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Nursing Inquiry 2015

Feature

Transforming a conservative clinical


setting: ICU nurses strategies to
improve care for patients relatives
through a participatory action
research
Concha Zaforteza,a Denise Gastaldo,b Cristina Moreno,a Andreu Bover,a Rosa Mir oa and Margalida Mir
oa
aUniversity of Balearic Islands, Balearic Islands, Spain, bUniversity of Toronto, Toronto, ON, Canada

Accepted for publication 3 May 2015


DOI: 10.1111/nin.12112

ZAFORTEZA C, GASTALDO D, MORENO C, BOVER A, MIRO  R and MIRO M. Nursing Inquiry 2015
Transforming a conservative clinical setting: ICU nurses strategies to improve care for patients relatives through a
participatory action research
This study focuses on change strategies generated through a dialogicalreflexiveparticipatory process designed to improve the
care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital
in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth
interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institu-
tionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-
centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between
physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to
change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit.
The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they
enhanced the care offered to patients relatives and patient safety. Transforming conservative settings requires capacity to nego-
tiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to
micropolitics, transformative proposals can be implemented and sustained.

Key words: action research, critical care, family, intensive care units, power, quality improvement, relatives, social change.

There is international recognition of the need to transfer the best strategies to transform health services, especially in
research results into clinical practice and to promote equita- complex practice settings (Brown and McCormack 2011;
ble quality care (Sudsawad 2007; Davison and National Col- Michie, van Stralen and West 2011; Slater and Kothari 2014).
laborating Centre for Determinants of Health 2013). Scholars who have examined this issue have highlighted the
However, little is known about how to promote change in relevance of contextual factors in shaping the possibilities
clinical practice (Grimshaw et al. 2001; Simpson and Doig for change (Dijistra et al. 2006) and the importance of strat-
2007), and there has been ongoing debate about which are egies developed by local actors to sustain change processes
(Brown and McCormack 2011).
Transforming health-care is particularly challenging in
Correspondence: Concha Zaforteza, Department of Nursing and Physiother-
apy, Critical Health Research Group, University of Balearic Islands, Campus
places historically structured by conservative values, where
Universitario, Cra. Valldemossa Km 7 5, 07122 Palma de Mallorca, Balearic patriarchal and physician-centered relations dominate daily
Islands, Spain. E-mail: <concha.zaforteza@uib.es> decision-making. Until the 1970s in Spain, power relations

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were anchored in the hierarchal superiority of most male that guided that larger project was: How to generate changes
physicians over patients and other healthcare professionals in an ICU to improve the care delivered to the relatives of
(Miro 2008; Mir o et al. 2012) and, even today, establishing critically ill patients? In Table 1, we present a summary of
collaborative practice and tackling physicians privilege the key changes achieved through the entire project. The
remains a challenge (Ruiz-Quiles 2008; Codorniu et al. specific objective addressed here is to understand which
2011). change strategies are generated through a dialogicalreflex-
It is in this context that we decided to explore the dis- iveparticipatory process in an ICU setting.
crepancy between the needs of relatives of intensive care unit
(ICU) patients and the care they receive (Zaforteza 2010). METHODOLOGY
Internationally, ICUs are characterized by an emphasis on
the treatment of pathological physical manifestations, with We utilized a qualitative PAR design. This design is recognized
special interest in controlling measurable parameters, due to as an appropriate methodology for health service intervention
the severity of patients conditions, where open unit policies and evaluation (Waterman et al. 2001; Delgado-Hito and Gast-
and family support remain a challenge (Capellini et al. aldo 2006; Hughes 2008), and it has been used in different
2014). However, in southern European countries, and in projects for changing clinical practice, both in the Spanish con-
particular in Spain, professionals prioritize a biomedical text and in the broader international context (Delgado et al.
approach that almost exclusively focuses on physical condi- 2001; Sanchez et al. 2009; Crozier, Moore and Kite 2012).
tions in detriment of communication and social dimensions The process was guided by critical theory (Denzin and
of health (Giannini 2007; Anzoletti et al. 2008; Rich-Ruiz Lincoln 2000; Sayer 2009), particularly that of authors who
2011). This conception of health-care excludes family mem- explore dialogic and reflexive processes. First, we drew on
bers and disregards the scientifically proven benefits that the ideas of Paulo Freire on how dialogue and reflection are
their presence produces for the patient (Fumagalli et al. engines for social change and for the empowerment of par-
2006; Happ et al. 2007). ticipants in the process (Freire 1970, 2002, 2004). Second,
Usually, Spanish ICUs have restrictive norms related to we adapted the model proposed by Kemmis and McTaggart
the access and presence of family members, which assigns (1988, 2005) on transforming reality, which suggests that
them an external and passive role (Velasco et al. 2005; successive cycles of reflection and action promote change.
Escudero, Vi~ na and Calleja 2014). In our previous studies, This dialogic dynamic had already been used successfully in
we found that nurses did not feel adequately trained to the ICU of another Spanish hospital (Delgado et al. 2001).
handle emotional aspects of family support, experiencing Third, we used the notion that complex social processes
distress (Zaforteza et al. 2003). They also did not know can be studied by introducing changes in them and observ-
which kinds of information they could provide to families ing their effects (Baskerville 1999). In this sense, PAR gener-
without triggering conflict with other professionals, and ates a privileged epistemological position to understand how
acknowledged that there was an unwritten rule that nurses social processes that reproduce or transform the status quo
should not be present during visitation (Zaforteza et al. work in different contexts, such as a conservative clinical set-
2003, 2005). Concomitantly, we encountered nurses who ting in this case. While trying to implement change, it simul-
wanted to change this situation in order to provide consis- taneously allows for the study of how actors, such as
tent routine care to patients relatives; however, they did healthcare professionals, justify their actions; the logics used
not know how to challenge the status quo in conservative to implement strategies to persuade others or themselves;
clinical settings (Zaforteza et al. 2004). and processes that aim to achieve consensus or those that
Identifying this interest in promoting change led us to generate confrontation (Gaventa and Cornwall 2004; Reason
develop a participatory action research (PAR) project. We and Bradbury 2008; Gooden and Gastaldo 2009). Therefore,
selected this methodology because, in addition to translating PAR supports knowledge generation about structural and
evidence into clinical practice, this approach focuses on trans- everyday practice changes, which can then be used by practi-
forming structural conditions within a context that is adverse tioners and researchers in other contexts.
to change (International Collaboration for Participatory This PAR study was structured in five phases: (i) diagno-
Health Research 2013a). In addition, PAR seeks to empower sis of the needs and care provided to the families of critically
those professionals who wish to adapt care to the needs of ill patients; (ii) selection of proposals for change, (iii) design
healthcare users (Waterman et al. 2001; Hughes 2008). of proposed changes; (iv) implementation of changes; and
In this study, we explore the results related to a specific (v) evaluation of the process and its impact on the unit. The
objective of a larger study. The general research question research was conducted in an ICU of a tertiary hospital in

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Transforming a conservative clinical setting

Table 1 Key changes achieved through a PAR process in the ICU

Before PAR process After PAR process


New assets and Absence of a continuing education plan A continuing education plan was
skills for ICU on therapeutic relationship and family- implemented to improve family-centered
(Garca et al. 2010; centered care care, including care in grief processes,
Zaforteza 2010) communicating bad news, and strategies
for therapeutic relationship
Absence of consensus on how to care for The Caring for the Critically Ill Patients Family
the relatives of critically ill patients Guide was developed (a pocket edition was
given to all the ICU healthcare
professionals)
Absence of any written information An informative poster was designed to meet
tailored to patients relatives some of the relatives information needs.
It was placed at the waiting room and used
at the first contact with the ICU
Changes in how ICU health professionals thought that The ICU health professionals considered
ICU health the relatives hinder their work (caring that the relatives might be an asset for the
professionals perceive for the patient) patient. In addition, they considered that
the critically ill the relatives needed care to withstand the
patients relatives situation
(Zaforteza ICU health professionals stated that The ICU health professionals recognized
et al. 2010, 2015) family that that family presence at the bedside
presence at the bedside might be could be beneficial for the patients
harmful
for the patients
Changes in clinical Visit schedule: 8:15 am8:45 am, 1 pm Professionals increased the visit time in two
practice toward the 1:30 pm, 8 pm8:30 pm hours per day: the last visit began at 6 pm
relatives instead of 8 pm
(Zaforteza 2010; Existence of rigid rules for visiting and Nurses valued the benefit of a broader visit
Zaforteza et al. 2010) accessing the ICU policy. Rules for access and visit were
flexible and case-sensitive
Relatives were not allowed to be present On a case-by-case basis, the health team
during the death process appraised possibility for the family to be
present during the process of death
Changes in healthcare Healthcare team members held different A shared postured became dominant and
team dynamics views on how to care for the relatives. the conflicts disappeared
(Zaforteza 2010; These different postures raised conflict
Zaforteza et al. 2015) among team members

the Balearic Islands (Spain). This unit had 30 beds and 205 potential time limitations that participants could have. We
employees and treated 1300 patients per year. The project called those who assumed a greater degree of participation
had 60 participants (53 nurses and nursing assistants, three representatives (11), and these were members of the group
hospital attendants, two physicians, and two social workers). discussions (described below). We called those who assumed
The sampling was intentional (Coyne 1996; Fossey et al. a lesser degree of involvement participants (49), and their
2002), aiming at recruiting a maximum representation of work was to convey their reflections to a representative.
employees. We publicized the project through various clini- To grasp the complexity of the phenomenon under
cal sessions, distribution of information through posters, study, various qualitative methods were used to generate
and used a snowball technique for recruitment (Fossey et al. data (Denzin and Lincoln 2000; Curry, Nembhard and
2002). Two levels of participation were offered in light of Bradley 2009). In Table 2, we describe the data generation

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Table 2 Outline of the data generation methods employed

1st phase 2nd phase 4th phase 5th phase


Research methods diagnostic proposals for change 3rd Phase design implementation evaluation
Group discussions 3 3 3 2
(opinions of
participants and
representatives)
Field diary of the Yes Yes Yes Yes Yes
principal investigator
(reflexivity and
decisions about the
process)
Field diaries of the Irregular Irregular Irregular Yes Very irregular
coinvestigators
(reflexivity and some
data about the process)
Field diaries of the Yes Irregular
representatives
(reflexivity and change
processes in the unit)
In-depth interviews with 5
professionals from the
unit (experience of the
change and impact of
the change on the
unit)

strategies and their distribution throughout different To meet the objective, which was to discover change strat-
phases of the project. egies generated by a dialogicalreflexiveparticipatory pro-
The discussion groups were always composed of the same cess, we analyzed participants narratives through PARs two
11 representatives (eight nurses, two nursing assistants, and streams of analysis, which are process analysis and content
one social worker) and moderated by the principal investiga- analysis. In the analysis of process, we sought to understand
tor (Morgan 1996; Barbour 2005). Each representative dia- how the dynamics of dialogue, reflexivity, and participation
logued and reflected with a small team of participants, and resulted in changes at three levels: in language, relationships,
their contributions were presented in the group discussions, and activities (Kemmis and McTaggart 1988, 2005). In the
which captured the views of all 60 participants. thematic analysis, we explored the transformation or repro-
Regarding the field notes, while the principal investiga- duction of understandings, feelings, and power relations in
tor captured the context, decisions being made about the ICU care-giving (Zaforteza 2010; Zaforteza et al. 2015).
process, and reflexive notes (Hughes 2000), participants Initially, we analyzed the data generated by each method
field notes were used to encourage reflection about the care in each phase, to create codes and subcategories, which,
provided to families of critically ill patients (Elliott 1997; when organized into categories, would explain the phenom-
Hughes 2000; Stringer and Genat 2004). enon of change. Codes and subcategories were reflected on
The interviews conducted in the evaluation phase were a grid, under each of the phases in which they were gener-
used to complement the data emerging from the group dis- ated. Second, a cross-sectional analysis in chronological
cussions. At that point, the group discussions were insuffi- order was undertaken, generating codes and subcategories
cient to describe individual experiences of change, and five for strategies that maintained or changed the status quo.
in-depth, semi-structured interviews were conducted (Kvale That is, we tracked how themes emerged, disappeared, per-
and Brinkmann 2009). sisted, or were modified as the dialogicalreflexiveparticipa-

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tory process moved forward, and as changes proposed by the involvement. Finally, ethics was handled as a process requir-
representatives and participants were implemented. ing collective decision-making by all involved in the study
The trustworthiness of the study is based on several pro- (Ramcharan and Cutcliffe 2001; International Collaboration
cesses: first, through the joint reflexivity and dialogue for Participatory Health Research 2013b).
between researchers and participants (McTaggart 1998)
which acknowledged different expertise among group RESULTS
members, that is more specialized knowledge of research-
ers on methodology and the more applied and contextual Four main change strategies were created during the study:
knowledge of participants and representatives (Freire 2002, (i) Institutionally supported practices were challenged by
2004); second, the individual reflexivity of the principal participants who attempted to make the whole unit shift its
investigator (first author CZ), which was supported professional-centered work to a more inclusive, patient-cen-
through an exploration of her theoretical position and the tered approach; (ii) traditional power relations were chal-
information emerging from the research (Bover 2013), and lenged to decrease the hierarchical power differences
verification of the initial coding scheme by other investiga- between physicians and nurses; (iii) consensus was built
tors (McTaggart 1998); third, the triangulation of methods about the need to shift from an individual to a collective
and sources used as an analytical strategy, critically contrast- position in relation to change; and (iv) consensus was built
ing the findings from various techniques, not to generate about the need to develop a critical attitude toward the con-
consensus, but to understand, for example, why certain servative context of the unit, rather than support the nave
codes were dominant in individual or collective data, and acceptance of the status quo.
subsequently contrasting findings with those of other stud-
ies, looking for similarities and developments within the From professional-centered to patient-centered
existing body of knowledge (Denzin and Lincoln 2005);
care
and finally, there were also PAR-specific criteria, such as
sense of personal and group development among partici- In the first group discussion and in the field notes, in the first
pants, evidence of progression toward change (Kemmis phase (diagnosis of the care given to families of critically ill
and McTaggart 2005), increased understanding of the con- patients), professionals spoke about their problems with fami-
ditions under which they executed their practice, and lies, their conflicts with other colleagues, or about shortcomings
participant adherence to the project (International Collab- in providing care to family members. In their field notes, they
oration for Participatory Health Research 2013a). used language that was emotionally charged, reflecting the diffi-
The study has three limitations that should be taken into culties nurses faced when dealing with these situations.
account. First, it does not capture the discourses of all
healthcare providers. Physicians were underrepresented, Today my patient is much worse. At the visit time, it was horri-
ble. There were more than 15 people crying and kissing him.
despite being encouraged to participate. The principal inves- I went into the room for a brief moment. I felt unwell and
tigator held several meetings with the unit medical director, powerless; I dont know how to help in this grieving phase.
and recruitment sessions were organized to fit physicians (Representative 9, field notes, phase 1)
schedule. In addition, although the researchers proposed to
include patients relatives in the study, healthcare providers As the process progressed (phase 2), professionals
did not feel they could share their views with the families. reflected, exchanged ideas, and recognized their responsibil-
For this reason, inputs from the intended beneficiaries were ity to respond to the needs of patients and family.
not included. Finally, PAR generates contextualized informa-
Representative 2: (. . .) the first thing to do is to consider
tion which can be transferred to other contexts, if social, cul- family members as care recipients.
tural, and political differences are considered.
This project was approved by the Hospitals Research Representative 8: Exactly, any of us could have gone outside
Commission and the Balearic Islands Clinical Research Eth- [waiting room] to tell the family all is well, but no, it took
ics Committee (CEIC-IBComite Etic  dInvestigacio Clnica us two hours to let them know the patient was fine. Ufff, I
felt really bad.
de les Illes Balears). In the informed consent, participants (Group discussion 5, phase 2)
were informed that their identity would remain confidential
in all project publications. However, participants were also However, these changes were partial. As soon as their
advised that due to the participatory nature of the project, more transgressive propositions were confronted by the most
other employees and managers would be aware of their reactionary positions by those who were not involved in the

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project, they chose a compromise between the two positions. importance to conflict and gave priority to their professional
Thus, in the third phase, when designing interventions, in role as caregivers.
the first group discussion participants proposed more ambi-
[A nurse is talking about the PAR project] For me, it has
tious changes, while in the third group discussion more con-
given me arguments to silence those who were against it
servative changes were articulated. In the case of extending [either flexible visit hours or expanding hours]. The con-
visiting hours, participants at the beginning of the third flict goes on, but I was always embarrassed and rarely felt
proud of things I do here, but now I got to the conclusion
phase proposed to change the initial visiting hours (three
that my ideas are as valid as the doctors ideas. So, now I
30-minute: 8:158:45, 13:0013:30, and 20:0020:30) to one practice what I think.
in which the family could remain in the unit for the entire (Interview 3, evaluation phase)
afternoon (8:158:45 and 13:0020:30). Upon reflecting on
However, as happened in the first strategy, some partici-
successive group discussions and sharing this proposal with
pants reproduced previous practices despite the PAR pro-
other colleagues, participants reconsidered this proposal,
cess. At this level, change was dependent on the individual
fearing that it would generate significant conflict or opposi-
capacities and not on the structure of everyday relations
tion that would ultimately impede the implementation of
within the unit. Another aspect related to the reproduction
this change. For this reason, the final visiting hours estab-
of the primacy of physicians over other professionals was that
lished extended the initial visitation schedule only by two
when change proposals were raised during the second
hours (8:158:45, 13:0013:30, and 18:0020:30).
phase, participants immediately dismissed those proposals
which involved modifying physicians routines.
Power differentials among professionals
Individual to collective position
The second strategy was to reduce the power differentials
between physicians and nurses. When thinking about the One of the steps taken by the study participants was to move
context of this unit, the participants and the representatives from individual to collective posturing in relation to change.
perceived that it was physicians who decided or vetoed Two phenomena supported such change. The first was a
initiatives. mutual discovery, through dialogue, that colleagues shared
similar views. As the process progressed, participants stopped
Representative 3: (. . .) to provide medical information
before the visit? We will see, because to tell them [physi- talking about individual ideas, discovered what other partici-
cians]: look, you have to provide information before the pants and representatives thought, and proposed strategies
family members come into the unit, we can propose that, for change that other team colleagues agreed with.
but it means we are looking for trouble.
(Group discussion 4, phase 2) The second phenomenon, derived from the first, was
observed in the evaluation phase. In general, there was an
However, many participants evolved throughout the pro- improved level of care for the families and decreased con-
cess and, in the evaluation phase, referred to challenging flict. This became particularly evident when professionals in
the status quo of reporting relationships and starting to dia- the same work shift found themselves defending the same
logue with their medical colleagues. They managed to affirm ideas. This led to collective synergies to maintain the change
their judgement when they thought their proposals for rela- in their clinical practice, and synergies which extended to
tives care responded to users needs and gave greater impor- other professionals who were less committed to change.
tance to their professional role (of nurses and assistants).
Representative 1: The relationship with the colleagues who
Yes, if I want the family in the unit, I have to fight for it. I have attended the continuing education classes [an out-
have to earn doctors respect. I need to have very clear come of the project] has improved considerably. In my shift,
points and tell: the patient is like this and that and I believe there are people who think like me [referring to providing
his care requires actions A, B, and C. care to patients relatives], but I didnt know it! This is very
(Interview 1, evaluation phase) positive when I work with them. The quality of care has
improved.
(Group discussion 10, evaluation phase)
This balance in hierarchical relationships occurred when
participants felt confident about the position they took, par-
ticularly when it was supported by evidence, by a critical mass [A nurse reflects on a situation where many children were
of colleagues, or after they have developed new negotiation taken to the unit to visit their grandfather. Initially, the rule
indicated that children under 12 were not allowed to access
skills. Another explanatory factor behind the change was the unit] (. . .) and I said Oh! All these children, do they
resilience, as there were professionals who stopped giving want to visit their granddad? Lets do like that, you are going

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Transforming a conservative clinical setting

to get in, one by one, say hello, and then leave [there were disrupted the status quo to different degrees, and that they
some 15 children]. . . and people [she refers to her shift col- generated different consequences for the unit, patients, fam-
leagues] accepted it. No one complained and said children
are not allowed! or why did you allow them in?. No one ily members, and professionals. We have grouped these four
complained. strategies under two main approaches: consensus-dependent
(Interview 3, evaluation phase) strategies and institution-dependent strategies, as discussed
below.

Nave to critical attitude Institution-dependent strategies


With respect to the potential for change in clinical practice, The institution-dependent strategies were as follows: (i) the
participants moved from a nave to a critical attitude shift from a professional-centered work to a patient-centered
anchored in the context of their unit. At the beginning of perspective; and (ii) a reduction in hierarchical power
the first phase, participants were perplexed, hesitant about between physicians and nurses. These strategies resulted in
their ability to influence the context, displayed hopelessness, more conservative transformations due to a higher degree of
and utilized a highly sentimentalized discourse. Toward the difficulty for implementation than consensus-dependent
end of this phase, these discourses disappeared, and the dis- strategies.
course that was consolidated was that change was possible. The difficulty in breaking the status quo stems from the
In an exchange of three representatives (Group discussion fact that these strategies were highly permeated by institu-
3, phase 1), they described themselves as being reflexive, tional norms, its history, values, and language. In this case,
changing attitudes, gaining awareness, and changing as we recognize that within the Spanish healthcare system,
good and positive. there are tensions between different ways of conceiving care,
In the second and third phases, the change from a nave despite the domination of the biomedical approach (Rich-
to a critical posturing was different. At the beginning of the Ruiz 2011). Within this perspective, the user is patient, a
second phase, participants generated many ideas for change. passive recipient of health-care, while the professional is the
As the process progressed, particularly in the third phase, expert in solving physical problems, the medical specialist is
participants initiated a detailed analysis of their context: placed at the center of the system (Dwamena et al. 2012;
They explored the potential barriers to change, sought alli- Hesselink et al. 2012; Reeve et al. 2013), and power relations
ances with people who held formal power in the unit, ana- are organized around physicians decision-making (Mir o
lyzed the feasibility of different proposals, selected some, 2008).
discarded most, nuanced selected proposals, and adapted There are multiple consequences for this particular mix
them to their context to make them viable. of values and relationships. In our case, changes in clinical
Representative 6: The problem with information. . . I con- practice have been produced (see Table 1), which
sider we should reach an agreement with each unit head, responded to users needs, but not all forms of control prac-
present a proposal, and think how to implement it. It can tices and exclusion of relatives were eliminated. In part, the
be done, if we negotiate alternatives.
difficulty in breaking hierarchical power derives from the
(Group Discussion 9, phase 3)
fact that nurses reproduced the discourse of the superiority
of physicians. For instance, in the group discussions, nurses
DISCUSSION discarded proposals that required significant changes in phy-
sicians routines because they doubted they could persuade
This study shows that the development of a dialogicalreflex- to them to do so.
iveparticipatory process can lead to changes that promoted Authors who work on quality of care and patient safety
family- and patient-centered care as well as learning critical warn about the consequences of playing down a person
analysis skills that can be widely employed in healthcare (Berenholtz and Pronovost 2003). They also caution against
work. However, such process was not able to fully transform the risk of working with depleted teams, where the knowl-
and overcome some well-established practices that justified edge of its members is not fully used for the health benefit
family exclusion and disregarded potential benefits for of the user (Parker and Gardner 2004; Curtis et al. 2006;
patients. Hills, Mullett and Carroll 2007). Still worse, health teams
During this process, we identified four change strategies with little cohesion and strong hierarchical relations can
held by participants. In analyzing the dynamics of change, it threaten users safety because they reinforce practices based
is visible that these strategies operate differently, that they on routines and hinder the protective effect of collaborative

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and critical practice (Newman, Papadopoulos and Sigsworth 2013). As a result, professionals improve their clinical prac-
1998; Makary et al. 2006). tices and avoid leaving their workplaces (Lindeke and Sieck-
Although changes achieved were limited, we consider ert 2005).
their consequences to be of paramount importance because In addition, the emergence of a critical position among
the user clearly benefited from them. In this study, clinical professionals can potentially be a benefit to the healthcare
practice evolved toward scientific evidence recommenda- system. People with nave attitudes tend to perceive any
tions, as professionals responded to the need of close prox- change as either impossible or beyond their capacity (Freire
imity between relatives and the patient by extending visiting 2002). They may fail to recognize how they are part of the
hours (Pardavila and Vivar 2012). This was possible in part system, critical social actors enmeshed in it (Freire 1970).
because teams worked best when, in the same shift, there Feelings of belonging and the ability to promote change are
were professionals who were empowered by the reflexive related to increased job satisfaction and diminish turnover
process and shared the same ideas about the best way to care (Hills et al. 2007; Kalisch and Lee 2010; Parmelli et al.
for the family. 2011). Through the dialogicalreflexiveparticipatory pro-
cess, practitioners established viable and lasting changes,
Consensus-dependent strategies adapted to their context, which enhanced care without gen-
erating much stress on the system.
The consensus-dependent strategies were as follows: (i) the
shift from an individual to a collective posturing; and (ii) the CONCLUSION
transition from a nave acceptance of the status quo to a criti-
cal attitude. These strategies, unlike the aforementioned, Faced with an opportunity to transform clinical practice
achieved greater transformation of the status quo. through a dialogicalreflexiveparticipatory process, health
What explains this increased transformative capacity was professionals were able to generate change strategies and
that these strategies operated in the interstices of the micro- incorporate recommendations from scientific evidence. The
politics and the daily ICU practices. These strategies strategies proposed were both transgressive and conservative;
depended more on individuals and groups rather than on however, when compared with the initial situation, they
the opposition to established values. They were related to enhanced the care offered to patients relatives and patient
learning new skills, such as collaborative practice and critical safety. Furthermore, they had deeper implications for service
awareness. The participatory nature of the methodology cre- delivery and skills development. Patients are the ultimate
ated opportunities for dialogue and reflection among pro- beneficiaries, given that the literature indicates that such
fessionals, who, until then, had not shared their concerns transformations improve their safety and well-being (Dwame-
regarding patients relatives care. As team members worked na et al. 2012; Hesselink et al. 2012; Reeve et al. 2013).
to incorporate this form of care into their practice, profes- However, this transformative process was not spontane-
sionals, who until then had not felt able to transform their ous and required considerable effort, as professionals had to
context, begun to critically review their clinical work and challenge institutional power relations and reactionary ways
transform it. of thinking. PAR should be seen as a learning opportunity
We argue that consensus building is a fundamental abil- where participants acquire critical awareness about their con-
ity for healthcare professionals working in complex settings. text and discover the game rules. Such understanding
Teams that establish collaborative practices are able to allowed participants to use micropolitical strategies (such as
improve safety, quality of care, and health outcomes (Pun- consensus building) as levers to implement transformative
tillo and McAdam 2006; Reeves, Nelson and Zwarenstein proposals. Thus, participants learned how to develop change
2008; Zwarenstein, Goldman and Reeves 2009). Some exam- strategies adapted to a specific context. In addition, this pro-
ples are the reduction of errors, nosocomial infections, and cess builds capacity for future engagement with issues partici-
surgical mortality (Zwarenstein and Bryant 2000; Zwaren- pants may deem as challenges (Gooden and Gastaldo 2009).
stein and Reeves 2000; McCallin 2005; Sirota 2007; Nembh- Our findings suggest that change processes developed
rad et al. 2008). collectively can occur even within conservative contexts. Our
Collaborative practice also contributes to the improved environment was initially averse to change, strongly rooted
perception of professional autonomy and job satisfaction, in traditions that placed the professional at the center of the
reducing, among others, the presence of chronic fatigue syn- system and which organized the provision of health-care
drome or occupational stress, such as burnout, harassment, within a hierarchical structure. Our position is that, in many
or professional exhaustion (Ajeigbe et al. 2013; Paradis et al. cases, waiting until conditions become ideal implies missing

8 2015 John Wiley & Sons Ltd


Transforming a conservative clinical setting

opportunities for change that would improve the quality of tion Science 6: 9. http://www.implementationscience.
care provided. com/content/6/1/9 (accessed 31 January 2015).
Finally, one of the challenges for knowledge translation Capellini E, S Bambi, A Lucchini and E Milanesio. 2014.
studies is to demonstrate how different institutional, team, Open intensive care units: A global challenge for
and individual factors influence change processes (Lemelin, patients, relatives, and critical care teams. Dimensions in
Hogg and Baskerville 2001; Dijistra et al. 2006). Our project Critical Care Nursing 33: 18193.
sheds light on this issue. We acknowledge that transforming Codorniu N, M Bleda, E Alburquerque, L Guanter, J Adell,
conservative settings requires great effort, capacity to negoti- F Garca et al. 2011. Cuidados enfermeros en cuidados
ate positions, and outcomes may not be ideal. However, paliativos: Analisis, consensos y retos [Nursing care in
when change is collectively articulated at the level of micro- palliative care: Analysis, consensuses and challenges].
politics in everyday practices, and capacity is built in this Index de Enfermer a 20: 715.
process, the potential for transformation is substantially Coyne IT. 1996. Sampling in qualitative research: Purposeful
improved. and theoretical sampling: Merging or clear boundaries?
Journal of Advanced Nursing 26: 62330.
ACKNOWLEDGEMENTS Crozier K, J Moore and K Kite. 2012. Innovations and action
research to develop research skills for nursing and mid-
The project has been funded by the Fondo de Investigaci on wifery practice: The Innovations in Nursing and Mid-
Sanitaria, Instituto de Salud Carlos III, Ministerio de Sanidad wifery Practice Project study. Journal of Clinical Nursing
y Poltica Social, Gobierno de Espa~ na (Health Research 21: 171625.
Fund, Institute of Health King Carlos III, Ministry of Health, Curry LA, IM Nembhard and EH Bradley. 2009. Qualitative
Spanish Government), Grant number PI06/90156. and mixed methods provide unique contributions to out-
comes research. Circulation 119: 144252.
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