care if they have
trouble coping [with] personal [problems], patient issues, or staffing. (I)
A manager with a diverse portfolio added, "I have groups of small teams all over the
organization along with regional responsibilities. Each team is unique; I find it hard to stay in
touch with the clinical picture and staff (I).
All managers in the organization have clinical leaders who support them in the day-to-
day operations of the unit and clinical educators who support knowledge and skill development
with frontline teams. In the survey, I sought to confirm if the formal and informal leaders that
work closely with managers felt the impact of the managers' span of influence in the managers'
ability to mentor, coach, and build leadership capacity. The results are presented in Table 2.
Table 2. Survey Responses to Question, "Does the Manager's Span of Influence Impact Your
Role?"
Response option Response percent Response count
Almost never 8.9% 5
Rarely 10.7% 6
Occasionally 25.0% 14
Fairly often 21.4% 12
Almost always 7.1% 4
Skipped this question 26.8% 15
Mentoring and coaching are competencies that are required of clinical educators. It is also
expected in the clinical leader role by managers. Clinical leaders at THC are in the process of
redefining their role and developing competencies to support their role within the organization.
Consequently, I expanded the survey question to ask participants if they spent time in their
current role developing leadership ability through the coaching and mentoring of frontline staff.
Data from this question are shown in Table 3.

Table 3. Survey Responses to Statement, "In My Current Role I Spend Time Developing
Leadership Ability in Frontline Staff by Mentoring and Coaching in the Current Unit
Environment."
Response option Mentor Co
Almost never 0.0% 0
Rarely 5.4% 3
Occasionally 10.7% 6
Fairly often 32.1% 18
Almost always 25.0% 14
Skipped this question 26.8% 15
In the free text portion of the survey, participants noted the greatest challenge in their
role. One participant wrote,
Covering a wide variety of areas creates a long, diverse collection of opportunities.

Balancing staff learning needs, patient needs, management and strategic needs, and
program development shifts the attention to and away from patient-centered care, and
requires different working styles, not just mentoring or clinical practice and patient-
centered care. That being said, the clinical staff I work with do a very good job at
providing patient-centered care.
Another survey participant wrote,
Trying to engage staff to see the patient is the focus. In speaking to staff [members], they
say they see the patient is the focus, but day to day that isn't always evident in their
practice. This is frustrating. If you try to speak to some staff [members] about their
behaviour, it isn't well received or [it's] seen as a way to create professionalism or a
better environment to work in.
Another survey participant indicated,
As the role is different in most units, the staff levels of what to expect are different,
which can make it challenging to be consistent. To me, patient care tasks take precedence
over all other clinical leader tasks. Therefore, quite often these things [clinical leader
tasks] are left undone. A designated space and time would be helpful to complete other
jobs. Regular meetings with staff to discuss patient-centered care philosophy and how to
successfully achieve it within the current environment would be helpful.
Similarly, one survey participant commented, "Managers and clinical leaders can have a
very profound influence on a unit (either positive or negative). It is something that can be a
consistent day-to-day challenge."
Coaching and mentoring are required skill sets for managers, clinical educators, and
clinical leaders to build leadership capacity. I will further expand this finding in my
recommendations.
Finding 5: A Cultural Change in Mindset Is Necessary to Sustain Patient-Centered Care
A year ago, THC introduced professionals and employees to the patient-centered
initiative, with the goal of transforming the patient and family experience and creating the ideal
patient experience. The organization realized early in its quest that the implementation of this
initiative would require a cultural change and shift in mindset for staff. To date, 1,500 of the
organization's more than 4,000 clinical and nonclinical employees have been involved in focus
groups designed to develop a greater understanding of what patient-centered care is and to
develop a critical mass of champions who embrace the initiative. Surprisingly, 70% of the focus
group participants involved in this research had not participated in the earlier focus groups.
The journey to transform the patient and family experience at THC from a provider-
driven model to a patient-centric model is a complex undertaking. Through conversations with
participants in the interviews and focus groups, I saw that most understood the concepts but
struggled to overcome old models of learning and behaviour. In the interviews with managers,
one said, "I struggle with this ideal patient experience. We need to have our ducks in a row to
roll it out. We need a lead on each unit, education, and follow-up to address issues. [We need] a
learning contract" (I). Another also described the struggle:
I feel disenabled to roll out the ideal patient experience initiative. We don't have this in
place. There is a lead for this in the organization but we need leads for the unit. Every day
we are dealing with the pressures of... discharges, the backlog in the Emergency
[Department], trying to provide quality care. The staff feels setting the goal on a
whiteboard is fluff. They feel they are listening to the patient. We need education and
follow-up to address the issues; we don't have the time or skill to go there. They see the
manager as heavy-handed when I ask why the patient's goal isn't on the whiteboard. I
feel my role is supporting them to deal with the pressures and stress every day. (I)
Similarly, one participant in the interview noted, "If the clinical leader gets the change,
you're a step up. The clinical leader must embody and understand the change. This is not always
the case." The dialogue with interview participants consistently showed that they wanted the
people consultants in the organization to support them and the teams in focused dialogue and
further education on the patient-centered initiative. The perception is that the organization at the
macro level has a vision of how patient-centered care should be integrated. However, there
appears to be a disconnect at the microsystem level of how to integrate, support, and sustain the
initiative in the current environment.
Finding 6: Manager Role Redesign Is Imperative to Build Leadership Capacity
THC is responding to a time study done by managers in an effort to support managers to
declutter their role and find time to build on their passion at work. The organization's vision is
contained in the title of the document: "Building Capacity Within Our Leaders" (THC, 2007).
The principles of this manager role redesign are that managers steward THC values, develop
distributed leadership, are a conduit and contributor to strategy development, ensure
accountability back to the patient and community, create sustainable systems through
microsystem development, are accountable for organizational outcomes, and optimize outcomes
of available resources, but they are not the doers of all. In the interviews, participants indicated
that currently, barriers such as time and a lack of adequate supports prevent managers with large
spans of influence from fulfilling the day-to day operations of their roles.
I asked the 6 participants in the interviews what they needed to close the gap and to
evolve their role to achieve the ideal unit environment that provides patient-centered care. They
identified the following gaps for a preferred future: (a) time to support attendance management,
(b) Risk Pro (incident reporting and investigation), (c) patient and family complaints, (d)
performance, (e) protocol development, (f) PACE (yearly performance reviews), and (g) regional
commitments. All participants felt that there was an opportunity for role clarity and
accountability for roles such as clinical leader and consultant, who support managers on a day-
to-day basis. Others expressed wanting to further develop opportunities for collaboration and
integration with consultants supporting the manager in providing professional development days
to staff on topics such as giving feedback, coaching and mentoring, and leadership. This included
colleagues from organizational development. Four of the 6 participants suggested that all roles
needed a formal redesign to integrate, support, and sustain the patient-centered initiative within
the organization.
Conclusions
The literature review, interviews, focus group discussions, and survey responses have
provided me with an opportunity to engage others in inquiry. The research has provided me with
a wealth of data to assimilate and integrate into my learning, while creating an opportunity for
change. I have reached five conclusions:
1. Professionals and employees are committed but need further education;
2. Communication and teamwork are vital;

3. There is a desire for standards of behaviour and accountability;
4. Managers want the clinical leader role developed; and
5. Health system managers can build leadership capacity.
Conclusion 1: Professionals and Employees Are Committed but Need Further Education
According to Fullan (2001), moral purpose and change agentry are two key forces that
bring either order or chaos to complex change. Hence, the culture of an organization is incredibly
important because it can forcefully influence human behaviour. If changes aren't securely
anchored in a workplace culture, they can become undone. As Fullan notes, culture is
increasingly recognized as an important variable in the success or failure of change initiatives.
Similarly, Senge (2006) notes that a core competency of an organization is its ability to accept,
lead, and manage change.
Professionals and employees at THC have begun to identify with the important
dimensions of patient-centered care and understand how incorporating daily goal setting with
patients can improve the quality outcomes of their care. However, efforts from teams to adopt
these changes into their everyday practice have been challenging and there are opportunities for
improvement.
Professionals in the interview, focus groups, and survey stated that they took pride in
providing high-quality care. Others, however, recognized limitations: "We are typically focused
on task and do not always incorporate patients and families as central members of the team in
making contributions to their care on a consistent basis" (FG). Similarly, all professionals in the
group made comments such as, "[There is] willingness. Constraints such as limited time and
increased workload are barriers to engaging] patients and families as a routine practice in daily
goal setting" (S). The Institute of Medicine (2004) notes that patients who are involved in their
care decisions and management have better outcomes than those who are not.
Not unlike the mangers interviewed and survey participants, THC employees who
provide support services said, "My role is pivotal in enhancing the overall experience of the
patient and family and we are willing to support all teams in contributing to the organization's
initiative by providing high-quality care" (FG). Similarly, the Advisory Board Company (2007)
remarks that employees trained and coached in patient-centered care are dedicated to the
provision of care.
THC's culture is deeply rooted in the organization's history and experience. Working to
modify it at the front line to integrate patient-centered care into teams of professionals and
employees requires an investment of time and resources. According to Fullan (2001),
Leading in a culture of change means creating a culture (not just a structure) of change. It
does mean adopting innovations, one after another; it does not mean producing the
capacity to seek, critically assess, and selectively incorporate new ideas and practices—
all the time, inside the organization as well as outside it. (p. 44)
As suggested by Fullan (2001), supporting innovative, diverse change agents in teams
within a learning organization such as THC is beneficial to the microsystem: "Investing only in
like-minded innovators is not necessarily a good thing. They become more like-minded and more
unlike the rest of the organization while missing valuable clues about the future" (p. 75). Those
who challenge the process can help to identify conflict as a source of energy and provide teams
with encouragement. Without such support, teams may not be able to observe their current
reality and see logic in things they normally take for granted. As THC continues on the patient-
centered journey, there is an opportunity to further educate and engage staff with innovative
approaches to engage patients in shared decision making in their care.

Kotter (1996) states, "Vision refers to a picture of the future with some implicit or explicit
commentary on why people should strive to create that future" (p. 68). He further describes how
change efforts take employee empowerment to build a guiding coalition. It is important that the
guiding coalition develops a common goal that is "sensible to the head [and] appealing to the
heart" (Kotter, 1996, p. 66). By aligning systems with the organization's vision, the change
process can be a more efficient and less timely process. Professionals and team are committed
and ready to embrace patient-centered care.
Conclusion 2: Communication and Teamwork Are Vital
McGilton et al. (2004) suggest that team interaction, collaboration, communication, and
coordination have an important effect on the quality of nurses' work lives and, more important,
affect the quality of care and outcomes for patients. Communication must be transparent, timely,
and complete. It must be present at all levels of the organization so that information is shared
from top to bottom and from bottom to top. According to Farquhar and Longair (1996), without
effective communication, no organization can survive.
Two themes that were present in the interviews, focus groups, and survey were
communication and teamwork. One participant noted, "[An] environment that supports building
and promoting collaborative relationships and teamwork, empowerment, opportunities for
autonomy, and personal and professional growth enables interactions between health care
professionals, patients, and families" (S). Another wrote,
Creating synergy amongst professionals and employees is essential to teamwork.

Effective problem solving, collaborative decision making, and valuing individual
differences builds on divergent strengths. Leveraging creative collaboration, while
embracing teamwork, will exceed the sum of what each member could achieve on his or
her own. The whole is greater than the sum of its parts. (S)
Similarly, Haddock, Walker, and Daniels (2005) note, "Teamwork is seen as an essential
prerequisite for delivering efficient and effective services by all professional groups" (p. 87).
Heifetz and Laurie (1997) believe that shifting to collaborative practices requires leadership
support that is empowering and encouraging of people to take initiative in defining and solving
problems.
While there is a long tradition of researching teams and teamwork in health care, finding
methods to assess teams and effectively intervening to improve them within the microsystem and
organization will be ever more important because of the complexity of patient care provided
today and the looming challenges to recruitment and retention of professionals. The Health
Council of Canada (2005) broadly illustrates the significance of improving teamwork to both
accelerating system change and to achieving improved quality and productivity for patients. It
goes further to note that teamwork can achieve improved efficiency and a balanced, productive
workforce that is better able to serve the needs of patients.
Collaboration between professionals is the core of teamwork. Teamwork as a means of
serving the patient implies a need for multiprofessional teams sharing responsibility. In addition,
structures and a culture valuing collaborative practice through organizational learning must be
adopted, particularly through continuing education. Appropriate education and learning
opportunities are critical to bridging the gap.
Empirical research on healthy work environments and magnet hospital environments
(McClure & Hinshaw, 2002; Studer, 2003) tells us that effective communication, collaboration,
and teamwork are ways to produce highly effective teams in the workplace. In reviewing the data
collected, evidence of interprofessional coordination and effective teamwork were consistent
themes. There is a cultural readiness within THC for professionals in the microsystems to work
together to create, share, and use best practice literature on how teams can evolve to work closely
in collaborative communities of practice.
Baker (2003) discusses the reciprocal nature of building collaborative relationships to
generate social capital where benefits to organizations include innovation, internal and external
strategic alliances, and organizational learning. These are all important components to enhancing
patient safety. From an organizational perspective, THC is ready to develop collaborative
practice models within systems and across the organization.
Conclusion 3: There Is a Desire for Standards of Behaviour and Accountability
Participants in the interviews, focus groups, and survey expressed the need for managers
and senior leadership to not only share the vision of patient-centered care, but to be deliberate in
sharing acceptable behaviours and to have accountability for professionals and employees that is
aligned with the vision and with frontline teams and units.
The participants voiced a need for "managers and senior leadership to establish and hold
everyone accountable with consequences for unacceptable behaviour" (FG). They articulated "a
need for leaders to discuss accountabilities and consequences before the roll out of new
initiatives and to engage professionals in taking accountability for their professional practice"
(FG).
One survey participant wrote,
[There is an] opportunity for health system managers and clinical leaders in the
organization supported by senior leadership to (a) tie the organization's vision into the
daily tasks with professionals and employees through daily conversations; (b) set clarity
and accountability on what needs to be done and why and include what is in it for the
team, patient, and family; (c) stress the team's commitment to the organization's vision in
transforming the health care experience; and (d) set tangible goals with clear expectations
and guidelines, which the team can achieve, and hold each other accountable to work
together effectively.
Farquhar and Longair (1996) describe how when authority is delegated, the responsibility
is always accompanied by accountability: "This act of empowerment provides the opportunity
that when coupled with capability and accountability contributes to individual, team and/or
organizational high performance" (p. 3). When staff members recognize that they are able to
influence the outcomes or ends, they are more willing to be accountable. Empowerment becomes
the enabler and the manager's role becomes the conduit that provides the tools and resources for
staff members to actualize their potential.
THC has just rolled out standards of behaviour, with accountability to the leadership team
for professionals, employees, and patients. The standards of behaviour communicate and clarify
the expectations with clear accountability of the organization's preferred future. These standards
will be the foundation for dialogue amongst teams.
As THC transforms the health care experience of patients and families, it provides its
employees with the tools they need to adapt to complex and difficult situations. Covey (1999)
explains that to effect change in behaviour management, people must model the change they
want to see:
If you focus on principles, you empower everyone who understands those principles to
act without constant monitoring, evaluating, correcting, or controlling. Principles have
universal application, and when these are internalized into habits, they empower people
to create a wide variety of practices to deal with different situations, (p. 98)
Teams are looking for opportunities to learn and improve. As teams live with principles
around the standards of behaviour, this behaviour will crystallize and become embedded and
intertwined into THC's culture. THC will be successful in this transformation by shifting the
organization's culture toward behaviour and thinking that reflects leadership, personal
responsibility, and accountability.

Conclusion 4: Managers Want the Clinical Leader Role Developed
Research has found that the span of influence of health system managers has an impact
on staff and patient outcomes (Cathcart et al., 2004; Doran et al., 2004). The literature identified
that factors such as similarity and complexity of the workers' functions, unit unpredictability,
and number of staff providing support to the unit need to be examined and taken into
consideration when determining span of influence.
The participants interviewed were asked what was needed in their current role to assist
them with large spans of influence. The participants identified a need for "the clinical leader role
to be formalized and redesigned with a set of clear competencies, accountability, and
responsibility to support the manager with large spans of influence" (I). Similarly, survey
participants were asked if the manager's span of influence impacted their role. One participant
explained what was needed to assist in the leadership role: "[A] clearer definition of my role
[and] I would like to see role clarity for the clinical leader role within the organization" (S).
Virtually all participants interviewed talked about the challenge they faced every day in
the nature of their work with their span of influence. They noted, "[I am] challenged to find
enough time in the day to manage the myriad responsibilities" and "It is very difficult, if not
impossible, to consistently provide positive leadership to a large staff, while at the same time
ensuring the effective and efficient operation of multiple or large units on a daily basis."
Similarly, a survey participant composed a list of challenges: "Leadership support, structures,
and process, . . . not having clear goals or practice expectations to guide practice, [and a] lack of
leadership to establish standardized processes for key functions on units."
The American Association of Colleges of Nursing (2007) describes the clinical nurse
leader (CNL):
The CNL functions within a microsystem and assumes accountability for healthcare
outcomes for a specific group of clients within a unit or setting through the assimilation
and application of research-based information to design, implement, and evaluate client
plans of care. The CNL is a provider and a manager of care at the point of care to
individuals and cohorts. The CNL designs, implements, and evaluates client care by
coordinating, delegating and supervising the care provided by the health care team,
including licensed nurses, technicians, and other health professionals. (Educating the
Clinical Nurse Leader section, f 2)
Participants interviewed and surveyed identified the need for a formalized job description
of the clinical leader with role clarity and competencies to support the organization. Covey
(2004) notes that "leadership occurs when one or more persons engage others in such a way that
leaders and followers raise one another to a higher level of motivation and morality" (p. 362).
McClure and Hinshaw (2002) describe how magnet hospitals communicate the clinical
leader role as essential to transformational leadership practices. Atkinson and Butcher (2003) and
the RNAO (2006b) assert that incorporating transformational leadership practices creates an
empowered work environment, builds trusting relationships, supports knowledge development
and transfer, and leads change, while creating an ability to balance competing priorities and
demands. The opportunity to develop a competency model is a natural extension of the
leadership competency guide for managers and positions THC as an agile organization. The
literature encourages employers to consider a reasonable, manageable span of control for nurse
managers, which will allow them to complete assigned functions and be present to meet nurses'
and patients' needs.
Conclusion 5: Health System Managers Can Build Leadership Capacity
The literature suggests that it is critical to take time to train and mentor your direct
reports to develop leadership capacity and to engage others to be better performers. Career
development, learning, and succession planning keep skills and motivation high in the team. The
ultimate goal of leaders is to enhance followers' strengths and develop plans to enhance their
opportunities for improvement.
In past studies (Cathcart et al., 2004; Doran et al., 2004), health system managers who
were directly responsible for maintaining standards of care and developing staff noted that they
were less able to provide nurses with the traditional mentoring, coaching, and individual support
and encouragement. In this research, the managers interviewed made comments like, "I get
caught up with urgent crises of the day and do little mentoring of employees."
According to Kouzes and Posner (2002), strategies that are supportive of transformational
leadership are challenging the process, inspiring a shared vision, enabling others to act, modeling
the way, and encouraging the heart. Similarly, Baker (2003) notes that "as a leader, you can also
unleash the power of reciprocity in your organization through experiential training and by
helping your employees create new routines in their everyday lives" (p. 15).
In the interviews, managers noted the importance of being able to delegate some
leadership activities to the clinical leader role and share information from an organizational
system perspective. Reciprocity is the key when the manager delegates or requires the team to
assist in initiatives in the unit. Professionals and employees look to managers and clinical leaders
to be knowledgeable and experienced in the day-to-day activities of the unit, patients, and
families. Having this requisite knowledge requires that managers spend time on the unit
interacting with the team.
Porter-O'Grady and Malloch (2003) suggest,
Leadership is not so much who you are as what you do with who you are. Leadership is
not a state of being. It is instead a set of internal tools possessed by a person with the
energy and skill to use them well. Much of the work in this new century will consist of
transferring new skills to people who live and work in organizations.... Leadership
requires a level of self-knowledge and vulnerability that makes the growth experience
visible to others, (p. 260)
Health system managers wear many hats on the team; key roles include coach, model,
initiator, facilitator, and negotiator. Leaders take risks that are consistent with their values, while
acting as a change leader who stretches and encourages others in spite of their own doubts and
fears.
Baker (2003) notes, "If, however, you give freely, and out of a genuine desire to help
others—without an expectation of getting something in return—then the reciprocity generated
will be far beyond what you could ever imagine" (p. 13). Building collaborative relationships,
coaching, mentoring, and developing trust within the team are the foundation on which strong
relationships are built. Managers at THC are ready to adapt their mental models of the manager
role in the current environment. They are ready to reconceptualize their role to build leadership
capacity.
Scope and Limitations of the Research
The research was insightful and gleaned an overwhelming amount of data. Feedback
from the focus groups was extremely positive and participants in the interviews were passionate
about their role. Research and information from the interviews, focus groups, and survey
triangulated with other research conducted in the organization. However, there are five factors
that may restrict or limit the application of the research findings and conclusions.
1. This research project was confined to one site: THC, a large community hospital.
Consequently, the research findings may not generalize well to other smaller acute care
settings or larger academic research centres.

2. The scope of the study needed to be contained due to the limited amount of time to
conduct the research. Hence, I only conducted focus groups with participants of the pilot
unit. Focus groups with multiple units, including critical care, emergency, and the
operating room departments, may have garnered different data.
3. I had a limited number of interviews, and they are considered a small sample. I only
interviewed clinical nurse managers in acute care. I would have liked to have had more
time to include nonclinical managers in the one-on-one interview process and to seek out
their perspectives.
4. The level of participation may have limited the study. I circulated 101 anonymous
surveys to clinical leaders and clinical educators and received a response rate of 55%.
This represents a good-quality response rate; however, there were still 45% who did not
participate. Nevertheless, I am confident that the sample accurately represented the
individuals at THC. Also, because the survey was anonymous, I did not ask the
participants to identify their gender. I caution against generalizing the results, even
though the percentage of men in the targeted roles at THC is less than 2%. These results
by gender may not be aligned with other organizations.
5. Finally, another potential limitation to this study is the timeframe. Conducting this study
a few months later with the same participants would determine if the behaviours or views
of the groups have changed since the initial conversations in the focus groups.
In summary, despite the above limitations, this thesis offers tangible constructive
opportunities for any organization conducting research on how health system managers can
evolve their role to foster the ideal unit environment. The recommendations in chapter 5 will
address and support the redesign of the health systems manager role to enable and sustain the
ideal unit environment, build leadership capacity, and develop a model of care and communities
of practice for professionals and employees.
Conclusion
Anderson and Ackerman Anderson (2001) note that complexities in today's
global business environment demand change towards greater awareness in order to

transform organizations to meet the human, marketplace, and environmental needs of the
times. Collectively, leaders and consultants must continually make decisions that balance
the needs of people, the organization, and society at large. Leaders must create business
strategies that add to their organizations' future viability and the well-being of people and
communities, (p. 203)
The role of the health system manager is integral to the success of the microsystem and
organization in building leadership capacities to support THC as it transforms the experiences of
patients, families, staff, and the community it serves. These findings provide the foundation for
the meaningful dialogue that will assist leaders at THC. Our challenge to transform the health
care experience does not stop here; we have only just begun the journey.
CHAPTER 5: RESEARCH IMPLICATIONS
In this chapter, I propose study recommendations that address my research question,
"What can the health system manager do to contribute to the creation of the ideal unit
environment for professional teams and employees who are dedicated to providing patient-
centered care?" I will present my recommendations and discuss organizational opportunities. As
well, I will discuss the implications for future research in this chapter.
Study Recommendations
There are several action steps that can be taken as a result of the organizational research
that has occurred at THC. This research seeks to ensure that staff members have the tools they
need to deliver timely, appropriate health care to patients. It is important to provide a healthy
workplace environment, where safety is the main concern, as well as an optimum work
environment, to sustain the capacity to meet patient needs. Sustaining the patient-centered care
initiative and shift in the culture will require a commitment to education and learning, while
engaging professionals and employees to work and think outside of the existing culture of
provider-centered care. The new culture will be one that wraps its arms around the patient and
family and places them at the centre of care.
Within THC, the foundation is set; full of positive enthusiasm, energy, and anticipation to
strategically implement the following recommendations and action steps. Investing in the talent
and ongoing work of staff with role clarity, education, training, and role modelling is critical.
Each professional and employee needs to understand his or her role, responsibility, and
accountability. If we fail to act in a timely fashion and to further engage teams in the patient-
centered initiative, we will lose the opportunities to build on THC's model of distributed
leadership capacity. We will be vulnerable in our ability to innovate, engage, and enable a
culture of learning.
I believe this action research study will build on the existing strengths and ongoing work
within the organization. The recommendations will provide constructive ripples through the
microsystem and organization. I propose the following six recommendations, each of which I
will discuss in depth:
1. Redesigning the manager role will provide clarity;
2. Restructure the clinical leader role to provide leadership supports;
3. Develop a model of care;
4. Develop communities of practice to support the model of care;
5. Implement the organization's standards of behaviour; and
6. Transition retired nurses to mentor and coach the units.
Recommendation I: Redesigning the Manager Role Will Provide Clarity
Results of a time study conducted at THC indicate that the role of manager needs to be
redefined. For the health system manager to foster an ideal unit environment role and to build
leadership capacity, redesign is essential. The ultimate goal of this redesign is to support
managers in decluttering their roles so that they can support the development of a high-
performance microsystem that ensures the delivery of excellent and safe care for patients and
families and a healthy workplace for staff, physicians, and volunteers. Functional competencies
that support the manager role include but are not limited to systems thinking, impact and
influence on others, business acumen, risk taking and innovation, self-awareness, and
development of others. Hence, role redesign for managers aims to develop managers' leadership
capacity and passion while enabling them to build leadership capacity in others. In order to foster
increased job satisfaction, managers must determine what professionals and employees desire
from their work. Although this varies from person to person, a significant number of participants
said they were satisfied because of the nature of the work.
A manager who was involved in this redesign noted, "The role redesign initiative
improves outcomes by increasing the meaningfulness of work whilst encouraging employees to
experience responsibility for outcomes and to have active knowledge of the results of work
activities" (N. Woloshyn, personal communication, July 5, 2007). In a healthy work
environment, it is important to foster open discussion about such matters. When this type of an
environment exists, employees know that they are valued for who they are.
Having teams vision in focus groups is a powerful process that assists in creating a
picture of an ideal future. Many authors (Kotter, 1996; Kouzes & Posner, 2002; Schein, 2004)
describe a vision as a dream, personally created, of how we would like our world to be. In
sharing our visions, we find common ground and a sense of connection.
Today, in an unprecedented way, health system managers are expected to exhibit
leadership in setting direction for nursing practice. Assisting professional teams and employees
to create and share their vision of the future is a mark of transformational leadership. It is an act
of empowerment and an expression of caring. There is consensus and agreement amongst
managers at THC that role redesign is best accomplished by unleashing the potential of
employees through team-based efforts. The reality of changing the work at the bedside means
asking professionals and employees at the point of service to participate in shaping the future of
their ideal unit environment.
What role do managers play? Booth and Farquhar (2003) note, "Middle managers are
essential to the success of organizations. They provide a vital connection between senior
management and the front line, between an organization's strategy and its implementation; and
they provide linkages horizontally, across the organization and its functions" (p. i).
Manager role redesign at THC aims to declutter the manager role while improving
service and quality and enabling the manager to find time to pursue passions related to the
creation of the ideal patient experience. It was and is time to begin the process of transforming
the existing health system manager role into a role that supports and facilitates the
implementation of a new model of care. Current managers voiced a demand for change and
highlighted the need to reshape the nurse manager role.
Analysis of the interviews, focus groups, and survey data generated four key themes to
improve the delivery of patient-centered care and the ideal unit environment. They include (a)
visibility of manager to coach and mentor, (b) communicating and holding teams accountable to
standards of behaviour, (c) shared decision making within the interdisciplinary team, and (d)
skilled consultation and resources to assist the managers to build leadership capacity.
The role redesign would allow managers to leverage their time and identify opportunities
to increase the breadth and depth of their passion. I recommend that health system managers all
participate in the role redesign initiative. Once capacity is realized, it is imperative that managers
connect with their professionals and employees within the microsystem to openly share
opportunities that can shape their environment and create the ideal unit environment. This is the
first step for managers to foster the creation of the ideal unit environment. Managers should do
this with four goals in mind:
1. Coach, mentor, and motivate professionals and employees;
2. Facilitate change and challenge the status quo;
3. Champion the patient-centered care initiative; and

4. Envision the future.
Rising demand for a coordinated effort by health care professionals and employees is
driving the current health care model in a rapidly evolving environment. According to Doran et
al. (2004) and the RNAO (2006b), the role of the health system manager is pivotal to the
development of interpersonal relationships at all levels and supports standards of evidence-based
best practices in the provision of quality patient care. This role sets the stage as a key decision
maker who drives professional development and standards of best practice and links performance
improvement strategies and outcome measurement within the organization.
I also suggest that acting in a timely manner in implementing this role redesign is critical
to providing a healthy workplace, one where safety is a priority and leadership is optimized to
support teams to meet the needs of patients and families within the work environment. Today, in
an unprecedented way, health system managers at all levels are expected to exhibit leadership in
setting direction for nursing practice. Assisting nurses to create and share their vision of the
future is a mark of transformational leadership. It is an act of empowerment and an expression of
caring.
Recommendation 2: Restructure the Clinical Leader Role to Provide Leadership Supports
The role of the clinical leader at THC is another key role within the microsystem that
supports health system managers and is pivotal in providing patient-centered care and
transforming the working environment. The relationship between the roles of the manager and
clinical leader is an area of opportunity. Currently the role of the clinical leader is neither clearly
articulated nor enabled across the organization. Managers want to support the ideal patient
experience and influence care and patient safety through coaching and mentoring professionals
and employees. However, managers at THC explained that with large spans of influence, this is
not feasible unless capacity is built through a formalized role redesign of the clinical leader.
Being patient centered may seem easy to understand, but it is a difficult concept to operationalize
for frontline teams.
Senge et al. (1994) note that a shared vision is vital for the learning organization as it
provides a focus and energy for learning. A redesigned clinical leader role has been created and
implemented in the birthing suite and obstetrics units in the Women's and Children's Health
system under the leadership of the health system manager. In an action research cycle, this model
has been formally operationalized with outstanding results through feedback and an evaluation
from the unit clinical leaders, staff, and manager. When interviewed, this manager clearly
articulated, "I have a whole new life; implementing this redesigned role has improved patient
safety, staff satisfaction, and decreased sick time, and built leadership capacity for me to follow
my passion" (K. Moore, personal communication, July 5, 2007).
In my findings to date, the birthing suite and obstetric units have lived with posting and
interviewing applicants for the newly designed role with human resources, have articulated the
expected competencies and supported them with a two-day education workshop, and have been
successful with the role redesign for 6 months. As an organization, THC does not need to
reinvent the process.
As discussed in chapters 3 and 4, Doran et al. (2004) found that span of influence has a
negative impact on health systems managers' ability to mentor and coach. Thus, "there is a need
for further research to develop guidelines regarding the number of staff a nurse manager can
effectively supervise and lead" (Doran et al., 2004, p. iv). I recommend that THC redesign the
clinical leader role and align the clinical leader role competencies on the pilot unit to support the
existing manager competencies with role expectations and accountabilities for all clinical leaders
across the organization.
Nurturing this role redesign requires adopting best practices and a commitment to
education and learning and engaging employees in a different way of thinking. THC's existing
culture embraces change and will be a significant factor in making the transition. I recommend
the organization repost all clinical leader positions with a role description and required
competencies so that all individuals in the organization who are dedicated to enabling the
patient-centered initiative and developing advanced leadership are given the opportunity to
apply-
There is an opportunity for all teams to meet and validate the clinical leader role
competencies, while discussing how the existing work processes can be tailored to meet each
health system. THC is an innovative learning organization, committed to best practice. As Moore
(2007) explains, it has access to a model created, developed, and aligned with the mission and
vision of the six strategic initiatives within the organization. To date, the metrics that have
reaped positive results from this redesign include decreased sick time and overtime and
improved staff satisfaction.
The clinical leader group is waiting with bated breath for clarity in its role, responsibility,
and accountability. The time to act is now. Failure to act in a timely manner will result in a loss
of credibility for the health system managers and the senior team.
Recommendation 3: Develop a Model of Care
One of the major issues facing health care institutions today is how best to care for the
growing population amid new environments and the multiple roles of health care professionals.
Health system reform demands new approaches to patient care that enable the effective use of
limited resources while optimizing the patient's health and well-being. Governments, health
system administrators, clinicians, and academics are increasingly interested in team-based
interdisciplinary care, which has been shown to improve patient outcomes, reduce readmissions
to acute care, and lower costs to the health care system (Health Canada, 2004).
Each health care discipline brings to the organization its unique professional knowledge
base. Within the current unit environment, each discipline typically works with its own cultural
norms, values, and attitudes. Thus, the environment enables the team to work together but
separately. Health Canada (2004) suggests patients are better served when health professionals
surpass these barriers to work cooperatively. Seamless Care offers a model of interprofessional
education designed to foster the attitudes and skills that promote positive, synergistic
interdisciplinary care. Bushe (2001) suggests that "organizational learning takes place when two
or more people inquire into their experience and generate new knowledge that leads to a change
in their pattern of organizing" (p. 184).
I recommend that THC conduct interviews with all professionals and employees to
further identify the roles and responsibilities of key staff required to provide the best care for
patients. In the current environment, health system managers are working with financial and
people consultants to standardize the key elements of the health care process and to ensure that
patients flow smoothly through the system and receive appropriate care at each stage, while
providing continuous feedback to their teams on the quality of outcomes as well as the cost of
delivery.
Second, I recommend that professionals and employees of each microsystem work
collaboratively with the performance excellence consultants to develop work flow maps using
different types of patient examples to observe how patients flow across systems. We need to
engage the physicians to better understand their role in communicating the treatment plans to
members of the interdisciplinary team, patients, and families. Each specialty unit needs to
develop clinical pathways to support patients who are transferred to other units.
The model of care must incorporate evidence-based best practice while maintaining a
lens of safety for patients and staff. Teams will need to a) integrate the unit philosophy of care,
b) identify appropriate staff-patient ratios, c) assess the required staff specialty and skill mix, d)
consider the design of the physical environment, e) look at methods of communication, and f)
address any other project, role, or resource needs as required.
From an efficiency perspective, the role of unregulated health care professionals in
supporting nonnursing tasks is a serious concern. The organization should consider further
analysis and research into the integration of unregulated health care professionals.
Recommendation 4: Develop Communities of Practice to Support the Model of Care
As outlined by Kotter (2001), "Each system of action involves deciding what needs to be
done, creating networks of people and relationships that can accomplish an agenda, and then
trying to ensure that those people actually do the job" (p. 86).
Linden (2003) defines collaborative leadership:
Collaborative leadership is the art of pulling people together from different units or
organizations to accomplish a task that none of them could accomplish—at all or as
well—individually. By definition, collaborative leaders have no formal authority over
their peers. They must use persuasion, technical competence, relationship skills, and
political smarts to get and keep the coalition together and produce the desired goal. (p.
42)
Doran et al. (2004) and the RNAO (2006b) explain that to develop a successful team of
professionals and employees, managers need to foster a work environment that enables teams to
work in synergy and that is dynamic and ready to change and reorient its core competences in
order to deal with new environmental challenges. An innovative learning organization such as
THC, with superior knowledge-based resources, has the capacity to support this endeavour.
One interview participant noted, "As professionals, we tend to work in silos to provide
care." Another participant commented in a focus group, "We have bullet rounds but it is focused
on discharge planning." THC will be creating and adding new and existing units to a new
building and wing with a state-of-the-art design. It is critical that all interdisciplinary teams and
employees who provide care or support teams conduct their care work collaboratively. Wenger,
McDermott, and Snyder (2002) describe the concept of communities of practice as "groups
of people who share a concern, a set of problems, or a passion about a topic, and who
deepen their knowledge and expertise in this area by interacting on an ongoing basis" (p. 4).
The ultimate goal of developing communities of practice is to engage professionals to develop
innovative ways of collaborating and communicating.
As THC plans to develop a model of care, health system managers and teams will need to
use Austin's (2000) seven C's of strategic collaboration: (a) connection with purpose and people,
(b) clarity of purpose, (c) congruency of mission, (d) creation of value, (e) communication
between partners, (f) continual learning, and (g) commitment to the partnership. I believe that the
leader's role is to "create the conditions that foster openness and release energy" (Mintzberg,
1999, p. 28).
I recommend that THC provide education, supported by the People Support SBU, to
engage, educate, and support teams as they trial new ways of working and interacting with a new
model of care. Ultimately, the goal is to create a learning environment where ongoing interaction
between different professional disciplines creates new and innovative ways to provide care that
combine operational effectiveness and strategic flexibility while maintaining the best possible
experience for patients and families. As Austin (2000) suggests, "Effective collaboration
ultimately involves jointly tailoring a garment that fits the unique characteristics and needs of the
partners" (p. 173).
Recommendation 5: Implement the Organization's Standard of Behaviour
THC believes that caring and compassionate behaviours are at the core of its commitment
to the ideal patient experience. Its customers include, but are not limited to, patients and their
families, physicians, coworkers, visitors, and volunteers. Recently, standards of behaviour have
been developed to reflect THC's commitment to service excellence. These standards provide
useful guidelines for treating customers in a considerate and respectful manner. By making an
official commitment to practice these standards, THC will reinforce and acknowledge that they
are the expected behaviours of the organization and will encourage employees to practice them
diligently. The organization's daily commitment to these standards of behaviour will ensure a
healing, safe environment.
Kosnik and Espinosa (2003) articulate the important role of the microsystem:
The microsystem, as an agent of change, plays a critical and essential role in developing
and deploying the macro system's strategic plan.... To effectively deploy a strategic
plan, the organization must align the plan's goals and objectives across all levels and to
all functioning units, (p. 452)
Now that the standards of behaviour have been developed, THC needs a strategic plan to
engage the microsystems within the organization and to engage professionals and employees to
build on this work as it relates to the patient-centered initiative. From previous experience, I
know that as initiatives roll out to the system, the message can become diluted as it is interpreted
by each unit. The roll out of the standards of behaviour will require a system lens to adapt to the
individual culture and mindset of each health system and unit. Anderson and Ackerman
Anderson (2001) note,
Collective behaviour creates and expresses an organization's culture. Behaviour speaks to

more than just covert actions: It describes the style, tone, or character that permeates what
people do. It speaks to how people's way of being must change to establish a new culture.
Therefore, leader and employee behaviour denotes the ways in which leaders and
employees must behave differently to re-create the organization's culture to implement
and sustain the new organization's design successfully, (p. 18)
Information collected from the focus groups indicates that staff members are requesting
that managers and the senior team hold individuals accountable and responsible. A change in
mindset will be required for professionals and employees to adapt to the organization's new
standard of behaviour, which is aligned with the mission and values.
I propose that the standards of behaviour be rolled out as a foundational piece of work to
support the ideal patient experience. Through strategically linking the standards with the mission
of the organization, clear role and behaviour expectations will be communicated. Meeting with
teams could be used to engage them in understanding the principles of the standards and how
professionals and employees in the microsystem can successfully incorporate the standards into
their current practices. It is important that these standards be integrated into the fabric of the
organization. THC can communicate and incorporate these standards into people's work through
biweekly huddles and staff council meetings. The Institute for Healthcare Improvement (2004)
notes the utility of huddles:
Using quick huddles, as opposed to the standard one-hour meeting, arose from a need to
speed up the work of improvement teams. Huddles enable teams to have frequent but
short briefings so that they can stay informed, review work, make plans, and move ahead
rapidly, (p. 1)
Incorporating multiple feedback loops will allow teams to continually assess and reassess
small models of improvements.

Recommendation 6: Transition Retired Nurses to Mentor and Coach the Units
Effective December 12, 2006, employees in Ontario are no longer required to retire at age
65. This amendment to the Ontario Human Rights Code makes mandatory retirement illegal in
the province. From a health human resource strategy, I recommend that THC engage retired
nurses and assign them to each unit to mentor and coach staff in the further roll out and
engagement of the patient-centered-care initiative. To prosper, O'Brien et al. (2003) suggest that
an organization must address retention strategies to mitigate the impact of the impending
shortages resulting from an aging workforce and early retirement. There is opportunity to work
collaboratively with the People Support SBU to implement creative, innovative opportunities for
experienced, retired nurses.
Currently, the Ministry of Health and Long Term Care is allowing organizations to
submit for funding to engage full-time nurses aged 55 years and older to support units for a
defined period of time. I recommend that THC take it a step further and work with its human
resource partners to support this initiative internally for the population of nurses who would like
to retire, but continue working part-time. This practice would build capacity for full-time
positions for new graduate nurses while engaging experienced nurses as mentors and coaches on
the unit.
Study Recommendations Conclusion
This action research study extends the education of what is needed to create a healthy
work environment, build leadership capacity, and shift the mindset and culture of an organization
through implementing change. The recommendations in this paper are based on the exhaustive
literature review that I conducted and are aligned with change initiatives being implemented
within the organization. The goal is to build on the existing work already in progress within the
organization.
As the pilot unit fully engages the recommendation from a microsystem perspective,
there is an opportunity to integrate the identified approaches throughout the organization with the
support of the senior team and sponsors of this project. Using a systems lens, human capital and
information technology will play a vital role in the success of implementing and integrating the
recommendations into THC's fabric.
In conclusion, this study provides evidence to help clarify exactly how a health system
manager at THC can foster innovative, healthy work environments so that teams of registered
nurses, registered practical nurses, interdisciplinary health professionals, and employees can
provide patient-centered care.
Organizational Implications
THC demands that health system managers have the requisite leadership skills to deliver
services effectively. There is an increasing demand for horizontal leadership with and across the
microsystem. To achieve this, managers at THC need to collaborate to lead change through
effective leadership and motivation of followers to perform to their full potential. In this
environment, a shared vision and values, common goals, and a commitment to excellence are
nurtured.
One of the most important enablers to transform the health care experience at THC is the
manager role redesign project. Outcomes of this role redesign project will ensure that all formal
and informal roles add value to create organizational capacity and support the patient-centered
experience. This study provides tangible opportunities to enhance the unit environment and
retain professionals and employees, while building an infrastructure that supports and explores
the advancement of professional practice. I have designed these recommendations to include
clinical leaders who support managers in ensuring the delivery of safe care to patients and
families in a healthy work environment.
The primary accountability of the health systems manager is to facilitate the creation of
the ideal unit environment. This will be accomplished by role redesign that frees managers to
develop their passion, which includes developing, mentoring, and coaching professionals and
employees. This study is aligned with the organization's purpose and values of excellence,
teamwork, leadership, learning, diversity, and integrity.
This study validates the idea that creating an ideal unit environment requires the full
participation of the team and a comprehensive approach. This study was performed exclusively
at THC. However, the literature correlated with the findings, which mirror data published by the
RNAO (2006b) and nursing leaders in Canada and abroad. Anderson and Anderson Ackerman
(2001) note, "The better the organization is at learning and course correcting—as individuals,
teams, and a whole system—the smaller the adjustments need to be" (p. 43). Sustainability of
change requires that the senior team and organization support professionals and employees in
this shift of cultural transformation.
Three-Step Implementation Process
I propose implementing the recommendations in a three-step process as follows.
Step 1: August 2007-December 2007
Teams must be identified to start working on the model of care. All interdisciplinary roles
need to be reviewed based on patient acuity and the new infrastructure being built. The skill mix
of the registered nurse and registered practical nurse needs to be revisited as the scope of practice
for the registered practical nurse role has changed. The education and training of developing
communities of practice with all interdisciplinary professionals and employees needs to begin to
support the model of care.
Step 2: September 2007-January 2008
Continue the manager redesign to build leadership capacity. Continue to have sessions
facilitated by organizational consultants in the People Support SBU. Provide an opportunity for
sharing lessons learned in monthly manager meetings. I suggest that the manager meetings be
redesigned to support building communities of practice for the managers. This environment
would support the free expression and exchange of diverse views on the successes and
opportunities of implementing role redesign, as well as the sharing of knowledge and risk taking.
It would link disparate parts of the nonclinical and clinical managers' findings that require
support to create further innovation in role redesign, versus the current model where this forum is
used for filtering and disseminating information for frontline staff and teams through the
manager.
The managers can also work with the information technology department to create a
space for managers to tell great stories on how they are redefining their role. Simultaneously, in
order for any capacity to be garnered for health system managers, implementation of the pilot-
redesigned clinical leader role must be rolled out to all clinical managers.
Step 3: September 2007-September 2008
Maintain positive momentum of the manager redesign initiative. With the chief nurse and
human resources, investigate opportunities to develop a mentor role for part-time retired nurses
to support the patient-centered initiative and emerging model of care. Plan an evaluation and
feedback cycle with staff as each change is implemented.

Implications for Future Research
The ideal unit environment is a huge topic, especially as it pertains to the role of the
health system manager, leadership, learning, culture and change, and human performance. While
triangulating the data the following implications were evident. They should be considered and
merit further research.
1. This study was limited to THC and some of the recommendations are specific to the
organization; however, the themes and general concepts could be transferable to other
health care organizations.
2. The time and scope of this project allowed only for a select group of participants. Only
six managers in the organization could relay their personal and experiential views of their
role within the organization. Therefore, there is opportunity to interview a more
representative sample of the organization.
3. Creating a healthy workplace has implications across an organization. Further research in
developing leadership capacity and its impact on organizational culture and environment
is another topic to consider.
4. This research was limited to clinical health system managers. There is an opportunity to
apply this learning to nonclinical managers within the organization.
Conclusion
In conclusion, professionals and employees are collectively committed and passionate
about providing and supporting the ideal patient experience, excellent care, and a healthy unit
environment. The outcome of an engaged, innovative workforce is a quality environment that
supports individual well-being in all aspects of our lives.

CHAPTER 6: LESSONS LEARNED
In all types of organizations, too many are filled with people exhausted, cynical, and
burned-out. I have witnessed the incredible levels of energy and passion that can be
evoked when leaders or colleagues take the time to recall people to the meaning of their
work. It only takes a simple but powerful question: "What called you here? What were
you dreaming you might accomplish when you first came to work here?" This question
always elicits a deep response because so few of us work for trivial purposes. Most
people come to their organizations with a desire to do something meaningful, to
contribute and serve. (Wheatley, 1999, p. 132)
This, chapter concludes my research study. My intent is to provide valuable insight on my
journey of conducting and participating in action research for future researchers. I will describe
the five lessons I learned on this leadership journey: (a) trust the process, (b) enlist critical
friends, (c) choose an engaging supervisor, (d) exercise personal leadership, and (e) envision the
future.
Trust the Process—The Leadership Challenge
When I began this journey, I was skeptical about a phrase frequently used by faculty and
previous learners: "Trust the process" seemed much too easy as I prepared to surrender 2 years
of my life. I was slightly scared and filled with anxious anticipation as I proceeded on this
leadership challenge. At times, the sheer volume of reading, writing, and technology felt
overwhelming, and I found myself just repeating over and over, "Trust the process." I quickly
understood the meaning of these three words intimately. Kouzes and Posner (2002) say:
At the heart of collaboration is trust. It's the central issue in human relationships within
and outside an organization. Without trust you cannot lead. Without trust you cannot get
extraordinary things done. Individuals who are unable to trust others fail to become
leaders, precisely because they can't bear to be dependent on words or works of others,
(p. 244)
The RRU faculty, my 2005 MAL Health Cohort, and my critical friends created a climate
of trust that encouraged vulnerability and resulted in the freedom to trust others and the process.
Enlist Critical Friends—Creating a Supportive Organizational Culture
Within my organization, three individuals who had not yet met each other were
sponsored to RRU. As we embarked on the journey together, we developed a special and tight
bond of friendship as coaches and mentors. As a group, we coached and supported each other as
editors for drafts of each of the chapters and shared our expertise on subject matter related to our
discipline of work within the organization. I thank my critical friends for their support in getting
me back on track if I became unglued with writing. After our online courses, we met on a weekly
basis at a restaurant for support and encouragement, offering feedback and keeping each other
focused with the end in mind. Certainly, I could not have gotten through the program without my
critical friends. Our friendship was a tool that unknowingly furthered and developed our
leadership competencies.
Choose An Engaging Supervisor—A Research Team Approach
My second critical support, in addition to my critical friends, included a research
supervisor who engaged, supported, and encouraged me along the way. My supervisor gave me
excellent feedback on how to theme the multitude of data I collected from the one-on-one
interviews, focus groups, and survey. He suggested to me,
Sit with the data, let it speak to you, then look at the themes and findings. Spread out the
data and highlight the themes with colour markers and relate them back to your research
question. List a total of five to seven themes and findings and then colour code each
theme. Next, go back and colour code quotes and data that match each theme.
This invaluable advice saved me from becoming paralyzed with the data collecting, sorting, and
theming in preparation for writing chapter 4. This process enabled me to pick out the data
relevant to each theme with quotes from the participants.
Exercise Personal Leadership—Self-Awareness, Timing, Resources, and Balance
Through this research project I became more aware of myself as a leader and of my
capabilities. Kahane (2004) notes,
To create new realities, we have to listen reflectively. It is not enough to be able to hear
clearly, the. chorus of other voices; we must also hear the contribution of our own voice. It
is not enough to be able to see others in the picture of what is going on; we must also see
what we ourselves are doing. It is not enough to be observers of the problem situation; we
must also recognize ourselves as actors who influence the outcome, (p. 82)
Throughout this journey I further developed this competency by listening closely to my mind,
body, and surroundings. As I continue this learning journey I will remember to listen deeply.
As for timing, when I started my research, my interviews were right on the heels of the
organization's accreditation process. Managers, professionals, and employees were so exhausted
from completing the work with their teams required for the preparation visit and culmination of
the accreditation process that it was virtually impossible to get full participation of managers in
my research interviews.
As well, I learned several things about resources. The importance of having an editor
cannot be highlighted enough. After living with the data, fresh eyes are needed to provide clarity,
feedback, motivation, and encouragement, and last but not least to fine-tune the APA format.
There is nothing more gratifying or motivating than seeing your work put together as you get to
the finishing line.
Other lessons about resources that emerged during the action research process related to
my initiation with the online SurveyMonkey® tool and the focus groups. I built the survey,
tested and retested it with my critical friend, and sent it out to participants quite unaware that the
server was updating the site and the program I was currently using. Consequently, the first 15
participants were not able to access the survey and incomplete data were collected. Having a
facilitator to do the focus groups was totally rewarding. It allowed me to listen effectively, take
notes, and observe the nonverbal behaviour of participants.
On a personal level, striking a balance between school, work, and family, despite the
advice from former RRU learners, was surreal. I found it difficult to achieve balance that did not
tip further to this project. I started a new role with a large portfolio 3 months after starting my
master's program and the scale always tipped towards ensuring I was supporting multiple teams,
completing readings and essays, and meeting deadlines for assignments for school or initiatives
at work. This meant that many times my family was on the back burner and meeting with friends
became virtually nonexistent. I am grateful to have an understanding and supportive family who
prayed that my project would soon end and our lives would go back to normal.
Envision the Future—The Key to Leadership
I have come to the end of my master's journey and my leadership challenge at RRU.
However, for me it is the beginning of a new chapter in my life. I have the requisite skills and
knowledge to take the lessons and experience of the leadership challenge to a new level. This
journey has helped me to grow both professionally and personally, while developing and
stretching my leadership ability. I am inspired and committed to action. I have increased
confidence in my ability to lead and a comprehensive worldview and systems perspective on
how organizations operate.
Kouzes and Posner (2002) note that "an organizational fitness to compete is dependent
upon the mental fitness of the workforce" (p. xx). I am fortunate to work in an innovative
learning organization that has supported me to further my education with the freedom to grow,
develop, and take risks. I have been able to implement my knowledge from the assigned courses,
residency, and action research study with my teams into my daily work. I will continue to build
on my capacity for ongoing learning personally and professionally. My pledge is to model the
way of lifelong learning:
The personal-best projects we heard about in our research were all distinguished by
relentless effort, steadfastness, competence, and attention to detail. We were also struck
by how the actions leaders took to set an example were often simple things. Sure, leaders
had operational .and strategic plans. But the examples they gave were not about elaborate
designs. They were about the power of spending time with someone, of working side by
side with colleagues, of telling stories that made values come alive, of being highly
visible during times of uncertainty, and of asking questions to get people to think about
values and priorities. Modelling the way is essentially about earning the right and respect
to lead through direct individual involvement and action. People first follow the person,
then the plan. (Kouzes & Posner, 2002, p. 14)
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APPENDIX A: MODEL FOR DEVELOPING AND SUSTAINING LEADERSHIP
Contextual Factors
factors Sociocultural Context P^^ioml/o^^^^

* * » Vmfl**$
Transformational Leadership Practices
Note: From Registered Nurses' Association of Ontario (2006). Developing and Sustaining Nursing Leadership. Toronto, Canada: Registered Nurses' Association of Ontario (RNAO), p. 22. Used
with permission of RNAO.
APPENDIX B: LETTER OF INTRODUCTION AND RESEARCH CONSENT FORM
Hello, my name is Cecile Marville-Williams and I would like you to participate in a
research project conducted by myself as part of my requirement for Royal Roads
University's Master of Arts in Leadership program. My credentials with Royal Roads
University can be established by telephoning Dr.Wendy Rowe at [telephone number].
Purpose
This document constitutes an agreement to participate in my research project; the
objective of my research project is, "What can the health system manager do to contribute to
the creation of the ideal unit environment for professional teams and employees who are
dedicated to providing patient-centered care?" The outcome will include recommendations to
be shared with the organization.
The research will consist of 90-minute interviews and focus groups. The foreseen
questions will examine what the health system manager can do to contribute to the creation
of the ideal unit environment for professional teams and employees who are dedicated to
providing patient-centered care, how the health system manager can evolve his or her role to
achieve the ideal unit, and what role or impact a large span of influence has on your current
environment. In addition to submitting my final report to Royal Roads University in partial
fulfillment for a Masters of Art in Leadership, I will also be sharing my research findings
with Trillium Health Centre.
Confidentiality
All information and documentation obtained during this action research study will be
kept strictly confidential. All data will be recorded in hand-written format and/or tape
recorded where appropriate. Data will be summarized in an anonymous format in the body of
the final report. At no time will any specific comments be attributed to any individual unless
specific agreement has been obtained beforehand. A copy of the final report will be housed at
Royal Roads University and will be publicly accessible.
Conflict of Interest
As researcher and health system manger of the pilot unit at Trillium Health Centre, a
possible challenge could include a potential power imbalance and a perceived conflict of
interest. As researcher, I will communicate the ethical frameworks of Trillium Health Centre
and Royal Roads University as guiding principles to support ethical research.
Voluntary Participation
The option to participate is voluntary at all times and the participant can withdraw at
any time without reprisal or impact on his or her employment or advancement within the
organization. Participants will be provided with contact information for the Royal Roads
University project supervisor and Trillium Health Centre project sponsor for any additional
questions or concerns that may arise. If you have any questions now or at any time during the
study, you may contact Cecile Marville-Williams at [telephone number].
I have read the information on the consent form for the study on understanding the in-
patient unit environment where professional teams and employees provide patient-centered
care. My questions have been answered to my satisfaction. By signing this letter, I give free
and informed consent to participate in this action research study.
Name: (Please Print):
Signature:
Date:
APPENDIX C: PILOT TEST INTERVIEW QUESTIONS
1. How long have you worked in your role within the organization?
Years: Months:
2. How long have you worked at Trillium Health Centre?
Years: Months:
3. Define the ideal unit environment for you and your team to provide patient-centered care.
4. Describe the characteristics of an ideal unit environment. What does it look like?
5. Describe how you as the health system manager can evolve your current role to foster
and/or support the creation of the ideal unit environment.
6. What factors do you consider contribute to the ideal unit environment for professionals
and employees to provide patient-centered care?
7. Describe any challenges or barriers you currently face in assisting your teams in
implementing the patient-centered care initiative.
8. From your perspective how can the clinical leader role support nurses in creating the
ideal unit environment to provide patient-centered care?
9. Describe from your point of view how the manager's span of influence (number of direct
reports) impacts:
a. Your role as health system manager
b. Ability to coach and mentor the team
c. Staff outcomes
d. Patient outcomes
10. Describe the ideal clinical leader role. What does it look like?
APPENDIX D: FOCUS GROUP FACILITATOR QUESTIONS
1. What are some of the characteristics of the ideal patient experience? Feel free to use your
own personal experience.
2. In order to support the ideal patient experience,
a) What is your ideal role?
b) What is your current role?
c) What are the gaps?
3. What are some of the things you need to do in order to close the gaps?
4. What are some of the things that others members in your teams need to do in order to
close the gaps?

APPENDIX E: SURVEY QUESTIONS
Introduction
Hello, my name is Cecile Marville-Williams and I would like you to participate in a
research project conducted by myself as part of my requirement for Royal Roads
University's Masters of Arts in Leadership program. My credentials with Royal Roads
University can be established by telephoning Dr. Wendy Rowe at [telephone number].
Purpose
My research project is, "What can the health system manager do to contribute to the
creation of the ideal unit environment for professional teams and employees who are
dedicated to providing patient-centered care?" Completion of this document constitutes your
agreement to participate in my online research survey. As a participant, you are agreeing to
complete the survey.
Confidentiality
Pseudonyms will be used throughout the research process to protect anonymity of
participants. Participant information and raw data will be summarized in an anonymous
format in the body of the final report. At no time will any specific comments be attributed to
any individual unless specific agreement has been obtained beforehand. All documentation
will be kept strictly confidential. In addition to submitting my final report to Royal Roads
University, I will also be sharing my research findings with Trillium Health Centre.
Survey
I am using SurveyMonkey®, which is located in the United States of America (USA).
In the event that your survey response is processed and stored in the USA, you are advised
that its governments, courts, or law enforcement and regulatory agencies may be able to
obtain disclosure of the data through the laws of the USA.
Conflict of Interest
As researcher and health system manger at Trillium Health Centre (THC), a possible
challenge could include a potential power imbalance and a perceived conflict of interest. As
researcher, I will communicate the ethical frameworks of THC and Royal Roads University
as guiding principles to support ethical research.
Voluntary Participation
The option to participate in this research project is voluntary. You are free to
withdraw at any time without reprisal or impact on your employment. If you have any
questions now or at any time during the study, you may contact Cecile Marville-Williams at
[telephone number].
Do you consent to participate in this survey?
• Yes
• No
For each question, please check the box that best describes you or enter the
information asked.
1. What is your role?
• Clinical Educator
• Clinical Leader
2. How long have you worked in your role within the organization?
Year(s): Months:
3. How long have you worked at Trillium Health Centre?

Year(s): Months:
4. Briefly describe your view of key elements of the ideal unit environment that would
enable professionals (nurses and allied health) and employees to provide patient-centered
care.
5. What do you consider to be barriers or challenges to creating the ideal unit environment
that you described above?
6. Does the manager span of influence (number of direct reports) impact your role?
1 2 3 4 5
Almost Never Rarely Occasionally Fairly Often Almost Always
7. The manager on my unit/units describes a compelling image of what our future could be
like.
1 2 3 4 5
8. To what extent does the clinical educator/leader role influence professionals and
employees to provide patient-centered care?
1 2 3 4 5
9. As the clinical educator/leader, I encourage the team to try out new and innovative
approaches to their work.
1 2 3 4 5
10. Briefly describe what you need in your current role to support you to assist professionals
and employees to provide patient-centered care.

11. In my current role I spend time developing leadership ability in frontline staff by
mentoring and coaching them in the current unit environment.
1 2 3 4 5
Leadership Practices
To what extent do you typically engage in the following behaviours? For each
statement, decide on a rating and record it in the appropriate box. In selecting each response,
please be realistic about the extent to which you actually engage in the behaviour. Do not
answer in terms of how you would like to see yourself, or in terms of what you should be
doing. Answer in terms of how you typically behave on most days and with most people.
12.1 seek out challenging opportunities that test my own skills and abilities.
1 2 3 4 5
13.1 develop cooperative or collaborative relationships with nurses, allied professionals, and
employees.
1 2 3 4 5
14.1 make certain the team adheres to principles and standards of the patient-centered care
initiative.
1 2 3 4 5

15.1 challenge and encourage staff to try out new and innovative approaches to their work.
1 2 3 4 5
16.1 seek out innovative ways to improve the environment to provide patient-centered care.
1 2 3 4 5
17. I experiment and take risks even when I know I could fail.
1 2 3 4 5
18.1 take initiative to implement change.
1 2 3 4 5
19. Please describe some of your greatest challenges and lessons learned as a clinical
educator or clinical leader.
20. Is there any additional information or comments you would like share?
Thank you very much for completing this survey!

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UNDERSTANDING THE IDEAL INPATIENT UNIT ENVIRONMENT WHERE

PROFESSIONAL TEAMS AND EMPLOYEES PROVIDE PATIENT-CENTERED CARE

RN, BScN, Ryerson University, 2005

A thesis submitted in partial fulfillment of

the requirements for the degree of

MASTER OF ARTS in LEADERSHIP

We accept this proposal as conforming

to the required standard

Project Sponsor, Patti Cochrane, MHSc

Faculty Project Supervisor, David Reagan, EdD

Committee Chair, P. Gerry Nixon, PhD

ROYAL ROADS UNIVERSITY

© Cecile Marville-Williams, 2007

Published Heritage Direction du

395 Wellington Street 395, rue Wellington

Your file Votre reference

The author retains copyright L'auteur conserve la propriete du droit d'auteur

In compliance with the Canadian Conformement a la loi canadienne

While these forms may be included Bien que ces formulaires

Findings were that involving patients as participants enables an ideal experience;

communication, cooperation, coordination, and teamwork are essential; recognition,

respect, and accountability are fundamental; several factors impact managers'

abilities to coach and mentor; a change in mindset is necessary to sustain patient-

system managers can build leadership capacity.

all for always believing in me.

your superior editing.

wanted to in life. This is for you and me.

Balancing Harms and Benefits 65

APPENDIX C: PILOT TEST INTERVIEW QUESTIONS 128

Table 1. Summary of Participants by Data Gathering Tool 56

Figure 1. THC's strategic framework 18

Nelson, Wasson, Mohr, & Batalden, 2003, p. 474).

knowledgeable, team-based individuals, managers need to develop high-performance teams that

bring interdisciplinary professionals and employees together to accomplish specific results.

person and capitalize on that special ability.

effectively manage and lead change to achieve a desired future state.

respond effectively in a patient-centered environment.

providing patient-centered care?" I have four subquestions:

require professional teams and employees to contribute to patient-centered care?

2. What are the characteristics of an ideal unit environment?

The Opportunity and Its Significance

freestanding day-surgery facility.

managerial role. I am committed to creating an environment that provides teams with an

leadership duties, through participation in interdisciplinary councils, have encouraged leadership

leaders in the organization, thus enhancing leadership capacity.

My leadership stretch involved working with professional teams and employees to

units (THC, 2006a).

environment that promotes empowerment. If THC is successful in creating an ideal unit

Systems Analysis of the Opportunity

however, consumer demand outpaces such growth.

of health care providers functioning in integrated systems, networked to provide a seamless

care. Bennett (2005) explains:

growing acknowledgement that a meaningful and sustainable relationship between professional

leaders of the functioning units.

throughout the management structure. Wheatley (1999) states,

outcomes and organizational performance.

Cardiac, Diagnostic, Emergency, Medicine, Mental Health, Neuroscience/Musculoskeletal,

include Decision Support, People Support, and Operations Support.

an unparalleled commitment to innovation, collaboration, and cutting-edge patient care. THC's

the following six values.

or indirectly involved in the provision of care.

and our external partners.

trustworthy in our relationships.