Mash B J, Mayers P, Conradie H, Orayn A, Kuiper M, Marais J
Stellenbosch University, Tygerberg, South Africa.
Educ Health (Abingdon). 2008 Jul;21(2):132. Epub 2008 Aug 26.
In South Africa, first-contact primary care is delivered by nurses in small clinics and larger community health centres (CHC). CHCs also employ doctors, who often work in isolation from the nurses, with poor differentiation of roles and little effective teamwork or communication. Worcester CHC, a typical public sector CHC in rural South Africa, decided to explore how to create more successful practice teams of doctors and nurses. This paper is based on their experience of both unsuccessful and successful attempts to introduce practice teams and reports on their learning regarding organisational change.
An emergent action research study design utilised a co-operative inquiry group. The first nine months of inquiry focused on understanding the initial unsuccessful attempt to create practice teams. This paper reports primarily on the subsequent nine months (four cycles of planning, action, observation and reflection) during which practice teams were re-introduced. The central question was how more effective practice teams of doctors and nurses could be created. The group utilised outcome mapping to assist with planning, monitoring and evaluation. Outcome mapping defined a vision, mission, boundary partners, outcome challenges, progress markers and strategies for the desired changes and supported quantitative monitoring of the process. Qualitative data were derived from the co-operative inquiry group (CIG) meetings and interviews with doctors, nurses, practice teams and patients.
The CIG engaged effectively with 68% of the planned strategies, and more than 60% of the progress markers were achieved for clinical nurse practitioners, doctors, support staff and managers, but not for patients. Key themes that emerged from the inquiry group's reflection on their experience of the change process dealt with the amount of interaction, type of communication, team resilience, staff satisfaction, leadership style, reflective capacity, experimentation and evolution of new structures.
The group's learning supported a view of change that sees the organisation as a living system in which information flow, participation and the development of resilience are key aspects. These themes fit well into an understanding of change based on complexity theory. If managers of the health system wish to enhance organisational change, then their goal may need to shift from optimising health care delivery in a mechanistic model to optimising health care workers in a living system.
在南非，首次接触式初级保健由小型诊所和较大的社区卫生中心（CHC）的护士提供。社区卫生中心也雇佣医生，他们通常与护士独立工作，角色区分不明确，几乎没有有效的团队合作或沟通。伍斯特社区卫生中心是南非农村地区一个典型的公共部门社区卫生中心，决定探索如何创建更成功的医生和护士执业团队。本文基于他们在引入执业团队的不成功和成功尝试中的经验，并报告了他们在组织变革方面的学习成果。
一项新兴的行动研究采用了合作探究小组的设计。前九个月的探究重点是了解创建执业团队的最初不成功尝试。本文主要报告随后的九个月（四个规划、行动、观察和反思周期），在此期间重新引入了执业团队。核心问题是如何创建更有效的医生和护士执业团队。该小组利用成果映射来协助规划、监测和评估。成果映射定义了愿景、使命、边界伙伴、成果挑战、进展标志以及期望变革的策略，并支持对过程进行定量监测。定性数据来自合作探究小组（CIG）会议以及对医生、护士、执业团队和患者的访谈。
合作探究小组有效地实施了68%的计划策略，临床护士从业者、医生、辅助人员和管理人员实现了60%以上的进展标志，但患者未实现。探究小组对变革过程经验的反思中出现的关键主题涉及互动量、沟通类型、团队适应力、员工满意度、领导风格、反思能力、实验以及新结构的演变。
该小组的学习支持了一种变革观点，即将组织视为一个生命系统，其中信息流、参与和适应力的发展是关键方面。这些主题与基于复杂性理论的变革理解非常契合。如果卫生系统的管理者希望加强组织变革，那么他们的目标可能需要从在机械模型中优化医疗服务提供转变为在生命系统中优化医护人员。
