Organizational Readiness for Change: A Case Study on Change Drivers and Inhibitors from Oman’s Health Professions

: Background: A study in 2014 on systems and processes needed to enhance the quality of health professions education during a period of transition at the Ministry of Health Educational Institutes; now known as Oman College for Health Sciences and the Higher Institute for Health Specialties, revealed positive expectations of staff towards the upgrade to a four-year college. However, staffs were uncertain about how they would manage the change, resulting in adverse psychological impact. The purpose of this study was to evaluate the overall readiness for change at Oman College of Health Sciences (OCHS) and the Higher Institute for Health Specialties (HIHS) during its second phase of transition. Aim of


INTRODUCTION
Luneburg (1) defines organizational change as: "The movement of an organization away from its present state toward some desired future state to increase its effectiveness". Within the context of higher education, change initiatives may experience multiple challenges in regards to change implementation. Specific to change during transition, evidence suggests understanding how people feel while change is taking place is vital to their acceptance and participation (2,6) . Moreover, the extent of employee participation in the change is dependent on the organization's leadership style and culture (7,8) . Therefore, efforts to integrate change management as a strategy regarding ongoing organizational change and development can help identify the drivers to overcome institutional barriers to change.
In a study by Al-Moosa to identify the needed systems and processes to enhance the quality of health professions education during a period of transition, showed participants perceived organizational change as a necessity, but they suffered adverse psychological impact because of how organizational change was managed (9) . The main study findings included (a) lack of a clear vision, and a systematic communication approach, and (b) lack of a change management strategy (10) . The findings were supported by Oman Academic Accreditation Authority's (OAAA) audit report of the Ministry of Health Educational Institutes MOHEI, recommending urgently developing a plan for change management that will facilitate a move to the next level of health education including leadership development, and effective strategies for change management (11) .
On June 6th, 2018, Royal Decree 18/2018 announced merging the Ministry of Health Educational Institutes (MOHEI) to a college. Creating Oman College of Health Sciences OCHS merged eight regional nursing institutes in addition to four health institutions at the Muscat Campus. The Higher Institute for Health Specialties HIHS replaced the Oman Specialized Nursing Institute OSNI (12) . Prior to college announcement, and as part of the Ministry of Health MOH strategy to improve the competencies of those institutes and to promote efficient use of its human resources, the MOH invited a World Health Organization WHO consultant to help identify core college requirements for the upcoming college (13) . The report indicated that the transformation into a college was possible; however, multiple challenges required prompt attention; those included: college environment and facilities, raising entry level standards, and having bylaws which support a college degree system.
Authors of this study put forth their findings and recommendations to help identify possibilities regarding the structural and human aspects that will drive successful change implementation.
The Promoting Action on Research Implementation in Health Services (PARIHS) framework is one of the tools used in implementation research. According to the framework, three core elements must be considered during the process of change management: evidence, context, and facilitation (14) . Successful implementation is likely to occur when (a) the evidence being used is scientifically clear, (b) the context is receptive to implementation by having a supportive leader, culture and evaluation systems in place and (c) the right facilitators are present to move forward effectively and efficiently (15) . In this study, it is argued that evidence is provided by the WHO consultancy report, the 2013 OAAA audit report of the MOHEI's, and the 2014 study findings by Al-Moosa,. Therefore, the focus here was on the context and facilitation components of the PARIHS framework.

AIMS OF THE STUDY
The aims of this study were to evaluate the overall readiness for change at Oman College of Health Sciences (OCHS) and the Higher Institute for Health Specialties (HIHS) during its second phase of transition.

METHODOLOGY
A sequential mixed design was chosen to carry out the case study during the period from August 2017 to March 2019. The quantitative phase provided an overview about the content of organizational change readiness at OCHS, and the qualitative part provided in depth explanation regarding barriers and drivers of change in both organizations. Ethical approval was granted by the Research and Ethics Committee at the MOH in Oman. The researchers obtained permission to adapt the Organizational Change Readiness Assessment Questionnaire (OCRA) designed by Canada Health Info way (16) . The tool comprises nine domains: strategic direction, external environment, leadership, organization structure tasks and work process, management process and communication, culture norms and morale, human resources system, employees' personal goals and competencies, and information processes. Each domain is represented by a set of questions. The tool provides a quick snapshot of the organizational context regarding readiness to implement change and how the domains are currently aligned to support change initiatives. To establish face and content validity of the tool to the context in Oman, a Delphi technique was used to obtain consensus of relevant experts. The tool was administered to participants in English and Arabic. The researchers followed a translation and cultural adaptation process in which the tool was translated to the Arabic language and then translated back to English (17) . 381 participants from the former 12 MOHEI's were invited to participate in the quantitative part of the study. The former Oman Specialized Nursing Institute OSNI, now known as the HIHS staffs were not included in the OCRA survey sample because this institution offers a postgraduate diploma program, and is not part of the OCHS. However, in accordance to Royal Decree 18 / 2018 members from OCHS and the HIHS represent the Academic Council, hence; the semi-structured interviews represented leadership from both entities. Of the total eligible sample of 381, 128 responded.
For the quantitative strand, researchers followed purposive sampling in which the target population included all the Omani and expatriates' staff who are working at the MOHEI's, currently OCHS. For the qualitative strand, researchers targeted a subset of the sample using purposeful sampling. The non-academic staff included administrative directors; the academic staff included deans, faculty, and heads of departments.
The quantitative phase of data collection included a questionnaire the authors constructed on surveymonkey.com, consisted of an informed consent, demographic data and the OCRA tool after adaptation and validation. The questionnaire was emailed to each participant individually. The initial email was followed by reminder emails for 3 weeks. The data was then exported in SPSS for cleaning and analysis. The total period for quantitative data collection was four months.
Guided by the findings from the OCRA tool, a purposeful sample of five participants in leadership positions were selected for the semi-structured interviews to provide in-depth information which was deemed significant during phase two of the transition (18) .
Questions guiding the interviews focused on change process and potential strategies to better manage this phase of transition. They were: 1. In your opinion, what are the immediate strategies required to overcome the top three hindrances as per the survey findings? 2. In your opinion, what is needed to close the gap during this period of transition? 3. As a member of leadership, in your opinion, what can be done to support people during this period? 4. Is there anything else you would like to add in lieu of the findings?
All interviews were audio-recorded with permission from participants. The recorded discussions were transcribed verbatim. Data analysis involved multiple readings and reflection of the transcripts. Data was then coded into themes and categories to form conclusions. A member check was carried out with each participant to validate that findings were their own views and not that of the interviewer. Interviews were analyzed using an inductive approach to allow researchers to establish a link in relation to the study's main purpose and the interpretations derived from the raw data (19) . To guard against researcher bias, and to enhance study trustworthiness, all qualitative data analysis was verified by two external qualitative research experts. Conclusions were made independently by each expert and were later compared for commonalities with the analysis carried out by the authors for common findings.

RESULTS:
The survey received a response rate of 33.6%. Respondents were predominantly female (69.5%) (n=89), while male respondents represented 30.6% (n= 41). Most participants (40.6%) were ages 31 to 40 years whereas, 39.1% were 40 to 50 years old, 14.7% were older than 50 years; and 5.4% were between 20 to 40 years old. All participants were bilingual native Arabic and English speakers. More than half (54.7%) of respondents were master's degree holders, and 14.1% had a PhD degree. Most of the respondents were faculty members or senior academics; only 21.9% were administrators.   Prominent among the hindrances to change was information process, which 36% of participants rated as a hindrance. This was followed by the organizational structure and task process, which 27% of participants perceived as a primary barrier. Over 23% of participants perceived the human resources system, management process and communication, leadership, and strategic direction as obstacles to readiness for change. The domains of employee personal goals and competencies, culture norms and morale, and external environment were perceived as presenting the least hindrance to organizational change.

Figure (3): Themes, sub-themes and categories from the semi-structured interviews
The qualitative strand was conducted to validate the findings from the OCRA tool. Five participants in leadership positions were asked to answer a set of open-ended questions. The interviews were conducted March 2019; nine months after the Royal Decree announcement. Participants were asked to share their views on strategies that could mitigate hindrances to a successful transition and potential ways to support the organization's employees during this period. The analysis resulted in two main themes, (1) organizational readiness for change, and (2) individuals' readiness for change. Each theme included two subthemes and a list of categories (See Figure 3).

-Organizational Readiness for Change:
This theme consisted of two sub-themes: hindrances and strategies to building organizational capabilities. Three interrelated categories emerged as hindrances: (a) the information processing strategy, (b) management of the transition phase, and (c) the organization's structure and its alignment with change requirements.
Participants expressed their views regarding lack of information about the organizational structure, specifically, lack of clarity regarding the academic bylaws and the financial and administrative status that denotes the independence of both institutions from the MOH. As reported by one participant: "I discovered what I told them is not right! I didn't lie, but it was based on what I knew at that time". All participants believed that driving effective organizational change was accompanied by several gaps: system gaps, resistance to letting go of the old ways of doing things, lack of transparency, and the status on the financial and administrative independence from the MOH. As summarized by one participant: "knowledge of the new organizational structure, its departments, and the required changes that accompany the new structure are still not clear to all".
Notably, new job classification and roles description were the most prominent issues in relation to the organization's structure, and its alignment with change requirements. Participants believed the lack of succession planning resulted in confusion about the new leadership's roles and responsibilities. A participant described those challenges saying: "…….people that were used to doing certain jobs moved to another position, and now the person getting the new role does not know what they should do." Participants were invited to share their views on what should be done to close the information gap; one participant stated: "I think part of the confusion which is affecting this period is communication". Another participant said: "Top leadership should re-communicate everything starting from the royal decree". The participant summarized what needs to be communicated by saying: "Where are we right now in terms of the change? The bylaws, the infrastructure, job titles, separation from the ministry in relation to finance and administration; who are the key people leading this change?" Another participant echoed the above sentiment: "The clarity of the journey, where we are heading has to be clear to all".

-Individuals Readiness for Change
A general consensus among participants regarding hindrances included: people's mindset with regards to the change. As addressed by one participant: "One of the biggest challenges we are facing now is the mindset of those people." While another said: "People are operating in the old mindset...that we are still under separate managements... how can we make people believe that we are now a college operating under one entity?".
Change-related uncertainties expressed by participants were focused on new leadership roles and responsibilities, the anticipated benefits from this change, and the psychological impact on employees. As one participant said: "We have been given new responsibilities and that we are working well" While another participant said: "The benefits out of the change we are going through right now is not clear". This sense of uncertainty was strongly captured by a participant saying: "The question is how long those people can tolerate the transition period? We have been going on in very slow motion". The above statements reflect the uncertainties faced by those who are expected to guide others during this period.
Suggestions to facilitate individual's readiness to change in accordance to participant included:  Transparency is very important.  Training has to go hand in hand with any change. And  There is an urgent need to write down all the requirements associated with the staff's new roles and responsibilities.

DISCUSSION
This study sought to evaluate the overall readiness for change at OCHS and the HIHS during the second phase of transition. Study findings indicated that readiness for change was influenced by organizational and behavioral factors. Both aspects were accompanied by challenges and possible opportunities regarding change implementation.
The quantitative part explored the context at OCHS by assessing the college readiness to implement change. Context as per the PARIHS framework refers to "the environment in which the proposed change is to be implemented" (20) . The main contextual factors contributing to successful transformation of evidence into practice are culture, leadership and evaluation (21) . Results from the quantitative strand revealed that information processing, specifically, clarity regarding readiness of the organizational structure, the bylaws, and new leadership roles were the most prominent hindrances to change. The qualitative strand also concluded that lack of a transparent communication and dissemination plan is problematic. (See Figure 4), Within the context of OCHS and the HIHS, existing evidence from the AL Moosa 2014 study, the WHO consultancy report and the OAAA audit report of the MOHEI's in 2013, it appears that the contextual challenges are a long standing issue that was not resolved. For example, the Al Moosa study findings indicated lack of a clear change management plan towards achieving college requirements, the OAAA audit report recommended improving the structure, functions and human resources capabilities of the institute governing bodies, while the WHO consultancy report addressed the need for creating bylaws that support a college degree system. In part, the failure of addressing some of aforementioned chronic contextual challenge that is hindering change can be explained by the organization lack of use and interpretation of the available evidences. As stated by Rycroft Malone, evidence is considered credible when the research, experience, and local information are considered in the decision-making process at an individual and organizational level. Additionally, Bergström and colleagues suggested that the key to successful knowledge translation into practice within the organization is a context receptive to change. Organizations those are receptive to change exhibit a culture that promotes learning and a leadership that values teamwork and democratic decision-making processes (23) . The organizational leadership must address challenges and explore potential opportunities regarding readiness of the environment, and the role of leadership in embedding a culture of change through the adoption of a learning mindset. An environment that reflects a culture of collaborative learning, flexible and adaptive to changing needs, through a shared vision that is integrated into all aspects of the organization (24) .
Facilitation of change in accordance to the PARIHS framework refers to the process of enabling the implementation into practice; facilitation is achieved by the individual carrying out his/her role in helping others; in the context of this study, the role of leadership as facilitators of change. Participants expressed feelings of uncertainty in regards to their new leadership roles. The literature shows that an important managerial function is the promotion of facilitation for learning within the organization.25 Similar findings are evident within the literature; in a study to explore the role of managers as facilitators of work-related learning, three main themes shaped the findings of the study: 1) How managers become involved in employee capability development; 2) the types of strategies deployed, and skills applied by managers to facilitate informal work-related learning and navigate challenges 3) how operations managers address the context of work to optimize learning. 26 Hence, OCHS and the HIHS should adopt a transparent communication system focusing on continual dialogue that reflects their needs and concerns. Further, leadership should adopt a culture of learning by creating a safe environment to share concerns and seek help, encouraging and valuing differing opinions, allowing safe experimentation of new ideas, and being the facilitators of change.
Since the time when this research was carried out, the following took place: several committees were established in relation to further review the organizational structures and the bylaws. Also, a change management taskforce was created in August 2018; the taskforce was charged with drawing a road map in relation to phase two of the transition period after the Royal Decree announcement; specifically, the activities required in order to meet the transition requirements of OCHS and the HIHS during the initial phase of preparation, a change management report was submitted to the College and Higher Institute Board in January 2019.

CONCLUSION
Organizations that have developed a continuous capacity to change are those that advance through finding opportunities to continuously evolve. Setting one's mind to change requires an understanding that change not only involves leadership and top management within the organization, but each employee plays a role. Therefore, being mindful that the period of transition is a period of learning is an important strategy to facilitate effective change management within the organization.

RECOMMENDATIONS
Further studies should extend the scope of this study to include students and external stakeholders. Also, future research would benefit from investigating the influence of creating a culture of learning organizations that is driven through leadership coaching for change initiatives.
This study had some limitations. Only five participants were included in the qualitative phase. Additionally, due to the nature of the qualitative strand, findings cannot be generalized.
Ethical Approval: Ethical approval was granted by the Research and Ethics Committee at the MOH in Oman. Funding: this research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors.