Table 5.

Staff Engagement

Theme	Quotes
Initial impressions and engagement: Frontline staff were often described as initially resistant to change, with some sense of cynicism and doubt about the program viability.	‘Please don't step on my toes, I just want to come in and do what I have to do and get through my day and provide patient care as best I can and not get beat up by irate patients and go home and, you know, feed my family’ (steering committee sponsor).
Strategies to enhance engagement: Emphasizing patient‐centeredness, holding the course, and communication.	We really took a focus from the beginning that this was all about the patient. So, keeping all of our improvement ideas and any of our projects patient‐focused; it's pretty hard to argue against that. Even if it means a bit of extra upfront work, I don't think there are too many people across the organization that can argue that improving the patient's journey has been a bad thing (ED team lead). And just holding your course; when you decide on a project and you're in the beginning phases of it, you can meet with a lot of resistance, but if you know that you've planned well and that it's going to work, to really stick with it because that initial pushback can be really strong and we certainly experienced it. So, holding the course, waiting for the flow to improve and for the staff to see the improvements (ED team lead). A lot of communication. They spent a lot of time talking with the staff, they spent a lot of time going step by step through the change that they wanted to see happen, but they also tried to ask them for a lot of feedback. ‘How would this form work if we did this?’ Bullet rounds, we took it to the staff many times about ‘how can we get more participation, how can we get doctors here at the bullet rounds?’ So there was a lot of collaboration with their peers (executive sponsor).
Physician engagement: Physicians were often described as skeptical about the program and in many cases seen to question the purpose, process, and motivation behind proposed change efforts. Effective leadership was critical to engagement efforts.	So I think physicians were probably in their own mind right to keep asking why, why are we doing this? You know, why are we doing this? Who is making the decision? (ED team lead). I think they were slow to buy into the whole process. They tend to be skeptical at first (inpatient physician lead). So the credibility from the physician lead, the nurses that you choose to be on your team need to have credibility amongst their peers (ED team lead). Our medicine physician lead was phenomenal, continues to be phenomenal … She was very successful with quite a lot of initiatives and she was a phenomenal ally, but she's still having that discussion with us, how do I move them? Physicians are just a totally different beast and she's the Chief of Medicine, like she … but she gets it and she's trying to figure out how to move her own team (inpatient team lead).