Change in Relational Coordination Over Time

The health professionals’ ratings of RC, as expressed by the RC index, were found to change over time. The changes over time are described in the following section by the progress in RC when assessed eight months after implementation of intervention, while a decline in RC is assessed 16 months after implementation.

8.3.1.1 Progress in Relational Coordination

RC was improved in the surgical unit some eight months after implementation of the intervention, as indicated by the strong statistically significant increase in the RC index (p = 0.0082). The increase is mainly attributable to an improvement in the frequency (p = 0.0010) and timeliness (p = 0.0130) of the communication between health professionals in surgical teams. However, the increases in the measures of the other RC dimensions were not statistically significant. The findings were based on independent group t-test comparisons of the RC index and the seven dimensions over time, as shown in Appendix 8 (Table F), supplemented by the statistically stronger paired t-test, as illustrated in Table 22. This latter analysis included measures from the 47 respondents who responded at both at Time 1 and Time 2.

Comparisons of RC Index and Seven Dimensions Between Time 1 and Time 2

Time n t df Sign mean SD mean diff

Table 22 Paired t-test comparisons of the RC Index and the seven dimensions between Time 1 and Time 2. Significance level *p-value < 0.05, ** p-value < 0.01.

When analyzing the RC measures, the frequency of communication in the unit was found to be very appropriate (Time 1, 3.88), and this dimension became stronger over time (Time 2, 4.17, and Time 3, 4.11), as shown in Appendix 8 (Table G). This meant that the health professionals in OR considered to a significantly greater extent frequency of communication about the tasks associated with preparing, performing, and completing surgical procedures to patient undergoing orthopedic surgery to be

appropriate eight months after implementation of the intervention than they did before.

The ways in which the health professionals were communicating with one another were proved less satisfactory. More accuracy and timeliness of communication were desirable, and both communication dimensions became stronger during the intervention. At Time 2, the health professionals were found to rate the timeliness of communication about the tasks associated with preparing, performing, and completing surgical procedures to patient undergoing orthopedic surgery significantly higher than they did prior to the implementation of Intervention I. Moreover, the communication could be more problem-solving if in problematic situations the participants were less concerned with blaming each other (Time 1, 3.29). This communication dimension became stronger during the intervention (Time 2, 3.38), although it stayed at the same level as before when measured some 16 months after intervention was launched (Time 3, 3.25). Finally, it seems important in the light of the specialized complex context to emphasize that the health professionals had relatively low scores on the dimension of shared knowledge at all times (Time 1, 3.34; Time 2, 3.39; Time 3, 3.23). An expression of this attitude was made visible by the survey question: “Colleagues have some knowledge about the work I do with tasks associated with preparing, preforming, and completing surgical procedures to patients undergoing orthopedic surgery in the OR.”

The minimal fluctuations in the health professionals’ ratings of this dimension indicated that the intervention did not influence their knowledge of what is importance for each other’s task performance.

The RC ratings (RC index) were found to vary across workgroups. The RC measures derived from the three large workgroups (OR nurses, AN nurses, surgeons) were all increased eight months after implementation of the intervention, although the changes over time were not statistically significant. The difference in the RC index across these workgroups remained the same, as shown in Figure 29.

Figure 29 RC index measured before (Time 1) and eight months after implementation of intervention (Time 2) across workgroups.

3 3,2 3,4 3,6 3,8 4

Time 1 Time 2

RC index

RC Index over Time Across Workgroups

OR nurses AN nurses SUR

At all times, the surgeons rated the RC higher (Time 2, RC index 3.76) than the other workgroups included in the survey, while the AN nurses rated the RC lower (Time 2, RC index 3.42) than the other workgroups. The difference in the RC index between the surgeons and the AN nurses during this time period was statistically significant (p <

0.0008). These findings may influence the assessment of the change over time in the RC index if the changes in the sample distribution over time are considered, since proportionately less surgeons were included in the survey at Time 3. These findings are discussed further in section 8.7 Strengths and Limitations. Analyses have been conducted for all the workgroups, but in order to ensure anonymity in the smaller workgroups (less than five respondents), the results from those groups were excluded from the following tables. Moreover, the small workgroups might be considered to be more sensitive to low response rate; therefore, these measures must be considered subject to great uncertainty.

8.3.1.2 Decline in Relational Coordination

A decline in the RC rating during the period from eight to 16 months after implementation of the intervention was identified, as the results showed a statistically significant difference in the RC index (p = 0.0387) between Time 2 and Time 3, as shown in Table 23.

Comparisons of the RC Index and RC Dimensions Between Time 2 and Time 3

Time n t df Sign mean SD mean diff

Table 23 Paired t-test comparisons of the RC index between Time 2 and Time 3. * p-value <

0.05.

This decline was mainly attributable to a decrease in the strength of the relationships between the health professionals in the surgical teams, which was indicated by statistically significantly lower scores for the relationship dimensions of shared goals (p = 0.0344) and shared knowledge (p = 0.0385). The measures of all other RC dimensions also decreased, but statistical significance was not found. Again, the findings were based on independent group t-test comparisons of the RC index and the seven dimensions between Time 2 and Time 3, as shown in Appendix 8 (Table H), supplemented by the statistically stronger paired t-test, as illustrated in (Table 23). This latter analysis included measures from the 32 respondents who responded at both Time 2 and Time 3.

Analyzing the RC measures for this time period revealed that the health professionals had some knowledge (Time 2, 3.46) about what was important for each other’s task performance, although this important knowledge decreased during the same period (Time 3, 3.22). This meant that the health professionals in the OR scored the shared knowledge about tasks associated with preparing, performing, and completing surgical procedures to patient undergoing orthopedic surgery significantly lower 16 months after implementation of Intervention I than they did eight months after. Moreover, the same professionals rated the shared goals significantly lower than they did eight months earlier.

Another change was identified, as the difference between the OR nurses’ rating of RC and the AN nurses’ rating of RC became larger some 18 months after implementation of the intervention, as illustrated in Figure 30. Now, the difference in the RC index derived from the AN nurses was statistically significantly different from the RC index derived from the OR nurses (p = 0.0359) and the surgeons (p = 0.0030).

Figure 30 RC index measured eight months (Time 2) and 16 months after implementation of intervention (Time 3) across workgroups.

3 3,2 3,4 3,6 3,8 4

Time 1 Time 2 Time 3

RC indexl

RC Index over Time Across Workgroups

OR nurses AN nurses SUR

8.3.1.3 Long Term Changes in Relational Coordination

RC remained the same in the surgical unit 16 months after implementation of the intervention, since no statistically significant differences in RC were found when comparing the RC index before and after implementation of the intervention. This means that no evidence exists that the health professionals working in the OR 16 months after implementation of interventions scored the RC dimensions concerning tasks associated with preparing, performing, and completing surgical procedures to patient undergoing orthopedic surgery differently than they did prior to the implementation of interventions. However, the statistically significant increases and decreases in the RC index seen during the intervention are findings that contribute very useful knowledge about RC at the micro level during an organizational intervention, which will be discussed further in section 8.6 Interpretation and Discussion.