Success factors when implementing a structured support model for systematic work environment management in operating departments: A case study from Sweden

Abstract Aim The study aimed to investigate how departments in a Swedish hospital worked with a structured support model between the sessions and what they identified as success factors. Background To improve the work environment in a Swedish hospital, a structured support model for systematic work environment management was implemented in operating departments. The structured work starts with sending a web‐based, open‐ended, anonymous questionnaire to all employees. In response, employees describe how they perceive their work environment ‘right now’. Next, a session is held where employees' viewpoints are discussed, and areas of improvement are agreed upon. Action plans are created between the sessions, and the employees start working with their plans with support from their managers. Implementing new models takes time and requires efforts from employees and managers. Method A case study was conducted, including three operating departments within a perioperative organization in a university hospital in Sweden. The participating departments had used the model without interruption during the Covid‐19 pandemic 2 years after implementation, and they had created a customized working method. Three first‐line managers were interviewed, and 22 action plans, 21 workplace meeting notes and two presentations were analysed using thematic analysis. Results The results are sorted under three main thematic headings: Experience of results and benefits, Marketing and cheering on and Making adjustments and making the model one's own. The results from the action plans and workplace meetings indicated that the employees had discussed problems with cooperation, work organization and how to treat each other. Conclusion Human factors, such as support, encouragement, seeing the benefits, allowing for time and respecting each other can facilitate and contribute to the implementation and success of a new model. Implications for Nursing Management The main finding of the study indicates that with a structured way of working, and with the participation of the employees in the systematic work environment work, the employees contributed with constructive suggestions for improvement. This, in turn, contributed to reducing the workload for first‐line managers. In addition, when working with a structured model, deficiencies in the workplace were identified, which triggered an improvement process in the participating hospital departments.

systematic work environment work, the employees contributed with constructive suggestions for improvement. This, in turn, contributed to reducing the workload for first-line managers. In addition, when working with a structured model, deficiencies in the workplace were identified, which triggered an improvement process in the participating hospital departments.
implementation, nurse, perioperative, structured work model, work environment 1 | BACKGROUND According to Swedish legislation, in workplaces, employees and their managers are obligated to create and maintain a healthy work environment (Swedish Work Environment Authority, 2001, 2015a, 2015b. Despite regulations, there are still organizations in Sweden that do not manage their systematic work environment work properly (Frick, 2014). The demand on health care is high and increasing in the world, especially in Sweden, and it is a challenge to recruit and keep personnel in the healthcare sector. Systematic work environmental management should improve the development and increase the attraction for employees to work and remain within the healthcare sector. A structured way of working with work environment issues should include employees and stimulate them to find constructive solutions to what they identify as environmental challenges. In turn, managers can be relieved from findings all answers.

| Work environment in a perioperative context
Perioperative context (pre-, before; intra-, during; and postoperative, after surgery) means working in a high-tech work environment, and employees can be affected by poor working conditions and poor work environment (Logde et al., 2018), which, in turn, affects the quality of patient care (Aiken et al., 2012;Woo et al., 2017), and patient safety (Logde et al., 2018). Wålinder et al. (2018) describe that 30% of almost 1000 perioperative employees (including nurse anaesthetists and operating room nurses) had sometimes thought of leaving their position (during at least 1 month in the last year). A shortage of nurses is a general problem (Drennan & Ross, 2019), especially in perioperative contexts where it may lead to surgeries being cancelled. Logde et al. (2018) described that nurse anaesthetists and operating room nurses left their jobs for several reasons: the nurse managers' betrayal and dismissive attitude, inhumane working conditions and colleagues' dismissive behaviour. In contrast, factors that contributed to nurses staying in perioperative contexts were organizational stability with low staff turnover, good spirits between colleagues, to recognize everyone's equal value at the workplace, sustained development in one's own profession and a humane nurse manager who helped employees to develop (Arakelian et al., 2019).

| Using a structured support model in a perioperative context
A structured support model was described by Svartengren and Hellman (2018) for systematic work environment management. The model is flexible and can be used with a successful outcome, both in municipalities and in a perioperative setting in hospitals with their unique working context. Working with the model, employees and their leaders are engaged in managing their work environment in a structured and systematic manner. There are three to four cycles in the model annually. A cycle starts with sending a web-based, openended, anonymous questionnaire to all employees. In response, employees describe how they perceive their work environment 'right now'. Next, a session is held where employees' viewpoints are discussed, and areas of improvement are agreed upon. Action plans are created between the sessions, and the employees start working with their plans with support from their managers. Each cycle is to be repeated three to four times annually. There is a built-in process feedback measurement in the model called Human Resources Index (HRI), which can be measured at any given timepoint as a single measure (see Figure 1). Changes in HRI value can be used to evaluate how the work environment changes over time . A longitudinal quantitative study by Arakelian et al. (2021) reported a positive trend in HRI, concluding that a structured support model is a helpful tool, and HRI is a simple measure to follow-up on work environment processes.
1.3 | Implementing a new model in new settings and the role of leadership Hojberg et al. (2018) identified four dimensions for a successful implementation of an intervention: a supportive organizational climate, a workplace with mutual goals for employees, and an 'attractive' intervention, which can be adapted to the workplace. In contrast, Martinsson et al. (2016) indicate that long-term implementation of interventions in organizations tend to fail if they do not produce rapid results. Moreover, finding a suitable intervention for a specific workplace is a challenge that needs to be addressed, as interventions work differently in various contexts (Goodridge et al., 2015;Greenhalgh et al., 2015). It is important to consider that interventions that are found to be effective in research may not be successful in practice (Hojberg et al., 2018). However, there is still a knowledge-gap regarding why an intervention is successfully implemented in several workplaces in an organization but fails to succeed in other workplaces in the same organization.
Leaders have an important role in the implementation process. Mann (2009) argued that 80% of the effort in implementation depends on changing the leaders' mindset, their practices and behaviours, as they set the tone for their employees. Mackenzie and Hall (2014) emphasize the leaders' important role in creating a vision and facilitating the understanding of the benefits of the intervention for the individuals and the organization as a whole. Leaders may have different roles during different phases of implementation. They may support implementation by motivating others, establishing goals and removing barriers. Some leaders work by delegating duties, or by 'modeling the way'. Arakelian et al. (2020) pointed out that the 'culture' of the organization, and the definition of the role for managers and the employees were important when implementing a structured support model in a perioperative setting. The results emphasized that there had to be a 'paradigm shift' in the role of employees, who more likely have a passive role, while managers are the active part in the implementation process. The managers were described as role models, the ones who the employees followed. Also, they needed to take a step back and allow the employees to step forward and take greater responsibility in the implementation process.
Role description, goal definition, timely feedback and sticking to one model were defined success factors. Molin et al. (2020) who studied first-line managers' experiences of implementing a structured support model in Swedish municipalities reported similar results. They found that despite managers' experiences of discomfort when giving the responsibility of working with work environmental issues to employees, they were impressed by their employees' success.
Managers balanced between being quiescent and, at the same time, actively monitoring progress in the work.
Thus, the work environment in a perioperative setting places specific demands on the employees. The structured support model was implemented in perioperative settings in a university hospital in Sweden as a continuation of a larger project (Svartengren & Hellman, 2018) to support work environment management. This study investigates success factors when implementing and using the model.

| AIM
The study aimed to investigate how departments in a Swedish hospital worked with a structured support model between the sessions and what they identified as success factors.

| METHODS
This study was performed as a case study (Yin, 2009) with a qualitative and prospective design, as part of a larger research F I G U R E 1 The yearly cycle of the Stamina model programme performed in municipalities in Sweden on work environment (Svartengren & Hellman, 2018). It is a continuation of the original protocol in a new context, in a perioperative setting within a hospital.

| The case
The included hospital was a university hospital in central Sweden, with approximately 8000 employees. The perioperative department consisted of operating departments, an intensive care department, postoperative departments and a sterile processing department and had approximately 900 employees, of which approximately 500 were introduced to the structured support model. The inclusion criteria were departments that continued working with a structured support model through and after the Covid-19 pandemic.
Departments that interrupted their work with the model were excluded. The case includes three operating departments within a perioperative organization in a university hospital in Sweden. The common denominator was that 2 years after implementation, all three departments out of nine had used the model without interruption during the Covid-19 pandemic, and that after a successful implementation of the model, they had created a customized working method. The remaining six departments interrupted their work with a structured support model due to the Covid-19 pandemic.
Thus, participating departments were sampled using a purposive sampling technique (Giacomini & Cook, 2000). The three departments had also shown a progression in the HRI measures (See Table 1).

| Data collection and the participants
The departments' first-line managers were invited to participate in the study, and all three accepted. Department B had a change of management between session one and session two (i.e., baseline and 6 months after implementation of the structured support model). The first line manager in Department B who worked with the structured support model after baseline was invited to participate, which she accepted. After obtaining informed consent, an interview was conducted face-to-face with one of the participants and through live video call with two of the first-line managers between October 2021 and January 2022. The interview lasted between 25 and 60 (mean 45) min. All three interviewees were women, between 39 and 52 (mean 46) years of age and had three to 11 (mean 5.8) years of experience as nurse managers. In addition to interviews, 22 action plans (from Departments A and B), 21 workplace meeting notes (from Department C) and two PowerPoint presentations (from Departments A and C) were collected and analysed.
Department A was provided with three action plans, one Power-Point presentation and one interview. From Department B, we had 19 action plans and one interview, and from Department C there were 21 workplace meeting notes, one PowerPoint presentation and one interview.

| The interview guide
The interview guide for this study included two main areas, that is, the process of implementing the structured support model (working with the action plans between the meetings) and the success factors The department has different management responsibilities for operation room staff and anaesthetist staff. b Change of management between session one and session two (i.e., baseline and 6 months after implementation of the structured support model).
for the implementation process, according to the managers (Table 3).
Probing questions were used to get in-depth information.

| Data analysis
Thematic analysis of the interview text was performed in accordance to (Braun & Clarke, 2006) in several steps. The interviews and the text from the action plans were analysed separately. First, the texts were read through to grasp the whole meaning. Second, a first coding was performed separately by authors EA and FM. Subsequently, the two authors discussed the coding. Third, the provisional codes and the text sections that were linked to the codes were reviewed again. The codes were refined based on consistency and agreement between the code and the text sections. Sub-codes that were irrelevant to the aim of this study were removed. Thereafter, themes were created, based on similarities and differences in the codes. Finally, the content in the themes was described, which are presented with quotes. The text from the action plans, workplace meeting notes and presentations, with focus on the manifest content of the text and study question 1, was analysed with content analysis according to Elo and Kyngäs (2008).
To ensure trustworthiness and credibility of the findings, the analysis process went back and forth between coding and the interview transcripts in several steps, as described previously (Nowell et al., 2017;Shenton, 2004). The analysis was discussed within the research group on several occasions. This case study has a limited scope because of its specific context. In our study some parts of the results/themes repeated themselves and some new information was discovered.

| Ethical considerations
The study followed the Main questions 1. When you started to work with the Stamina model, how did you work with your action plans between the meetings? 2. (Knowing the fact that subgroups had started to work actively with action plans) how did you come up with the idea of setting up a subgroup of employees to work with your action plans between the meetings? 3. What would you say were the challenges to work with the action plans between the meetings? 4. How did you work with the action plans between the meetings? 5. How did you influence the model to adapt it to your needs? 6. What was the next step in working with the action plans in your opinion?

Probing question
Please tell me more.
Can you give an example?
What do you mean?

| Marketing and cheering on
The managers describe the importance of cheering on and encouraging the groups, which were viewed as success factors. They supported the work groups by being available and creating the right conditions for the work groups by making time in the schedule for meetings, which made the employees feel they were recognized and not ignored. 'I was there as a support, and they never felt alone. I was there' (Manager 3).
Another type of support was referred to as lobbying for the model. 'What I did was to market the model as a work tool that was important and helpful and to help my employees to put words to their feelings' (Manager 1). This manager expressed that there was a negative attitude from the staff at the beginning of the process, and therefore he tried to talk positively about the model. 'It was not positive the first time/ … /Then I started to cheer them on during the work in the group' (Manager 1). The manager started to support the group by giving positive comments and encouraging the employees to fill in the web questionnaire to get an even better basis for suggested improvements.

| Making adjustments and making the model one's own
The first-line managers described adjusting the model, making it their own and not following the suggested work process exactly.
This was identified as a success factor because it allowed for the groups to work with the model without major disruptions in the department's ordinary work schedule. It also made it easier for the manager to get the groups to accept the model. One manager stated: 'According to the concept, this is something you should work with at every meeting, but I said [to the group] that this is the way we are working with the model. We decided to keep it simple' (Manager 3).
Two managers had created separate work groups, with a rotating participation that prepared the results from the web-based questionnaire and presented suggested actions to the group at a later stage. This adjustment allowed the groups to work more efficiently with the model. It seemed that news of this particular adjustment had spread between the departments when the managers of the groups had participated in common manager meetings.
The suggested timeframes for the sessions were also adjusted depending on time available at the departments, by all three managers.

| Action plans and workplace meetings notes and presentations
The results from the action plans and workplace meetings indicated that the employees had discussed problems with cooperation, work organization and how to treat each other. 'More structured meetings are required on Wednesdays.
We need to prepare ourselves before the meetings. It will increase the feeling of participation' (Department B)

| Planning resources and operating capacity
Need for better planning of resources in the operating department and in the postoperative ward versus operating programme was identified as an area of improvement. 'Heavy programmes' or sudden/late changes to operating programmes had to be reviewed, for example, in weekly plans, especially when staff members became sick or when additional operating rooms were used.

| Education
Educating staff members about different operating procedures was another action plan that the staff members desired to work with.
Daily educations, mini lectures, review of device usage, presenting the latest research in current and relevant topics were mentioned.
Also, it was suggested to have a specific person with a specific responsibility for working with staff education and continued skill development.

| Experience of results and benefits
The managers describe of the importance both for the groups and for the managers to see early benefits from the model. This finding confirms previous literature regarding implementation and change. For instance, Kotter (1995) describes the importance of celebrating early wins and see early concrete results of a change effort.

| Marketing and cheering on
One success factor when implementing the structured support model, described by the managers, was marketing the model so that the employees would understand how they could benefit from using it. Hojberg et al. (2018) pointed out the impact of making the implementation 'attractive' for those who had to work with it. In this study, the managers tried to show connections between the changes within the operating department and the structured support model and supporting their employees when they needed. Mackenzie and Hall (2014) and Mann (2009) emphasized the role and importance of leaders, to change their employees' mindset and modelling the way.

| Making adjustments
Furthermore, modifying the model to meet one's own department's needs was important to succeed with the model, according to the first-line managers. Adjustments and the possibility to modify the model are described in the literature as important factors when implementing workplace interventions because models need to be adjusted to different contexts (Greenhalgh et al., 2015). Both Arakelian et al. (2020) and Molin et al. (2020) explained the need to back down as a manager and leave room for employees to take an active role in working with the model. This is confirmed in this study, where independent groups of employees were created in two of the three departments to work actively with the structured support model.
An important finding here was the importance of allowing for time and making room in the organization for the employees to work with their action plans, to keep the model 'alive' and continuing over a longer period (more than 2 years). This was confirmed by the action plans, which describe the implementation's success from the employees' point of view. Also, the managers expressed that they created groups of employees and gave them time to work with their action plans, which is an obvious example of managers and employees working towards the same goal, leading to success.

| Action plans
The results from the action plans show the broader engagement of the employees in workplace issues, big and small, from opportunities to educate themselves further, organizational balance between resources and tasks, engaging oneself in work environment issues, and respecting each other and everyone's profession. Main findings from the analysis of the action plans were the importance of work organization and stable prerequisites for performing one's task, and the importance of a respectful social climate among the employees.
These results would indicate the importance of social climate factors of concern in the investigated departments. Examples of social climate factors in the literature are involvement, co-worker cohesion, supervisor support, autonomy, task orientation, work pressure, clarity, control, innovation and physical comfort (Moos, 1994). Geue (2018) show the positive relationship between social climate and positive practices, which includes respect and treating one another with integrity. Wheelan (2015) highlights the importance of a positive climate among team members and hoe this may influence group development and team performance.

| Limitations
This study focuses solely on departments that have used the structured support model during a prolonged time. There is thus a potential bias that the studied departments have a positive bias since they have used and adopted the model with good results. This may have influenced the findings in a positive direction.
Another limitation of the study is that it only includes a managerial perspective regarding the issue of how the work groups engaged between the sessions. Getting an employee perspective on this issue would be valuable for further study.

| CONCLUSION
Human factors, such as support, encouragement, seeing the benefits,

| IMPLICATIONS FOR NURSING MANAGEMENT
The take home message of the study is that with a structured way of working, and with the participation of the employees in the systematic work environment work, the employees contributed with constructive suggestions for improvement. This, in turn, contributed to reducing the workload for first-line managers. In addition, when working with a structured model, deficiencies in the workplace were identified, which triggered an improvement process in the participating hospital departments.

ACKNOWLEDGMENTS
The participants are acknowledged for sharing their thoughts. FA Insurance and the regional agreement on medical training and clinical research between Uppsala University and University Hospital (ALF), Uppsala, Sweden were acknowledgede for funding this research.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.