Patricia Satterstrom

Background 

There is increasing recognition that beyond frontline workers’ ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard.

Purpose 

This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals.

Methodology 

We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals (N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected.

Findings 

Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time.

Conclusion 

Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed.

Practice Implications 

Encouraging responsive practices may help ensure that frontline health care workers feel heard.

To foster bottom-up innovations, health care organizations are leveraging interdisciplinary frontline innovation teams. These teams include workers across hierarchical levels and professional backgrounds, pooling diverse knowledge sources to develop innovations that improve patient and worker experiences and care quality, equity, and costs. Yet, these frontline innovation teams experience barriers, such as time constraints, being new to innovation, and team-based role hierarchies. We investigated the practices that such teams in federally qualified health centers (FQHCs) used to overcome these barriers. Our 20-month study of two FQHC innovation teams provides one of the first accounts of how practices that sustained worker engagement in innovation and supported their ideas to implementation evolve over time. We also show the varied quantity of engagement practices used at different stages of the innovation process. At a time when FQHCs face pressure to innovate amid staff shortages, our study provides recommendations to support their work.

Issue 

When frontline employees’ voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

Critical Theoretical Analysis 

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

Insight/Advance 

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers’ personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

Practice Implications 

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Background

Engaging frontline clinicians and staff in quality improvement is a promising bottom-up approach to transforming primary care practices. This may be especially true in federally qualified health centers (FQHCs) and similar safety-net settings where large-scale, top-down transformation efforts are often associated with declining worker morale and increasing burnout. Innovation contests, which decentralize problem-solving, can be used to involve frontline workers in idea generation and selection.

Objective

We aimed to describe the ideas that frontline clinicians and staff suggested via organizational innovation contests in a national sample of 54 FQHCs.

Interventions

Innovation contests solicited ideas for improving care from all frontline workers—regardless of professional expertise, job title, and organizational tenure and excluding those in senior management—and offered opportunities to vote on ideas.

Participants

A total of 1,417 frontline workers across all participating FQHCs generated 2,271 improvement opportunities.

Approaches

We performed a content analysis and organized the ideas into codes (e.g., standardization, workplace perks, new service, staff relationships, community development) and categories (e.g., operations, employees, patients).

Key Results

Ideas from frontline workers in participating FQHCs called attention to standardization (n = 386, 17%), staffing (n = 244, 11%), patient experience (n = 223, 10%), staff training (n = 145, 6%), workplace perks (n = 142, 6%), compensation (n = 101, 5%), new service (n = 92, 4%), management-staff relationships (n = 82, 4%), and others. Voting results suggested that staffing resources, standardization, and patient communication were key issues among workers.

Conclusions

Innovation contests generated numerous ideas for improvement from the frontline. It is likely that the issues described in this study have become even more salient today, as the COVID-19 pandemic has had devastating impacts on work environments and health/social needs of patients living in low-resourced communities. Continued work is needed to promote learning and information exchange about opportunities to improve and transform practices between policymakers, managers, and providers and staff at the frontlines.

The upward voicing of ideas is vital to organizational performance. Yet power differences between voicers and those with authority may result in valuable ideas being overlooked. In this ethnographic, 31-month longitudinal study of a multi-disciplinary team in the healthcare sector, we examine how upwardly voiced ideas can endure to reach implementation. Of 208 upwardly voiced ideas, most were rejected in the moment, but 49 reached implementation despite appearing to be initially rejected. These ideas were kept alive by other team members who later drew upon and revived the initial ideas through what we call the voice cultivation process. We detail this process and describe five pathways through which voiced ideas stayed alive to reach implementation by overcoming different forms of resistance. We illustrate how the allyship of others can help voice live on beyond its initial utterance to reach implementation and generate change, even when the person who initially spoke up is no longer on the team or advocating for the idea. By reconceptualizing voice as a collective, interactional process rather than a one-time dyadic event, this paper develops new theory on how employees can help one another’s voice be heard to positively impact their teams and organizations.

Novel forms of teamwork—created by rapid change and growing diversity among collaborators—are increasingly common, and they present substantial methodological challenges for research. We highlight two aspects of new team forms that challenge conventional methods. Factors pertaining to change (e.g., in membership) create entitativity challenges such as whom to count as team members, while factors pertaining to difference (e.g., in expertise) create concordance challenges such as how to interpret disagreement in groups. We review research methods that are well-suited to each of these specific challenges. We identify the particular challenges of studying teams that exhibit high difference and change simultaneously and call for adaptive methods that enable insight into how they work. Clarity about the dimensions of deviation from ideal team forms, along with shared terminology, will help researchers make and discuss tough methodological choices and assist reviewers in evaluating them.

In this paper, we explore whether perceivers can accurately assess the effectiveness of groups, how perceivers use group properties to inform their judgement, and the contextual and individual differences that allow some perceivers to be more accurate. Across seven studies, we present consistent evidence that perceivers can judge workgroup effectiveness in videos of different lengths—60, 30, and 10 s—and in 10-second silent videos and 10-second audio clips. We find that perceptions of collective properties of groups, including cohesion, affective trust, and cognitive trust partially mediate perceivers’ ability to accurately judge groups. Furthermore, increased attentional focus improves perceivers’ ability to judge group effectiveness. Finally, we find that perceivers with higher levels of social sensitivity are more accurate at judging group effectiveness. We discuss the implications of these findings for the groups literature and social perception literature.

Background: 

How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care.

Purposes: 

This inductive qualitative study examines primary care clinics implementing improvement efforts in order to identify mechanisms that enable implementation despite common barriers, such as lack of time and fragmentation across stakeholder groups.

Methodology: 

Using an embedded multiple case study design, we leverage a longitudinal data set of field notes, meeting minutes, and interviews from 16 primary care clinics implementing improvement over 15 months. We segment clinics into those that implemented more versus those that implemented less, comparing similarities and differences. We identify interpersonal mechanisms promoting implementation, develop a conceptual model of our key findings, and test the relationship with performance using patient surveys conducted pre-/post-implementation.

Findings: 

Nine clinics implemented more successfully over the study period, whereas seven implemented less. Successfully implementing clinics exhibited the managerial practice of integrating, which we define as achieving unity of effort among stakeholder groups in the pursuit of a shared and mutually developed goal. We theorize that integrating is critical in improvement implementation because of the fragmentation observed in health care settings, and we extend theory about clinic managers’ role in implementation. We identify four integrating mechanisms that clinic managers enacted: engaging groups, bridging communication, sensemaking, and negotiating. The mean patient survey results for integrating clinics improved by 0.07 units over time, whereas the other clinics’ survey scores declined by 0.08 units on a scale of 5 (p = .02).

Practice Implications: 

Our research explores an understudied element of how clinics can implement improvement despite barriers: integrating stakeholders within and outside the clinic into the process. It provides clinic managers with an actionable path for implementing improvement.

Although recent research has consistently demonstrated the benefits of multicultural experience for individual-level creativity, its potential advantages for collective creativity in culturally diverse teams have yet to be explored. We predicted that multicultural experience among members of a collective would enhance joint creativity in a superadditive fashion. Using a two-step methodology that included both individual and dyadic brainstorming sessions, we found that even after controlling for individual creativity, multicultural experience had a superadditive effect on dyadic creativity. Specifically, dyads performed best on a creative task in terms of fluency, flexibility, and novelty—three classic dimensions of creativity—when both dyad partners had high levels of multicultural experience. These results show that when it comes to multicultural experience, the creative whole is greater than the sum of its parts. Implications for diversity research are discussed.