Organizational transformation elements for evidence-based practice by hospital nursing staff: a qualitative study using 7-S framework

Abstract

Background

Existing models that promote the implementation of evidence-based practice (EBP) give a fragmented picture of the process and factors. This means that a comprehensive view of the elements necessary for an organization to implement sustained EBP is lacking. Clarifying organizational transformation elements using the 7-S framework (Styles, Superordinate goals, Skills, Staff, Strategy, Systems, Structure) allows the organizational conditions to be comprehensively assessed, guiding transformation efforts toward sustaining EBPs. In addition, while ward-level group learning supports EBP sustainment, its organizational antecedents remain unclear.

Aim

This study aimed to clarify organizational transformation elements for the sustainable implementation of EBPs by the nursing staff through group learning.

Methods

This qualitative study used face-to-face or online focus-group interviews with 30 healthcare professionals in eight wards of five hospitals. The participants were nursing staff (nurse managers, registered nurses, clinical nurse specialists), and other healthcare professionals involved in the implementation of the EBPs in the selected wards. In the interviews, for the eight activities in the Group Organizational Learning Activities Inventory, participants were asked about the facilitating/inhibiting factors for performing each activity related to sustaining the selected EBP. Qualitative content analysis was conducted using the 7-S framework as the axis of analysis. After the researchers repeatedly checked the categories, member checking was conducted with the four interview participants to confirm content validity and face validity of the extracted categories and items, as well as data saturation.

Results

In total, 39 items in eight S categories, including socio-political context and healthcare policy as the new S category, were extracted as elements of an organizational transformation framework for EBPs. Furthermore, group conversations suggested that each S and item may be related to each other.

Conclusions

This study systematically and comprehensively identified the elements required to transform organizations and sustain EBP. The novelty of the 8 S framework is based on how it enables a multifaceted assessment of both the soft and hard aspects of organizations concerning EBP sustainability. Given that the eight S elements are likely to be interrelated, successful organizational transformation can be achieved by intervening in multiple elements.

Clinical trial number

Not applicable.

Background

When organizations adopt evidence-based practices (EBPs), implementation strategies [1, 2] are an effective way of enacting them [3]. Combining multiple strategies can be even more effective [4, 5], and a multifaceted approach can be beneficial as well [6]. Healthcare professionals who implement EBPs must understand the facilitating factors and inhibitors within the context that the EBP will be implemented, and apply the implementation strategy from multiple perspectives [7]. However, EBP providers may not necessarily select the most appropriate strategy [8], as choosing a strategy is complex [9]. Healthcare professionals may struggle to select and combine EBP strategies in their own practice settings. Due to the lack of a comprehensive, multifaceted strategy that takes the context into account, nursing staff in particular may have a difficult time selecting and applying the appropriate strategies in their clinical settings.

Implementing EBP into clinical practice can be viewed as an organizational transformation [10, 11]. Implementation strategies can be effectively constructed by approaching the implementation of EBPs in hospitals as an organizational transformation, such transformations include building an infrastructure, creating a good practice environment, and fostering an EBP culture [10]. Incorporating an organizational transformation perspective into the implementation strategy may lead to a successful implementation [11, 12]. Although various implementation strategies have been presented in healthcare [13] and nursing [14–16], little research has considered the organizational transformation perspective [17], and only a few studies suggest the type of organization that should be transformed and examine intervention points within the organization [18]. There is also a lack of research regarding organizational infrastructure to EBP [19]. A multifaceted view of organizational factors in regards to organizational transformation may enable healthcare organizations select appropriate strategies for each clinical setting.

Models and frameworks that can be used to examine EBP implementation at the organizational level include the Alberta Context Tool [20], the Organizational model [11], and the PARIHS framework [21]. Models that can promote EBPs in the nursing field include the Advancing Research and Clinical Practice through Close Collaboration (ARCC©) model [22] and the IOWA Model [18, 23]. Existing models and frameworks predominantly focus on the process of EBP within the organization, one particular aspect of the organization, or the EBP mentor or advanced practice nurse. Multiple aspects of the organization, as well as identifying the elements that are needed for the organizational transformation, are neglected, leaving the critical elements that facilitate organizational transformation to sustained EBP underexplored. This gap highlights the need to investigate what organizational transformational elements are essential for enabling a shift toward an organization where the nursing staff can sustain EBP implementation.

This study applies the 7-S framework [24] to uncover systematic elements of organizational transformation. This framework consists of seven elements: Style, Superordinate goals, Skills, Staff, Strategy, Systems, and Structure [24]. Each element is interdependent, and is centered around superordinate goals. An organization can achieve its goals when all elements are in harmony [25]. Style refers to the culture and climate of the organization, including the leadership styles of its managers. Superordinate goals refer to the ideals that the organization has ingrained in its members, as well as benchmark concepts, common values, and philosophy. Skills refer to the abilities collectively possessed by the concerned personnel and organizations. Staff includes soft aspects, including morale, attitude, motivation, and behavior, and hard aspects such as evaluation systems and training programs. Strategy refers to the methods employed to provide better value for clients, achieve superiority of service, and make the organization stand out. Systems refer to all formal and informal procedures for running an organization. Finally, structure refers to the characteristics of an organizational structure. One of the advantages of this framework is the ability to simultaneously approach both the soft (style, superordinate goals, skills, staff) and hard (strategy, systems, structure) aspects of an organization. This framework effectively assists organizations in achieving their objectives [26], and can be used to understand their strategy execution process [27]. In healthcare settings, however, the framework has only been used to measure hospital performance [28], or to explore the factors related to whistleblowing [29]. Therefore, in contrast to previous studies which have focused on individual, group, and discrete organizational factors and processes, this study examines the organizational context using the 7-S framework.

Group factors are essential for organizational change [30]. Organizational transformation consists of first-order and second-order changes [31]. First-order change is the introduction of new technologies or practices [32], which is an incremental adjustment to the organization’s structure, processes, and practices ​​ [33, 34]. Making only first-order changes cannot move organizational transformation closer to implementing EBP. Second-order change, however, involves major transformation within an organization, fundamental and radical changes that are far-reaching in scope [32]. Second-order change is necessary for organizational transformation, and group learning could be a theoretical perspective that explains second-order change. Following the introduction of new technologies or rules within the organization, group learning can catalyze changes in individual behaviors and values [35, 36]. Therefore, group learning in hospitals (ward-level learning) may accelerate organizational transformation and encourage nursing staff to implement EBPs in a sustainable way.

This study focuses on ward-level group learning for EBPs to clarify the organizational transformation elements by applying the 7-S framework. Group learning in this context relates to nursing staff’s sustainable implementation of EBP adopted by hospitals through ward-level internalization of EBP [36]. It promotes the establishment of routines [37] and the implementation of innovations [38], and is essential in sustaining EBP. This study addresses the following research question: What are the organizational transformation elements achieved through group learning that allow nursing staff to continuously implement EBP? Previous studies do not indicate what type of organization should be cultivated or where interventions should be made within the organization to promote organizational transformation for EBP implementation. The results of this study could enable managers or those in charge of EBPs to better assess the organizational situation, allowing them to proactively intervene. The results of this study show the effectiveness of organizational transformation theory in implementation science, and they indicate the development of new strategies.

Methods

Aim, design, setting

This study aimed to clarify the elements of the organizational transformation framework for the EBPs through group learning based on the 7-S framework [24]. A qualitative study using focus group interviews was conducted to clarify organizational transformation elements for the EBPs through ward-level group learning.

A total of 800 hospitals were randomly selected from 2,439 hospitals in Japan, each with 200 or more beds, and a request letter and research description were sent to the nursing directors of these hospitals. We also use an opportunistic sampling method.

Evidence-based practice

In the focus group interviews, EBPs were defined as the nursing care or practices introduced by the hospital or nursing department to the participating ward within the past year for which evidence was provided in original articles or guidelines. The person in charge of the participating hospital selected the EBPs; the person in charge and the researcher discussed whether the practices met the inclusion criteria.

Hospitals, wards and participants

Most studies on group learning and organizational transformation have been conducted in hospitals. The hierarchy and complexity of hospitals allows the elements of organizational transformation to be captured in a comprehensive manner. Therefore, this study targeted hospitals with 200 or more beds, as such organizations are generally larger in scale and have a greater number of staff, making them more suitable for examining organizational transformation. The person in charge of research at the participating hospitals selected the participating wards. The selection criteria for participants were nursing staff (e.g., nurse managers, registered nurses, certified specialist nurses/certified nurses) and other healthcare providers (e.g., physicians and physical therapists) involved in the implementation of EBPs from their adoption to implementation in the target wards. Candidates for interview participation were recruited by the person in charge of the hospital. Nursing staff and healthcare providers who became affiliated with the ward after EBPs were introduced were excluded.

Data collection

Focus group interviews were facilitated by a researcher (K.I.) who has experience in both implementing EBP among hospital nursing staff and interviewing those staff regarding implementation. The semi-structured interviews were conducted between March and July 2023, either in person or online. For online interviews, Zoom URLs and IDs were sent to the person in charge. An interview guide directed the questions that were asked. The guide was developed based on the group organizational learning activities (GOLAs) inventory [39], consisting of eight factors; it began with an open question about how the selected EBP was introduced, and also inquired about its implementation status. It then presented the eight factors of GOLA (Organizing a team to lead EBP in unit; Evaluating the implemented EBP from multiple angles; Ensuring that the staff can acquire common knowledge of EBP; Ensuring that the staff can understand why EBP is being implemented; Ensuring that the staff can implement EBP in a unified manner; Sharing the significance of EBP implementation with the unit and staff; Encouraging the staff to better implement EBP within the unit; Encouraging staff to take ownership of EBP). For each factor, the guide included questions regarding the resources required (human, material, financial), facilitating and inhibiting factors, events that contributed to the success or failure of group learning, job characteristics, and organizational characteristics. It would be difficult to recall specific learning activities based on factors alone, so we provided several examples of items included in each factor. All questions were structured in a funnel-shaped discussion [40] to keep the discussion focused and balanced and use neutral questions. The interview guide was distributed to participants in advance. All participants were given an equal opportunity to speak. To mitigate moderator bias and to make sure that participants could speak freely, they were assured both in the research description and at the beginning of the interview that the content of their statements would not affect their employee evaluation or job duties, and that the content of the interview would only be known to the researcher. During the interviews, the facilitator was responsible for monitoring group dynamics and nonverbal cues to guide the discussion effectively and to maintain neutrality so that unbiased data collection would be ensured. Facilitators tried to encourage respectful and inclusive communication among the participants, especially since the focus group was composed of members with different professions and positions.

Participants were asked about the following: the status of their ward’s group learning related to the selected EBPs, the factors that encouraged group learning, the sustainable implementation of the selected EBPs in their ward, and the factors necessary to conduct group learning and the sustainable implementation of the selected EBPs. They were also asked about the factors that inhibited group learning in each of the eight activities. For example, regarding Factor 6 of the GOLA inventory, “Sharing changes by implementing EBP with the entire department/ward”, they were asked: “Have you implemented activities and initiatives to ‘share with staff the significance of implementing EBP’ in your department? Why do you think ‘activities to share the significance of implementing EBP with ward and staff’ were implemented? Why do you think it was not implemented? What do you think is needed to implement ‘activities to share the significance of implementing EBP’ with wards and staff?” Participants were asked to respond from various perspectives, including staff, resources, and contextual factors. After the interviews, a survey questionnaire was administered to participants regarding the status of their ward’s organizational learning activities for the target EBPs and personal attributes.

Data analysis

After removing the names of hospitals and individuals from the collected audio data, the data were transcribed by a professional transcription company and a verbatim transcript was prepared. A qualitative content analysis [41] was employed. The 7-S framework [24] was used as the axes of analysis to elucidate the elements of an organizational transformation for EBPs. The conversation content was used as the unit of analysis, and K.I. repeatedly read the verbatim transcript and analyzed each grouping of the same meaning to create a code. The similarity of the created codes was checked, similar codes were aggregated, and subcategories were created according to the 7-S framework. Considering the possibility of reinterpreting the analysis units, the verbatim transcript of each ward was repeatedly read to check the re-interpretability of the coding sections, sort codes with overlapping meanings, and check the consistency of the subcategories and categories. During the coding process, the researcher (K.I) also repeatedly used the interview notes to confirm the meaning of the interviewee’s speech. The analysis was conducted by three researchers: Y.T., who specializes in nursing management and has qualitative research experience, A.K., who specializes in the development and implementation of educational programs and evidence, and K.I. To ensure the reliability and rigor of the analysis, we discussed the names of the subcategories and consistency between subcategories and categories during the analysis. After iterative discussion, we confirmed that adding more information would not generate new subcategories and that theoretical convergence had been achieved. To ensure the rigor of the analysis and to confirm its validity and trustworthiness, we conducted additional interviews with six interview participants in January 2024. To enhance the trustworthiness of the results, member checking was performed [42], where participants were asked about the names of subcategories (Items) and the consistency between the subcategories (Items) and categories (Elements). We also asked whether there were any missing items other than those extracted. MAXQDA2022 (VERBI Software, 2021) software was used to conduct the analysis.

Results

Hospitals, wards, and evidence-based practice

Table 1 outlines the characteristics of the hospitals and wards involved in the study, showing that advanced care planning (ACP) was the most frequently selected EBP (Table 1).

Table 1.

Characteristics of hospitals, wards, and selected evidence-based practice

Type of hospitals		Number of beds	Wards		Selected EBP	Number of participants
A	Regional Medical Care Support	367	1	Mixed	Rapid response team: RRT	5
B	Advanced treatment	830	2	Urology, orthopedic surgery	Advance care planning: ACP	3
C	General	400	3	Outpatient chemotherapy	Implementation of Guidelines for Extravasation with Cancer Chemotherapy	4
			4	Neurosurgery	Implementation of CDC Guidelines for Catheter-Associated Urinary Tract Infection Prevention	3
D	General	500	5	Digestive surgery	Advance care planning: ACP	4
E	General	765	6	Intensive Care	Advance care planning: ACP	4
			7	Emergency	Advance care planning: ACP	4
			8	Dermatology, ophthalmology	Advance care planning: ACP	3

Note: EBP, Evidence-based practice

Participants’ characteristics

Table 2 shows the demographics of the participants, highlighting that the majority were female nurses with an average of 12.7 years of experience. Occupations other than nursing staff were Doctor and pharmacist (Table 2).

Table 2.

Participant characteristics (n = 30)

		Mean ± SD
		n (%)
Age		41.7 ± 8.1
Sex	Female	27 (90)
	Male	3 (10)
Current occupation	Head nurse	7 (23.3)
	Chief nurse	12 (40.0)
	Registered nurse	8 (26.7)
	Doctor	2 (6.7)
	Pharmacist	1 (3.3)
Total working years in the current job	(years)	12.7 ± 9.5
Total working years in the current hospitals	(years)	12.5 ± 6.9
Total working years in the current wards/departments	(years)	4.7 ± 2.8

Elements and items of the framework

With this diverse group of participants, we conducted a content analysis that identified key elements necessary for organizational transformation in EBP implementation. From the content analysis, 39 items in eight categories were extracted as the elements of the organizational transformation framework. In this study, the category sociopolitical context and healthcare policy consisted of two items and was generated as the eighth S (Fig. 1; Table 3).

Fig. 1.

Eight-S elements related to the organizational transformation for the EBPs. Note. Fig. 1 was modified by the researcher based on 7-S framework [25]. In this study, we did not examine the relationship between each S, but each S is indicated with a dotted line because it was possible that each S was interrelated in the narrative. Sociopolitical context and healthcare policy: The social context and healthcare policy that influences an organization implementing EBP to transform it into one where EBP is continuously implemented, Structure: The organizational structure and mechanisms for transforming the organization into one where EBP is continuously implemented, Style: The organizational culture, climate, atmosphere, and symbolic behavior to transform the organization into one where the introduced EBP is continuously implemented, Staff: The attitudes, behaviors, motivation, organizational evaluation system, and training programs of staff to transform the organization into one where the introduced EBP is continuously implemented, Systems: The organizational rules, regulations, and systems (e.g., workflow and goal management systems) to transform the organization into one where EBP is continuously implemented, Strategy: The strategic initiative to transform the organization into one where the introduced EBP is continuously implemented, Skills: The skills that the entire organization should possess to transform it into one where EBP can be continuously implemented, including the skills of individual staff and the behaviors that supplement those skills, Superordinate Goals: The organizational philosophy, guiding principles, and common values for transforming the organization into one where EBP is continuously implemented.

Table 3.

Organizational transformation elements for evidence-based practice through ward-level group learning

Elements	No.	Items	Example quotes
Style: The organizational culture, climate, atmosphere, and symbolic behavior to transform the organization into one where the introduced EBP is continuously implemented	1	A climate where EBP protocols created by organizations are observed	I think this is probably in place for daily evaluation. This is created in the hospital as an indicator to check if it meets the criteria every day, and to consider whether it should be retained or removed (Ward ID-4 RN).
	2	A climate in which doubts and feelings of discomfort can be expressed among staff members and people of different professions	Staff members sometimes directly ask me things like, “This is the situation right now, so what should we do?” Rather than limiting discussions to conferences, they often consult during day-to-day work. In such cases, I might suggest, “Why not check with the rehabilitation team?” or “How about reaching out to palliative care?” It seems that they can consult quite easily, and I think this reflects how consultation has become more accessible in daily practice (Ward ID-5 Chief Nurse).
	3	An open attitude toward novel methods and tools	We’ve only just started implementing it, so it still feels like we’re in the initial phase. We introduced it with the goal of trying it out and assessing which types of patients might benefit from it (Ward ID-6 Chief Nurse).
	4	Leadership in terms of EBP among nursing managers	I think it’s important for us as chief nurses to observe the staff’s daily activities and actively reach out to them. We also need to take the lead in showing that we are proactively engaging in ACP ourselves (Ward ID-2 Chief Nurse).
	5	Customs of collaborative brainstorming	There’s a whiteboard in a spot where everyone passes by, and that’s where we gather to discuss things. When it’s decided, “Let’s have a discussion at such and such a time,” the nurses in charge, as well as other nurses, add information about the patient to the board. The doctors also contribute by writing down the medical indications and the patient’s current condition. Then, once everyone has gathered, we start the discussion and gradually fill in the board as we talk (Ward ID-7 Chief Nurse).
	6	A climate where proposals from the staff and departments are adopted	It was initiated by the staff, in a sort of bottom-up approach, which led the hospital to decide to establish a consultation team like this (Ward ID-5 RN).
Superordinate Goals: The organizational philosophy, guiding principles, and common values ​​for transforming the organization into one where EBP is continuously implemented	7	Trans-occupational sharing of values what can be achieved with EBP	I think there was a common understanding of why we were doing this practice, although there was a lack of understanding of how to do it. I think everyone has a common understanding that this was important, so there may not have been much of a barrier in terms of helping the staff understand why we were doing it (Ward ID-4 Head Nurse).
	8	Correct understanding of what the organization and department intend to achieve by introducing EBP	In the clinical setting of emergency care, I often find myself questioning what this person truly wants and what the best course of action would be for us to meet their needs. I realized that this connects to ACP. When the connection became clear, it felt like everything fell into place—I understood that this is the essence of ACP in emergency care. It wasn’t just a matter of recognizing the term or the overarching challenges; it felt like the critical aspects of ACP in the acute phase became evident, and I understood that this is what we need to focus on (Ward ID-7 RN).
	9	Nursing managers’ vision of the department/ward	The theme of this ward this year is to share information with everyone. It is the policy of this ward that everyone should think together, give their opinions, and make decisions together, and this applies to this meeting as well (Ward ID-2 Head Nurse).
	10	Understanding of differences in value standards of practice among staff members and people of different professions	In nursing, there’s a sense of responsibility—we have to do what needs to be done, and if something is truly beneficial for the patient, we want to incorporate it. However, even without engaging in ACP, physicians will still provide medical care and treatment, often focusing on cutting-edge approaches in the hopes that they will succeed. This makes me feel that there is, to some extent, a difference in values between physicians and nurses (Ward ID-8 Chief Nurse).
Skills: The skills that the entire organization should possess to transform it into one where EBP can be continuously implemented, including the skills of individual staff and the behaviors that supplement those skills	11	Understanding of the patient’s pathological conditions and characteristics	There were some nurses who did not quite understand why patients in this ward, such as neurosurgery and neurology patients, were prone to urinary tract infections (Ward ID-4 Head Nurse).
	12	Project management ability of the department’s EBP personnel	I created educational materials with the understanding that everyone has their tasks, so the content is designed to be understandable even in a relatively short study session. To establish a shared understanding, I also included definitions of key terms (Ward ID-4 RN).
	13	Nurses’ abilities to analyze issues and conceptualize	Some staff struggle with conveying patient information or organizing it into words. Being able to communicate the minimum necessary information immediately and on the spot is extremely difficult for them. This may lead to hindering the implementation of this practice (Ward ID-1 Head Nurse).
	14	Nurses’ ability to reflect on their practice	From the time nurses first began performing chemotherapy punctures up to the present, we have consistently analyzed our success rates. This includes tracking whether the procedure was successful on the first attempt and analyzing the reasons behind any unsuccessful attempts (Ward ID-3 Chief Nurse).
	15	Doctors’ soft skills (communication skills, creativity, open-mindedness, etc.)	The doctors in the intensive care unit are all incredibly kind and approachable, making it easy to talk to them. They don’t discriminate between nurses or junior staff and often ask, “What do you think?” to hear our opinions. They create a very positive and welcoming atmosphere (Ward ID-6 RN).
Staff: The attitudes, behaviors, motivation, organizational evaluation system, and training programs of staff to transform the organization into one where the introduced EBP is continuously implemented	16	Collaborative relationships between departments and occupations	I carry out this practice while sharing information with the nurses. It’s easy to feel like I have to do everything on my own, but I try to avoid that mindset by asking for help where I can, in a way that feels natural and manageable (Ward ID-5 Pharmacist).
	17	Nursing managers’ appreciative attitudes toward staff efforts	When I tell all the staff that we have provided good care to a patient, I find that more often than not, the next nursing care plan is up and running, and the intervention is done properly (Ward ID-6 Head Nurse).
	18	Psychological burden/resistance to the adopted EBP	There is a strong perception that implementing EBP is fundamentally difficult, and I still feel that the number of nurses who are willing to participate in such activities is limited (Ward ID-1 RN).
	19	Healthcare providers’ interest in the adopted EBP	Nurses who are truly interested and motivated will carefully review the nursing records and learn on their own that this is the approach. I believe those who take the initiative to learn and work hard will be able to find meaning in this practice (Ward ID-6 Head Nurse).
	20	Work styles tailored to individual lifestyles	With the introduction of work style reforms and work-life balance, the pressure to finish tasks within working hours can create the impression that tasks are being added, making it feel like something is taking up more time. This can lead to the perception that the extra time required is a burden. It’s not just an issue with the individuals’ attitude toward EBP. Personal values, such as the desire to leave work early, can also become obstacles (Ward ID-7 RN).
	21	Physicians’ supportive attitudes toward the implementation of EBP	When I asked the doctor for his cooperation, he was willing to come and approach the puncture together with me, and even if I made a mistake first, he did not blame me for it, but gave me advice. I think that kind of relationship, or the doctor’s attitude, is also a big factor in terms of being able to implement EBP with peace of mind (Ward ID-3 RN).
	22	Professionalism in the implementation of EBP	All nurses are very conscious of the fact that we want patients to continue to receive treatment safely, and we have a strong sense of responsibility to protect them (Ward ID-3 Head Nurse).
Strategy: The strategic initiative to transform the organization into one where the introduced EBP is continuously implemented	23	Strategic thinking of nursing managers (head nurses/chief nurses) in the wards/department	In the first place, we discussed what the problems were and what we needed to do to introduce ACP to our hospital, and the initial members used the KJ method to discuss. At that time, we realized that there were no rules within the hospital, or rather, there were no manuals on how to do this practice. We decided to create a guide to address this practice (Ward ID-5 Chief nurse).
	24	Assignment of nursing managers (head nurses/chief nurses) versed in the adopted EBP to the EBP-implementing department/ward	The current and previous nurse managers were both leaders from departments involved in cancer chemotherapy. Having someone with this background in our department made it much easier to approach this new practice (Ward ID-3 Chief Nurse).
	25	Presentation of the EBP protocol	It’s a template, but there is a protocol that describes what to ask and when to think about it (Ward ID-5 RN).
Systems: The organizational rules, regulations, and systems (e.g., workflow and goal management systems) to transform the organization into one where EBP is continuously implemented	26	A system for EBP practitioners to learn how to implement the adopted EBP	In this ward and another ward, the staff received direct guidance from the doctors, and the educational materials are stored in a shared folder for everyone to refer to. Those who received direct guidance were presented with the materials this way (Ward ID-8 Chief Nurse).
	27	Standardized systems within the organization for the sustainment of EBP (including information sharing, management, and record systems)	The sheet contains five sections within the template, and each section has a specific purpose. In the group, we used the form to clearly explain what should be included in each section (Ward ID-8 Chief Nurse).
	28	A system allowing for consultation with other professionals and departments versed in EBP	We are trying to establish a team called the Clinical Ethics Consultation Team. This team is working on the dissemination of ACP and is also preparing a guide to ACP (Ward ID-5 RN).
	29	A system for the nursing department to support and instruct the EBP-implementing department/ward	We have been progressing with guidance from the education staff in the nursing department. Currently, all nurses in the chemotherapy room have acquired the same level of knowledge and skills (Ward ID-3 Chief Nurse).
	30	An educational system to enhance nurse managers’ management skills	At the chief nurses’ meeting, I learned about what types of discussions are necessary at team meetings, what questions to ask, and how to draw out opinions, so I think it’s also important to know how to ask questions that will draw out the opinions of staff (Ward ID-8 Chief Nurse).
	31	A system for reviewing and evaluating the department’s/ward’s challenges and achievements	We checked the nursing records of patients with bladder catheters every day to see if the necessary observation items were included in the nursing plans, and we worked to standardize the process by pointing this out to the staff who were not able to implement them (Ward ID-4 Chief Nurse).
	32	A system for sharing cases of patients and families for whom EBP has been implemented with the staff	We listen to the feelings of patients and their families, discuss them with people at the support center, and connect them to the local community. If there is good practice, I tell the staff that there was a case like this. I also write it down and put it in a file so that staff members can see it at any time (Ward ID-6 Head Nurse).
	33	Sharing of information on EBP with patients and families	We need the cooperation of patients too. To let patients know when to eat meals and go to the bathroom, it is advantageous to clearly state this in the instructions, as it makes it easier to explain things to them (Ward ID-3 Chief Nurse).
	34	An EBP-education system tailored to nurses’ career paths	For example, regarding ethical content, there are tasks to be achieved according to different levels on the ladder, so we propose tasks that match the appropriate level of each staff. We say, “You can work toward achieving something at this level” (Ward ID-2 Head Nurse).
Structure: The organizational structure and mechanisms for transforming the organization into one where EBP is continuously implemented	35	A system for flexibly reviewing the allocation of duties	As the workload increases and the responsibilities become a bit more hectic, other staff take on some of the tasks so that everyone can work together to implement EBP (Ward ID-4 RN).
	36	A system that allows the staff to secure time for work to advance departmental EBP	If I ask for an hour for EBP-related work, they give it at a time when I don’t have to see patients during that hour (Ward ID-4 RN).
	37	A system that leverages personnel resources capable of supporting the implementation of EBP across the organization	We have been working to create a system in which staff from other departments can cooperate with each other in administration, even only for a short time, through on-the-job training. We are expanding a system that allows us to distribute appropriate human resources throughout the hospital (Ward ID-3 Chief Nurse).
Sociopolitical context and healthcare policy: The social context and healthcare policy that influences an organization implementing EBP to transform it into one where EBP is continuously implemented	38	A policy for correcting long working hours	I’ve recently become more and more concerned about compressed work, and I’m wondering if doing that more and more will make it harder to implement these EBPs at the same time (Ward ID-7 Doctor).
	39	Social demands for implementing/promoting EBP	I think the reason why our hospital is focusing on patient support is because the government has announced the establishment of a community-based comprehensive care system, and they feel that it is necessary to focus on patient support. I think many wards started to incorporate EBPs after this (Ward ID-6 Head Nurse).

Note: EBPs in the items refer to EBPs that were implemented as rules by the hospitals included in this study. EBP: Evidence-based practice, RN: Registered nurse, ACP: Advance care planning

Style was defined as the organizational culture, climate, atmosphere, and symbolic behavior that transformed the organization into one where the introduced EBP; it included six items. The following quotations are examples of “an open attitude toward novel methods and tools.” A participant explained an episode regarding the entire atmosphere of the ward when EBP was introduced:

We’ve only just started implementing it, so it still feels like we’re in the initial phase. We introduced it with the goal of trying it out and assessing which types of patients might benefit from it. We were discussing what kind of tool or method would be good for everyone to share information, and I think that led to the idea of putting a whiteboard here. (Ward ID-6 Chief nurse)

Superordinate goals were defined as organizational philosophy, guiding principles, and common values ​​for transforming the organization, and included four items. The following were contained in the item “trans-occupational sharing of values that can be achieved with EBPs.” In this example, a participant explained how the entire ward recognized why EBPs were being implemented, for themselves and those in other healthcare professions.

I think there was a common understanding of why we were doing this practice, although there was a lack of understanding of how to do it. I think everyone has a common understanding that this practice was important, so there may not have been much of a barrier in terms of helping the staff understand why to do it. After the introduction, everyone understood, or at least felt, that this was the situation (in which EBP must be implemented). (Ward-4 Head nurse)

Skills were defined as the skills that the entire organization should possess to transform it into one in which EBP can be continuously implemented, including the skills of individual staff and the behaviors that supplement those skills; it included five items. The item “nurses’ abilities to analyze issues and conceptualize them” contained the following data. A participant explained the reason why the EBP was not conducted when it should be done.

Some staff struggle with conveying patient information or organizing it into words. Being able to communicate the minimum necessary information immediately and on the spot is extremely difficult for them. This may lead to hindering the implementation of this practice. (Ward ID-1 Head nurse)

Staff was defined as the attitudes, behaviors, motivation, organizational evaluation system, and training programs of staff that transformed the organization into one where the introduced EBP would be continuously implemented; it included seven items. The following were examples of physicians’ supportive attitudes toward the implementation of EBPs. A participant spoke about the physicians’ support when the nurse failed to conduct the EBP.

When I asked the doctor for his cooperation, he was willing to come and approach the puncture together with me, and even if I made a mistake first, he did not blame me for it, but gave me advice. I think that kind of relationship, or the doctor’s attitude, is also a big factor in terms of being able to implement EBP with peace of mind. (Ward ID-3 Registered nurse)

Strategy was defined as the strategic initiative to transform the organization into one where the introduced EBP is continuously implemented, and included three items. The following were contained in the item “strategic thinking of nursing managers (head nurses/chief nurses) in the wards/department.” In this example, a participant explained her efforts when she assessed the challenges of their ward when they tried to implement the EBPs.

In the first place, we discussed what the problems were and what we needed to do to introduce ACP to our hospital, and the initial members used the KJ method to discuss. At that time, we realized that there were no rules within the hospital, or rather, there were no manuals on how to do this practice. We decided to create a guide to address this practice. (Ward ID-5 Chief nurse)

Systems were defined as the organizational rules, regulations, and systems (e.g., workflow and goal management systems) to transform the organization into one in which EBPs are continuously implemented, and included nine items. The item “standardized systems within the organization for the sustainment of EBP (information sharing, management, record systems, etc.)” contained the following data. A participant explained the tools used to share the EBP information among doctors.

The sheet contains five sections within the template, and each section has a specific purpose. In the group, we used the form to clearly explain what should be included in each section. (Ward ID-8 Chief Nurse)

Structure was defined as the organizational structure and mechanisms for transforming the organization into one where EBP is continuously implemented, and included three items. The following is an example of “a system that allows the staff to secure time for work to advance departmental EBP.” A participant narrated the workplace system meant for having to do tasks regarding the EBPs.

If I ask for an hour for EBP-related work, they give it at a time when I don’t have to see patients during that hour. (Ward ID-4 Registered nurse)

Sociopolitical context and healthcare policy was defined as the social context and healthcare policy that influences an organization implementing EBP to transform it into one in which EBP is continuously implemented; it included two items. Government-provided financial incentives for EBP implementation, along with widespread societal recognition of its importance, functioned as external drivers that influenced the attitudes and behaviors of both hospitals and individual healthcare professionals. In addition, labor policies related to working hours affect changes in organizational work-hour regulations as well as the actual working hours of healthcare professionals. The following is an example of “social demands for implementing/promoting EBP.” In this example, a participant narrated the reason why their hospital introduced EBPs.

I think the reason why our hospital is focusing on patient support is because the government has announced the establishment of a community-based comprehensive care system, and they feel that it is necessary to focus on patient support. I think many wards started to incorporate EBPs after this. (Ward ID-8 Head nurse)

Interlink between the eight elements and 39 items

In the interviews, there were stories in which each element item was influenced by the items in another element. For example, the formulation of protocol (Strategy-25) originated from the project management skill of the project manager (Skill-12); the learning opportunities of the EBP (Systems-26) were established by the doctors’ soft skills (Skill-15); and nurse managers’ vision (Superordinate goals-9) was supported by the educational system to enhance nurse managers (management skills System-30). Furthermore, nursing staffs’ open attitude toward EBP was influenced by nurse managers’ vision (Superordinate goals-9). The participants understood the common values ​​and meaning of conducting EBP in their ward or hospital (Superordinate goals) and social issues and social background (Sociopolitical context and healthcare policy) for the EBP in question, and used these factors as the basis of their actions.

Discussion

In this study, 39 items in eight categories were generated as elements of an organizational transformation framework for EBPs, revealing the eight categories—style, superordinate goals, skills, staff, systems, structure, socio-political context, and healthcare policy—from a comprehensive and multifaceted perspective. Socio-political context and healthcare policy are new elements revealed in this study.

Eighth S: sociopolitical context and healthcare policy

Sociopolitical context and healthcare policy refers to the social context and healthcare policy that influenced the organization to transform itself and ensure that the EBPs introduced are sustainably implemented. Previous studies show that support from the government [43] and federal/state initiatives [44] influence the sustainment of EBPs. In addition, the EBPs in this study included practices that are being promoted by the government (ACP) or by academic societies (Rapid Response Team, Catheter-Associated Urinary Tract Infection Prevention), which are demands for EBPs from outside the hospital. External financial support and incentives from outside organizations are necessary for practices to be sustained [43]. Similarly, this study’s results suggest that government policy and societal demands may affect ward-level group learning and be new elements of organizational transformation for EBP implementation.

In Japan, the Labor Standards Act was revised in 2019, mandating the establishment of limitations on overtime work and the prevention of long working hours [45]. From 2024, physicians’ work style reforms were also introduced to regulate doctors’ long working hours [46]. Long working hours for nurses are also regulated [47]. Although these were introduced to improve the health of healthcare workers and provide a sustainable healthcare system, they may also influence the organizational efforts to implement EBP. By analyzing based on the organizational transformation framework, we revealed that not only financial incentives (as shown by previous studies), but also changes in social structure and trends influence the implementation of EBPs.

Soft aspects of the framework: style, superordinate goals, skills, staff

An organizational change model in patient care improvement suggests a leader’s commitment, staff’s involvement to change, and organizational goals and values [11]. In addition, leadership and psychological safety promote team learning [48]. Similar elements, such as nurse managers’ leadership (No. 4) and a psychologically safe climate (No. 2), have been extracted in this study by analyzing group learning factors through an organizational transformation framework.

Although making sense of EBP by members and aligning values to it are important for EBP sustainability [49], the formation of common values and objectives across the organization has not been presented. We identified the concepts of understanding the differences in value between professions (No. 10) and managers’ vision (No. 9) as key elements to organizational transformation for EBPs. These elements may have been identified because this study captures the implementation of EBP in the hospital as organizational transformation.

In previous studies, the skills of those involved in EBP in hospitals have not been incorporated into the organizational transformation framework. This study revealed that not only the project management skill of the personnel in charge (No. 12) and cognitive skills of the nurses (No. 13 and No. 14), but also the physicians’ soft skills (No. 15) are required for organizational transformation. It is important to enhance these skills in hospital staff and acquire knowledge in specialized areas.

The organizational change framework for improving patient care emphasizes human resources [11]. Additionally, a study of a hospital-wide improvement project found that human resources were important factors [50]. Similarly, items indicative of individual interest in EBP (No. 19) and professionalism (No. 22) were extracted from this study, while the attitudes of nursing managers (No. 17) and physicians (No. 21) were also identified as elements. As group learning includes initiatives that are difficult for nursing staff to implement alone, managers’ and physicians’ attitudes may enable organizational transformation for EBPs. The staff’s psychological burden (No. 18) and work styles tailored to individual lifestyles (No. 20) were also extracted. Progressing organizational transformation through group learning may be difficult in wards where there are members who try to maintain the status quo, and where many members prioritize their personal lives over work. In workplaces involving healthcare, being able to tailor working styles that suit the lifestyles of each staff member is increasingly emphasized. Thus, future challenges may be how to reconcile conflicting efforts such as work-life balance and organizational transformation.

Hard aspects of the framework: strategy, systems, structure

Strategic planning, including the development of a formal implementation blueprint, is presented as part of the implementation strategy [13]. In this study, more specific elements were extracted, such as the strategic thinking of nursing managers (No. 23) and allocation of nurse managers (No. 24). To enhance EBPs, previous studies have suggested system elements, such as annual audits of EBP projects, and the placement of EBP facilitators both within and outside the organization [16]. Integrated systems, such as data collection [51], are important for team learning. Based on the organizational transformation framework, this study revealed formal (No. 27 and No. 34) and informal systems (No. 31 and No. 33) for hospitals and nursing departments. Establishing these systems in a hospital may encourage group learning and successful organizational transformation to EBP.

Previous implementation strategies have presented changes in the physical structure of the organization [13]. Group learning is associated with the physical structure, such as room for discussion [52], member composition [38], and relationships among members [53]. Group learning is also associated with the human resource structure within the organization. In this study, elements representing the human resource structure of the organization were identified (No. 35 and No. 37). Approaches to these organizational aspects may transform them into organizations that effectively conduct EBPs.

Existing strategies, models, and frameworks fail to account for the multifaceted nature of organizations and the key elements required to drive organizational transformation toward the implementation of EBP [1, 46, 54]. Similar to the strength of the 7-S framework [24], this study showed that the 8-S element has the potential to interrelate with every other element. In addition, providing an overview of both the soft and the hard aspects to change could select strategies to fit each organization’s status. As a result, the 8-S framework may help nursing staff select and use the appropriate strategies in their clinical settings. Considering these elements during EBP implementation, in conjunction with the other S elements, may move the organization toward EBP implementation. Furthermore, this study presents new items that encompass organizational status, including organizational, group, and individual hierarchies. Efforts to implement change must address the differences in hierarchy within the organization, consider interdependencies between levels, and coordinate all hierarchies [11, 55]. This framework enables organizations to identify the key elements necessary for organizational transformation toward sustaining EBPs and formulate appropriate organizational policies. Moreover, hospital administrators and ward leaders can assess the current status of their units and consider specific intervention strategies to address deficiencies and reinforce essential elements. However, the 7 S framework is designed to review an organization and consider points for improvement in reforming the organization, and its use in hospitals has only just begun. When aiming to address more specific challenges faced by hospitals, such as patient safety, it is necessary to combine other models or methods in addition to 8 S framework.

Limitations and recommendations for future research

This study has several limitations. First, group interviews were conducted for each of the eight factors in the GOLA inventory. However, most participants talked about one antecedent across multiple learning activities. Therefore, the antecedents were not extracted for each of the eight learning activities but were identified as antecedents from the overall group learning. Second, although the group interviews inquired about the factors necessary for fostering or inhibiting group learning, this study did not indicate the direction of the relationship. Third, among the data collected, one hospital, three wards, and 11 participants were recruited through opportunistic sampling. This hospital had been involved in a questionnaire survey conducted by researchers not affiliated with the current study, and was introduced as a hospital with interest in organizational change. Therefore, the participants from this hospital may have had a high level of awareness regarding organizational transformation, and this characteristic may have been reflected in their interview responses. Although selection bias may have occurred in part of the data, the remaining 19 participants from four hospitals were recruited through random sampling. Therefore, the transferability of this study is maintained to a certain extent. Fourth, only a few types of EBPs were selected as subjects for group learning, with ACPs accounting for half of the total. If group learning is conducted on EBPs other than those selected in this study, there may be antecedents that are not included in the results. Lastly, there are interpretive limitations in the analytical method. Content analysis allows for the examination of both the latent and interpretive meanings within the data [56, 57]. This approach allows elements related to organizational transformation to be classified and labeled while considering the contextual background of the text. However, qualitative content analysis assumes that a text may have more than one meaning [58]. To address this, we included participants involved in implementing the target EBP and, during the analysis process, engaged in repeated discussions among researchers to verify the meanings and interpretations of the text. We also conducted member checking with interview participants to ensure the validity of the findings. Despite these limitations, the results of this study can be used by hospitals implementing EBP to capture organizational status and address each element to transform the organization toward EBP implementation. Previous models [22, 59, 60] can also be used at the organizational level. However, these studies have not shown what kind of organization should be cultivated or what aspects of the organization should be changed [18]. By using the 8-S framework for EBPs, nurse managers or persons in charge of EBPs can assess their organizational status and cultivate an organization that is more likely to conduct and sustain EBP through group learning. Future research should examine the validity of the 8 S framework and its applicability across various healthcare organizations. Future studies should also investigate the interrelationships among the elements and the directionality of these relationship depending on the type of EBP, and propose effective combinations of the eight factors as conditions to facilitate organizational transformation. In particular, the relationships between the eight elements, group learning, and the sustainability of EBP should be quantitatively assessed. Ultimately, by conducting longitudinal studies that include EBP implementation, it may be possible to present a new organizational model that supports the sustained implementation of EBP.

Conclusions

Based on the 7-S framework, this study clarified the eight elements and 39 items of organizational change for the sustainment of EBP through group learning. There was no existing method based on organizational transformation theory to evaluate organizational status for the sustained implementation of EBPs, making it difficult for nurses to select strategies appropriate to their organizations and clinical settings. This study was the first to apply an organizational transformation framework to EBP implementation and expand existing frameworks, thereby making a theoretical contribution to both implementation research and organizational theory. By fully presenting the elements of organizational transformation required for sustaining EBPs, this study helps overcome the challenge nurses face in selecting appropriate strategies tailored to their organizational and clinical contexts, enabling them to enjoy the benefits of EBP. Furthermore, healthcare managers and policymakers are expected to utilize the elements of this framework to provide organizational support and propose relevant organizational policy.

Abbreviations

EBP

Evidence-based practice

ACP

Advanced care planning

GOLA inventory

Group organizational learning activities inventory

Author contributions

K.I. designed the research plan, conducted and analyzed the research, and made revisions to the draft paper. Y.T. and A.K. advised on the research plan, analyzed it, and proposed revisions to the paper prepared by K.I. All authors read and approved the final manuscript.

Funding

This study was supported by the JSPS KAKENHI (grant number: JP22K21079).

Data availability

The data analyzed in this study are partially available within the manuscript.

Declarations

Ethics approval and consent to participate

This survey was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo (2023098NI-3), and the Medical Research Ethics Committee of Institute of Science Tokyo (M2023-107). The study description document, interview guide, and face sheet were sent to the interview participants before the study. Before starting the interview, an overview and purpose of the study, benefits and disadvantages to the study participants, how to withdraw consent, refusal to answer, and protection of personal information during the interview were explained. Informed consent was obtained from all participants by having them sign the consent form prior to the start of recording. In the case of online interviews, only audio data were stored, and image data were deleted immediately after the interview. Consent forms and face-sheets were returned to the researcher after the interviews were completed. Confidentiality was ensured by anonymizing data and securely storing all research materials. Participants were given a QUO card worth JPY 3,000 as an appreciation of their time. This study adhered to ethical guidelines for Medical and Health Research Involving Human Subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.