3 1 A Complete Dissertation The Big Picture OVERVIEW Following is a road map that briefly outlines the contents of an entire dissertation. This is a comprehensive overview, and as such is helpful in making sure that at a glance you understand up front the necessary elements that will constitute each section of your dissertation. This broad overview is a prelude to the steps involved in each of the chapters that are described and demonstrated in Part II. While certain elements are common to most dissertations, please note that dissertation requirements vary by institution. Toward that end, students should always consult with their advisor and committee members to ascertain any details that might be specific or particular to institutional or departmental requirements. FRONT MATTER Order and format of front matter may vary by institution and department. • Title page • Copyright page (optional) • Abstract • Dedication (optional) • Acknowledgments (optional) • Table of contents • List of tables and figures (only those in chapters, not those in appendices) 1. Title Page The title gives a clear and concise descrip- tion of the topic/problem and the scope of the study. The title page will show the title; Chapter 1 Objectives • Provide a cursory glance at the constitution of an entire dissertation. • Offer a comprehensive outline of all key elements for each section of the dissertation—that is, a precursor of what is to come, with each element being more fully developed and explained further along in the book. • For each key element, explain reason for inclusion, quality markers, and frequent or common errors. Objectives PART I. TAKING CHARGE OF YOURSELF AND YOUR WORK4 the author’s full name; the degree to be con- ferred; the university, department, and col- lege in which the degree is earned; and the month and year of approval. Margins for the title page and the entire document are left—1.5 inches; right, top, and bottom— 1 inch. Also, the title should be in all capitals. Reason The title both guides and reflects the pur- pose and content of the study, making its relevance apparent to prospective readers. The title is also important for retrieval pur- poses enabling other researchers to locate it through a literature search. Quality Markers A well-crafted title conveys the essence and purpose of the study. The title should include the type of study (“An Analysis”) and the participants. Use of keywords will promote proper categorization into data- bases such as ERIC (the Education Resources Information Center) and Dissertation Abstracts International. Frequent Errors Frequent title errors include the use of trendy, elaborate, nonspecific, or literary language, and grandiose or unrealistic expec- tations (e.g., “Finally, a Solution to . . .”). 2. Copyright Page (optional) Copyright is the legal right of an owner of created material to control copying and own- ership of that mate.

1. 3
1
A Complete Dissertation
The Big Picture
OVERVIEW
Following is a road map that briefly outlines
the contents of an entire dissertation. This is
a comprehensive overview, and as such is
helpful in making sure that at a glance you
understand up front the necessary elements
that will constitute each section of your
dissertation. This broad overview is a prelude
to the steps involved in each of the chapters
that are described and demonstrated in Part II.
While certain elements are common to most
dissertations, please note that dissertation
requirements vary by institution. Toward
that end, students should always consult
with their advisor and committee members
to ascertain any details that might be specific
or particular to institutional or departmental
requirements.
FRONT MATTER
Order and format of front matter may vary
by institution and department.

2. • Title page
• Copyright page (optional)
• Abstract
• Dedication (optional)
• Acknowledgments (optional)
• Table of contents
• List of tables and figures (only those in
chapters, not those in appendices)
1. Title Page
The title gives a clear and concise descrip-
tion of the topic/problem and the scope of
the study. The title page will show the title;
Chapter 1 Objectives
• Provide a cursory glance at the constitution of an entire
dissertation.
• Offer a comprehensive outline of all key elements for each
section of the dissertation—that is,
a precursor of what is to come, with each element being more
fully developed and explained
further along in the book.
• For each key element, explain reason for inclusion, quality
markers, and frequent or common
errors.
Objectives
PART I. TAKING CHARGE OF YOURSELF AND YOUR

3. WORK4
the author’s full name; the degree to be con-
ferred; the university, department, and col-
lege in which the degree is earned; and the
month and year of approval. Margins for the
title page and the entire document are
left—1.5 inches; right, top, and bottom—
1 inch. Also, the title should be in all capitals.
Reason
The title both guides and reflects the pur-
pose and content of the study, making its
relevance apparent to prospective readers.
The title is also important for retrieval pur-
poses enabling other researchers to locate it
through a literature search.
Quality Markers
A well-crafted title conveys the essence
and purpose of the study. The title should
include the type of study (“An Analysis”)
and the participants. Use of keywords will
promote proper categorization into data-
bases such as ERIC (the Education Resources
Information Center) and Dissertation
Abstracts International.
Frequent Errors
Frequent title errors include the use of
trendy, elaborate, nonspecific, or literary
language, and grandiose or unrealistic expec-
tations (e.g., “Finally, a

4. Solution
to . . .”).
2. Copyright Page (optional)
Copyright is the legal right of an owner of
created material to control copying and own-
ership of that material. Authors of research
documents who wish to protect their writing
through copyright may do so. A student may
file a claim to copyright by corresponding
directly with the U.S. Copyright Office
(Library of Congress, 101 Independence
Avenue S.E., Washington, DC 20559-6000).
The copyright symbol (©) should appear
with author’s name and year centered
between the margins on the lower half of the
backside of the title page. Below the copy-
right line, include the statement “All Rights
Reserved.”

5. © Carla Nicole Bloomberg
All Rights Reserved
3. Abstract
The abstract, limited to 350 words, is a
concise summary description of the study,
including statement of the problem, pur-
pose, scope, research tradition, data sources,
methodology, key findings, and implica-
tions. The abstract is written after the dis-
sertation is completed, and is written from
the perspective of an outside reader (i.e., not
“My dissertation examines” but “An exami-
nation of . . .”).
The page numbers before the text are in
Roman numerals. The abstract page is the
first page to be numbered, but as iii. All
Roman numerals should be centered between
the left and right margins, and 1 inch from
the bottom of the page. The title of the page,
“ABSTRACT,” should be in all capitals and
centered between the left and right margins,

6. and 2 inches from the top.
Reason
The abstract’s inclusion in Dissertation
Abstracts International (which mandates a
350-word limit) makes it possible for other
researchers to determine the relevance of this
work to their own studies. Over 95% of
American dissertations are included in Dis-
sertation Abstracts International.
Quality Markers
Marks of quality include conciseness and
accuracy. The abstract should also be written
Chapter 1. A Complete Dissertation 5
in the third person (active voice without the
personal pronouns I and we). Generally, the
first sentence of an abstract describes the
entire study; subsequent sentences expand on

7. that description.
Frequent Errors
Inclusion of irrelevant material (i.e.,
examples, information extraneous to the dis-
sertation itself), exclusion of necessary mate-
rial (i.e., problem, purpose, scope, research
tradition, data sources, methodology, key
findings, and implications), and incorrect
format are frequent abstract errors.
4. Dedication and
Acknowledgments (optional)
These pages are optional, although most
dissertations include a brief acknowledg-
ment of the contributions of committee
members, colleagues, friends, and family
members who have supported the students’
research. “ACKNOWLEDGMENTS”
should be capitalized and should appear
centered between the left and right mar-
gins, 2 inches from the top. Text should
begin two line spaces after “ACKNOWL-

8. EDGMENTS.”
The dedication page is separate from the
acknowledgments page. If included, the dedi-
cation text should be centered between the
left and right margins and between the top
and bottom margins; it should also reflect a
professional nature. Do not include the title
“DEDICATION” on the dedication page.
5. Table of Contents
An outline of the entire dissertation, list-
ing headings and subheadings with their
respective page numbers, the table of con-
tents lists all chapters and major sections
within chapters and all back matter with
page numbers.
The heading “TABLE OF CONTENTS”
is centered between the left and right mar-
gins, 2 inches from the top of the page. The
listing begins one double space below and
even with the left margin. Leader dots are
placed from the end of each listing to the cor-

9. responding page number. All major titles are
typed exactly as they appear in the text.
When a title or subtitle exceeds one line, the
second and succeeding lines are single-spaced
and indented two spaces. Double spacing is
used between major titles and between each
major title and its subtitle.
The table of contents may be followed by
any of the following, if needed, and any of
these subsequent lists are formatted in the
same manner as the table of contents:
• List of tables
• List of figures
• List of illustrations
• List of symbols
Reason
The table of contents assists the researcher
in organizing the material while promoting
accessibility for the reader.
Quality Markers

10. The headings and subheadings clearly and
concisely reflect the material being presented.
Headings and subheadings are parallel gram-
matically (i.e., “Introduction,” “Review of
Literature” not “Introduction,” “Reviewing
the Literature”). The headings and subhead-
ings in the table of contents are worded
exactly the same as those headings and sub-
headings in the text.
Frequent Errors
Frequent errors include lack of parallelism
in headings and subheadings, as well as
wording in the table of contents that does
not match wording in text.
PART I. TAKING CHARGE OF YOURSELF AND YOUR
WORK6
DISSERTATION CHAPTERS

11. Order and format of dissertation chapters
may vary by institution and department.
1. Introduction
2. Literature review
3. Methodology
4. Findings
5. Analysis and synthesis
6. Conclusions and recommendations
Chapter 1: Introduction
This chapter makes a case for the signifi-
cance of the problem, contextualizes the
study, and provides an introduction to its
basic components. It should be informative
and able to stand alone as a document.
• Introduction: The introduction includes an
overview of the purpose and focus of the

12. study, why it is significant, how it was con-
ducted, and how it will contribute to pro-
fessional knowledge and practice.
• Problem statement: The problem indicates
the need for the study, describes the issue or
problem to be studied, and situates it in a
broader educational or social context. The
problem statement includes a brief,
well-articulated summary of the literature
that substantiates the study, with references
to more detailed discussions in Chapter 2.
• Statement of purpose: Describing the research
purpose in a logical, explicit manner, the
statement of purpose is the major objective or
intent of the study; it enables the reader to
understand the central thrust of the research.
• Research question(s): Research questions
are directly tied to the purpose. They
should be specific, unambiguously stated,
and open ended. These questions cue read-
ers to the direction the study will take and
help to delineate the scope of the study.

13. • Overview of methodology: This section out-
lines the methodological type or approach,
the research setting, the sample, instrumen-
tation (if relevant), and methods of data
collection and analysis used.
• Rationale and significance: Rationale is the
justification for the study presented as a
logical argument. Significance addresses the
benefits that may be derived from doing
the study, thereby reaffirming the research
purpose.
• Role of the researcher: This section explains
the role of the researcher in planning and
conducting the study.
• Researcher assumptions: This section
makes explicit relevant researcher assump-
tions, beliefs, and biases (if applicable).
• Definition of key terminology: Some terms
may be unfamiliar to readers. Additionally,

14. the meanings of certain terms can vary
depending on the context, conceptual frame-
work, or field of study. Making terms
explicit adds precision and ensures clarity of
understanding. These terms should be oper-
ationally defined or explained; that is, make
clear how these terms are used in your study.
• Organization of the dissertation: This
brief concluding explanation delineates the
contents of the remaining chapters in the
dissertation.
Reason
The introduction sets the stage for the
study and directs readers to the purpose and
context of the dissertation.
Quality Markers
A quality introduction situates the context
and scope of the study and informs the reader,
providing a clear and valid representation of
what will be found in the remainder of the

15. dissertation. Discussion is concise and precise.
Frequent Errors
Errors occur when the introduction does
not clearly reflect the study and/or its rela-
tionship to the proposed problem and
Chapter 1. A Complete Dissertation 7
purpose, or it does not stand alone as a
document.
Chapter 2: Literature Review
This chapter situates the study in the con-
text of previous research and scholarly mate-
rial pertaining to the topic, presents a critical
synthesis of empirical literature according to
relevant themes or variables, justifies how
the study addresses a gap or problem in the
literature, and outlines the theoretical or con-
ceptual framework of the study. A disserta-

16. tion does not merely restate the available
knowledge base of a particular topic, but
adds to or augments it.
• Introduction: The introduction describes
the content, scope, and organization of the
review as well as the strategy used in the
literature search.
• Review of literature: This section
− is clearly related to the problem state-
ment, purpose, and research questions;
− states up front the bodies of literature
that will be covered, and why;
− reviews primary sources that are mostly
recent empirical studies from scholarly
journals and publications, as well as
secondary sources;
− is logically organized by theme or sub-
topic, from broad to narrow;

17. − synthesizes findings across studies and
compares and contrasts different
research outcomes, perspectives, or
methods;
− notes gaps, debates, or shortcomings in
the literature and provides a rationale
for the study; and
− provides section summaries.
• Conceptual framework: The conceptual
framework draws on theory, research, and
experience, and examines the relationship
among constructs and ideas. As such, it
is the structure or heuristic that guides
your research. In essence, the conceptual
framework provides the theoretical and
methodological bases for development of
the study and analysis of findings. When
appropriate, a graphic depiction of the
model is included, showing the relation-
ships between concepts, ideas, or vari-
ables to be studied.

18. • Summary: A comprehensive synthesis of
the literature review should complete this
section.
Reason
This chapter provides a strong theoreti-
cal basis for the dissertation by analyzing
and synthesizing a comprehensive selec-
tion of appropriate related bodies of lit-
erature. The review of literature should
build a logical framework for the research,
justify the study by conceptualizing gaps
in the literature, and demonstrate how the
study will contribute to existing knowl-
edge. The review serves to situate the
dissertation within the context of current
ongoing conversations in the field.
The conceptual framework guides the
research, and plays a major role in analy-
sis of findings.
Quality Markers

19. A comprehensive and thoughtful selec-
tion of resources that cover the material
directly related to the study’s purpose and
background, not the full scope of the field,
is considered a mark of a quality literature
review. All relevant primary sources and
empirical research studies are cited (these
are preferable to secondary sources, which
are interpretation of the work of others).
The writer adopts a critical perspective in
discussing the work of others, and provides
a clear analysis of all available related
research. Relevant literature is critiqued,
not duplicated, and there is a clear connec-
tion between the purpose of this study and
the resources included. The conceptual
framework’s role and function are clear:
The conceptual framework clearly draws on
PART I. TAKING CHARGE OF YOURSELF AND YOUR
WORK8
theory, research, and experience, providing

20. conceptual coherence to the research.
Another quality marker is the correct use of
American Psychological Association (APA)
format, citations, and references throughout.
Frequent Errors
Frequent errors include insubstantial
breadth of review (i.e., insufficient number
or range of resources; failure to include rel-
evant primary sources) and insubstantial
depth of review (i.e., use of nonscholarly
material; inability to demonstrate clear
understanding of resources). Another error
is that the review reads more like a catalog
of sources than a synthesis and integration
of relevant literature. There is also a ten-
dency to eliminate literature that contra-
dicts or questions the findings of the disser-
tation’s study. Other errors include incor-
rect or insufficient citation of sources,
resulting in accidental plagiarism, and pre-
sentation of a diagrammatic conceptual
framework with no accompanying narrative
explanation.

21. Chapter 3: Methodology
This chapter situates the study within a
particular methodological tradition, pro-
vides a rationale for that approach, describes
the research setting and sample, and des-
cribes data collection and analysis methods.
The chapter provides a detailed description
of all aspects of the design and procedures of
the study.
• Introduction: The introduction restates the
research purpose and describes the organi-
zation of the chapter.
• Rationale for research approach: This sec-
tion describes the research tradition or
paradigm (qualitative research) and the
research methodology (phenomenology,
case study, action research, etc.) with a
rationale for their suitability regarding
addressing the research questions, and cit-
ing appropriate methodological literature.

22. • Research setting/context: This section
describes and justifies selection of the
research setting, thereby providing the his-
tory, background, and issues germane to
the problem.
• Research sample and data sources: This
section
− explains and justifies the sample used
and how participants were selected
(including population and sampling pro-
cedures);
− describes the characteristics and size of
the sample, and provides other pertinent
demographic information; and
− outlines ethical considerations pertain-
ing to participants, shedding light on
how rights of participants were pro-
tected, with reference to conventions of
research ethics and the IRB (institutional
review board) process.

23. • Data collection methods: This section
describes and justifies all data collection
methods, tools, instruments, and proce-
dures, including how, when, where, and by
whom data were collected.
• Data analysis methods: This section
describes and justifies all methods and tools
used for analysis of data (manual and/or
computational).
• Issues of trustworthiness: This section dis-
cusses measures taken to enhance the study,
as well as credibility (validity) and depend-
ability (reliability).
• Limitations and delimitations: This section
identifies potential weaknesses of the study
and the scope of the study. Limitations are
external conditions that restrict or con-
strain the study’s scope or may affect its
outcome. Delimitations are conditions or
parameters that the researcher intentionally
imposes in order to limit the scope of a

24. study (e.g., using participants of certain
ages, genders, or groups; conducting the
research in a single setting). Generalizability
is not the goal of qualitative research;
rather, the focus is on transferability—that
Chapter 1. A Complete Dissertation 9
is, the ability to apply findings in similar
contexts or settings.
• Summary: A comprehensive summary over-
view covers all the sections of this chapter,
recapping and highlighting all the important
points. Discussion is concise and precise.
Reason
The study is the basis for the conclusions
and recommendations. In many ways, it is
what makes the difference between a disser-
tation and other forms of extended writing.
A clear description of the research sample,

25. setting, methodology, limitations, and delim-
itations and acknowledgement of trustwor-
thiness issues provide readers with a basis for
accepting (or not accepting) the conclusions
and recommendations that follow.
Quality Markers
A quality study achieves the purposes
outlined in the introduction’s research prob-
lem and research questions. The relationship
of the research paradigm and type of data
collection and analysis used in this study is
clear. All relevant information is clearly
articulated and presented. Narrative is
accompanied by clear and descriptive visuals
(charts, figures, tables).
Frequent Errors
Errors occur when data are not clearly
presented; the study is not applicable to pur-
poses outlined in the introduction; and meth-
ods of gathering and analyzing data and
trustworthiness issues are insufficient or not

26. clearly explained.
Chapter 4: Findings
This chapter organizes and reports
the study’s main findings, including the pre-
sentation of relevant quantitative (statistical)
and qualitative (narrative) data. Findings
are often written up in different ways depen d-
ing on the research tradition or genre
adopted.
• Introduction: The introduction provides a
brief summary of and rationale for how
data were analyzed. It describes the organi-
zation of the chapter according to research
questions, conceptual framework, or the-
matic categories.
• Findings build logically from the problem,
research questions, and design.
• Findings are presented in clear narrative
form using plentiful verbatim quotes, and

27. “thick description.” Narrative data are
connected and synthesized through sub-
stantive explanatory text and visual dis-
plays, if applicable, not simply compiled.
Some tables and figures may be deferred to
the appendices.
• Headings are used to guide the reader
through the findings according to research
questions, themes, or other appropriate
organizational schemes.
• Inconsistent, discrepant, or unexpected
data are noted with discussion of possible
alternative explanations.
• Summary: This section explains in sum-
mary form what the chapter has identified,
and also prepares the reader for the chap-
ters to follow, by offering some foreshad-
owing as to the intent and content of the
final two chapters.
Reason

28. The challenge of qualitative analysis lies
in making sense of large amounts of data,
reducing raw data, identifying what is sig-
nificant, and constructing a framework for
communicating the essence of what the data
reveal. The researcher, as storyteller, is able
to tell a story that is vivid and interesting,
and at the same time accurate and credible.
This chapter is the foundation for the analy-
sis, conclusions, and recommendations that
will appear in the next/forthcoming chapters.
PART I. TAKING CHARGE OF YOURSELF AND YOUR
WORK10
Quality Markers
Markers of a quality findings chapter
include clear, complete, and valid representa-
tion of the data that have emerged as a result
of the study and effective use of graphs,
charts, and other visual representations to
illustrate the data. Findings are presented

29. objectively, without speculation—that is, free
from researcher bias. Presentation and struc-
ture in this chapter are neat and precise,
and related to the study’s qualitative tradition
or genre.
Frequent Errors
Errors occur when study findings are
manipulated to fit expectations from research
questions, or when researcher bias and/
or subjectivity is apparent. Other frequent
errors include poor or invalid use of visual
representation, and findings not overly
generalized.
Chapter 5: Analysis and Synthesis
This chapter synthesizes and discusses the
results in light of the study’s research ques-
tions, literature review, and conceptual frame-
work. Finding patterns and themes is one
result of analysis. Finding ambiguities and
inconsistencies is another. Overall, this chapter
offers the researcher an opportunity to reflect

30. thoroughly on the study’s findings, and the
practical and theoretical implications thereof.
• Introduction: The introduction provides an
overview of the chapter’s organization and
content.
• Discussion: This section provides an
in-depth interpretation, analysis, and
synthesis of the results/findings.
− Analysis is a multilayered approach.
Seeking emergent patterns among findings
can be considered a first round of analysis.
Examining whether the lite rature corre-
sponds with, contradicts, and/or deepens
interpretations constitutes a second layer
of interpretation.
− Issues of trustworthiness are incorpo-
rated as these relate to and are applied
throughout the analysis process.
− Discussion may include interpretation of

31. any findings that were not anticipated
when the study was first described.
Establishing credibility means that you
have engaged in the systematic search
for rival or competing explanations and
interpretations.
− This section restates the study’s limita-
tions and discusses transferability of the
findings to broader populations or other
settings and conditions.
Reason
Analysis is essentially about searching
for patterns and themes that emerge from
the findings. The goal is to discover what
meaning you can make of them by compar-
ing your findings both within and across
groups, and with those of other studies.
Interpretation that is thoughtful and com-
pelling will provide the opportunity to
make a worthwhile contribution to your
academic discipline.

32. Quality Markers
There is no clear and accepted single set
of conventions for the analysis and interpre-
tation of qualitative data. This chapter
reflects a deep understanding of what lies
beneath the findings—that is, what those
findings really mean. Interpretation is pre-
sented systematically, and is related to the
literature, conceptual framework, and inter-
pretive themes or patterns that have emerged.
A key characteristic of qualitative research is
willingness to tolerate ambiguity. As such,
examining issues from all angles in order to
demonstrate the most plausible explanations
is an indication of high-level analysis. Integ-
rity as a researcher is given credence by
Chapter 1. A Complete Dissertation 11
inclusion of all information, even that which
challenges inferences and assumptions.

33. Frequent Errors
Frequent errors include analysis that is
simple or shallow. Synthesis is lacking; there
is no clear connection to other research litera-
ture, or theory. Credibility and/or plausibility
of explanations is in question. The chapter is
poorly structured, presented, and articulated.
Chapter 6: Conclusions and
Recommendations
This chapter presents a set of concluding
statements and recommendations. Conclu-
sions are assertions based on findings, and
must therefore be warranted by the findings.
With respect to each finding, you are asking
yourself, “Knowing what I now know, what
conclusion can I draw?” Recommendations
are the application of those conclusions. In
other words, you are now saying to yourself,
“Knowing what I now know to be true, I
recommend that . . .”
• Conclusions are based on an integration of

34. the study findings, analysis, interpretation,
and synthesis.
• Concluding statements end the dissertation
with strong, clear, concise “takeaway mes-
sages” for the reader.
• Conclusions are not the same as findings;
neither are conclusions the same as inter-
pretations. Rather, conclusions are essen-
tially conclusive statements of what you
now know, having done this research, that
you did not know before.
• Conclusions must be logically tied to one
another. There should be consistency
among your conclusions; none of them
should be at odds with any of the others.
• Recommendations are actionable; that is,
they suggest implications for policy and
practice based on the findings, providing
specific action planning and next steps.
• Recommendations support the belief that

35. scholarly work initiates as many questions
as it answers, thus opening the way for
further practice and research.
• Recommendations for research describe
topics that require closer examination
and that may generate new questions for
further study.
Reason
This chapter reflects the contribution the
researcher has made to the knowledge and
practice in his or her field of study. In many
ways, it provides validation for the research-
er’s entrance into the ranks of the body of
scholars in the field.
Quality Markers
Clearly stated and focused concluding
statements reflect an integration of the study
findings, analysis, interpretation, and synthe-
sis. Recommendations must have implica-
tions for policy and practice, as well as for

36. further research, and must be doable. The
reasonableness of a recommendation depends
on its being logically and clearly derived
from the findings, both content and context
specific, and most important, practical and
capable of implementation.
Frequent Errors
Overgeneralization of importance or rele-
vance sometimes leads to grandiose state-
ments. Other frequent errors include the lack
of a clear link to the review of literature, or
recommendations that have no clear useful-
ness for practice and future research; that is,
they are not “doable.”
Epilogue, Afterword, or Final Thoughts
This final section offers the researcher
an opportunity to reflect on the overall
PART I. TAKING CHARGE OF YOURSELF AND YOUR

37. WORK12
process, review the findings that have
emerged, and share any new learning and
insights that she or he has developed over
the course of the research and writing
process. How do you personally value the
research experience? What are the lessons
you have learned from conducting the
study? What insights, knowledge, and
inspiration have you derived from con-
ducting this study?
BACK MATTER
Appendices
Appendices contain all research instru-
ments used, as well as any relevant additional
materials such as sample interview tran-
scripts, sample coding schemes, summary
charts, and so forth. Each item that is
included as an appendix is given a letter or
number and listed in the table of contents.

38. References
…
Running head: IMPACT OF CHANGE MANAGEMENT IN
HEALTHCARE1
IMPACT OF CHANGE MANAGEMENT IN HEALTHCARE 6
The Impact of Change Management in Healthcare
Name:
Institution:
Date:
Introduction
Change management is one of the pressing issues every
organization is confronted with especially in an environment
where change is associated with success or failure. The
healthcare organizations are not left out in this change frenzy as
they also seek to succeed through successful change
implementation. Rapid change is being recorded in the health
care organizations, mostly as they try to adopt new technologies
and improve the quality of patient care, as well as manage the
performance of the healthcare personnel. The best way to deal
with the change, as literature reveals, is helping the employees

39. adopt new ways of doing things (Campbell, 2008).
By definition, change management entails the process leading to
the realization of the ideal state of the organization. In other
words, change management in an organization entails
overseeing the transition from the current state to the desired
state. The process of change begins with the creation of a vision
for the change. This is then followed by empowering the people
responsible with the change to act as agents of the change and
help attain the change. The change management process often
involves many participants with roles that are clearly defined.
These may include the owners of the change, the managers of
the change, and the owners of the processes among others.
Change management often impacts on various people
differently. The stakeholders in a change management are
varied and this includes the participants to the change and other
groups that affected directly and indirectly by the change. In the
healthcare organizations, these impacts will be felt depending
on the type of change and the result of change. For example, the
change might be concerned with the introduction of new
technologies, and this will mean new skills for the personnel
and possibly a new structure for the entire organization. Change
management in healthcare organizations, therefore, requires that
the managers fully understand change and its impacts before
making efforts to implement the change.
Problem statement

40. The changes in the organizational environment in the healthcare
can force the organizations to adopt new structures, strategies
and business models and requirements among other core
aspects. The environment in the healthcare sector cannot be said
to be stable, but one characterized by a high rate of volatility.
The change management in these organizations has not always
been successful – the success rate of the implementation of new
changes is quite low. This can be partly because the people
responsible do not fully understand the nature of the change and
its impacts on the various stakeholders. The low rates of success
in change implementation call for some deliberate efforts to
examine what changes take place in the healthcare
organizations, the people responsible for the change, and the
impacts of these changes on the various stakeholders. More so,
managing change will include managing the resistance to
change, and this presents another reason for understanding
change and its impact on the stakeholders
Objectives
The primary objective of this research is to present an
understanding of the change management in healthcare
organizations. The focus in on the impact of change
management practices on stakeholders such as nurses,
physicians, and doctors among others. The specific objectives
are as outlined below:
· To establish the key types of change experienced in the

41. healthcare organizations.
· To establish the people involved in the change management
process in the healthcare organizations.
· To establish the impact of change management in healthcare
organizations.
· To establish the role of management and leadership in change
management in healthcare organizations.
· Establish the implications of change management on nurses
and other professionals.
Research questions
The research questions are derived from the research objectives
presented above. As such, the primary research question is what
is the impact of change management in healthcare
organizations? The research questions are as follows?
· What are the key types of change experienced in the
healthcare organizations?
· What groups of people involved in the change management
process in the healthcare organizations?
· What is the impact of change management in healthcare
organizations?
· What is the role of management and leadership in change
management in healthcare organizations?
· What are the implications of change management on nurses
and other professionals?

42. Literature review
There are several major types of changes explained in the
literature that are experienced in the healthcare industry. In this
case, literature has revealed that technological changes,
strategic changes and innovations in pursuit of better patient
care are among the most influential ones. Change management,
it has been hypothesized, will entail managing the change
process itself and the people who most likely to resist the
change.
It is acknowledged that the healthcare managers today tend to
occupy an extremely challenging position requiring them to
maintain a competitive edge in a healthcare market while
leading the organization through a constant change (Campbell,
2008). Organizations today, regardless of the industry or
sector, are experiencing rapid technological change. The
healthcare organizations are also subject to this phenomenon
whereby technology is the key driver of change. The healthcare
organizations are adopting new technologies as they try to
implement quality improvement initiatives and performance
management initiatives such as pay-for-performance (Campbell,
2008). Technology can be disruptive in that it can completely
change the face and operations of the organizations, and the
change management in healthcare will need to take into account
that new models and structures might result. In such a case, the
biggest challenge is often preparing the nurses to cope with

43. such changes which could have huge impacts in the nature of
their careers. For example, they could not be required to have
IT skills for them to handle the new IT systems being
implemented.
Besides the technology changes, the change management in
healthcare is also concerned with the shifts in the environment
which tend to compel the healthcare organizations to change
their strategies (Caldwell, Chatman, O'Reilly III, Ormiston, &
Lapiz, 2008). Research in change management in healthcare has
revealed that strategic change often fails owing to the inability
of the individuals to adopt the necessary behaviors for the
successful implementation of the new strategy. The healthcare
management and leadership, therefore, are seen to be deficient
in terms of proper change implementation. A change in strategy
is something that would require a change in behavior, meaning
that the behavioral change should be the first thing to
implement. The behavioral change should lay the foundation for
the strategy change whereby everyone is brought on board.
Literature has established that this form of change requires a
unique approach. The hypotheses set out by Caldwell, Chatman,
O'Reilly III, Ormiston, & Lapiz (2008) include that the
management and leadership should gain support for the strategic
change and introduce norms for change readiness. According to
Klein, Conn, and Sorra (2001), a successful change
implementation will require an ‘implementation climate’, a term

44. defined as support for the specific change. Their study was
concerned with the application of advanced computerized
manufacturing technology, but the principle applies to all
organizational contexts. An implementation climate in a
healthcare organization would probably be that climate where
the organizational members are not only ready for the change,
but also support the change entirely.
Teamwork in change management in healthcare has also been
found to facilitate a successful change implementation.
Researchers like Markóczy (2001) have established that when
the members of the management team are in agreement or have
a consensus on the change direction, there is a greater
likelihood of success. This leads to another hypothesis that
there will be greater performance improvements where the
members agree on the nature of the new strategy. The healthcare
management is, therefore, presented with a challenge of
achieving this unity that will drive the speed and effectiveness
of the change process. Team leadership becomes a necessity
because, as research has established, the senior leaders may
have a critical role in the identification and implementation of
the new strategy, the middle managers leading the various
groups have the ability to enhance or undermine this
implementation (House & Aditya, 1997). This means that the
middle managers and the nurses collectively and individually
have an influence on the success of change implementation.

45. Each individual must be brought on board, a challenge for the
managers who need to overcome the resistance to change.
According to Kodama & Fukahori (2017), the nurse managers
are the first-line managers who are responsible for inducing
change in the clinical environment.
According to Al- Abri (2007, p. 9), the change management in
healthcare has to contend with the fact that the healthcare
professionals, including nurses, are obligated to acquire and
maintain the expertise requisite for their tasks as they will only
be given tasks falling within their individual competencies.
With the change occurring frequently, all these professionals
may be required to update continuously their expertise in order
to remain relevant to this sector. This is why researchers like
Al- Abri (2007, p. 9) argue that change management entails
managing the complexity of the processes – that is, planning,
evaluating, and implementing operations, strategies and tactics
that ensure that the change is relevant and worthwhile.
Managing resistance is especially important at the lower levels
where professionals like the nurses could face and resist a
change in the nature of their careers.
The pursuit of patient safety initiatives is another reason why
the healthcare organizations have to be worried about change
management. There are often some unintended consequences
when these organizations pursue patient safety without
undertaking effective change management (Ramanujam, Keyser,

46. & Sirio, 2005, p. 455). Herein, the management and leadership
in the healthcare organizations need to understand the inputs
shaping the strategy (both internal and external) before
developing strategies to achieve specified outcomes. According
to these researchers, the senior management and leadership has
an active role in the change initiation, and are also responsible
for energizing the process of change. This leadership must also
make sure that on board are senior administrators, clinicians,
nurses, and opinion leaders among others. In other words, all
members of the organization have to participate in the change
process.
The improvement of patient care has been a top priority in
almost all healthcare organizations and this exerts a lot of
pressure. Ducharme, Buckley, Alder, and Pelletier (2009, p. 70)
establish that among the challenges facing Ontario healthcare
organizations include overcrowding and long wait times that
degrade the quality of care. Innovative and timely solutions to
such challenges are a priority. A literature review presented by
Antwi and Kale (2014, p. 1) also indicates that the Canadian
healthcare organizations were in need for solutions to problems
such as long wait hour and timely access to care. This literature
review reveals that the patient care is a critical factor affecting
the changes in the healthcare. The pursuit of better patient care
means pursuing innovations in both systems, structures,
technologies, etc. These researchers express the need for the

47. managers and decision makers to understand how change occurs
in order for them to create a conducive environment for the
innovations.
Theoretical framework
Today, several theories have been developed in the field of
change management. Models have also been developed by
several of the world’s renowned thinkers like John Kotter and
William Bridges. Kotter, for example, developed a model
expressing eight steps of managing change:
· Increasing urgency
· Building guiding teams
· Getting the vision right
· Communicating for buy-in
· Enabling action
· Creating short term wins
· Making sure not to let up
· Making the change stick
Lippitt, Watson, and Westley (1958) present a change
management theory focusing on the role and responsibilities of
the change agents. There are seven steps in this theory – 1)
diagnosing the problem; 2) assessing the motivation and
capacity for the change; 3) assessing the resources and
motivation for the agent of change; 4) choosing progressive
change objects, strategies and plans for action; 5) clarifying the
roles and expectations of all parties; 6) maintaining change

48. through actions such as feedback, communication, and
coordination; and 7) withdrawal from the change agent. This
theory is basically a collective development of behavioral
change setting up the change environment.
Significance to nursing
Nursing profession is particularly affected by the various types
of changes highlighted herein. They are faced with a situation
whereby their occupation is subjected to change and where the
changes often result into new structures, perspectives, and even
environments. This research will be particularly important to
the nurses as they learn how the changes affect them and their
careers. This will help them to appreciate the fact that the
change is necessary and that they need to facilitate it through
creating a conducing implementation environment. They will
learn to anticipate the change and get ready for it.
Research design and method
Introduction
The research methods, by definition, entail the tools and
techniques used in doing the research (Willian, 2011, p. 1).
They are a range of tools used for the various types of inquiry,
reasoning that a research is basically an inquiry or search of
knowledge (Kothari, 2004). This section of the proposal
presents an overview of these tools and how they will be
methodically used to answer the research questions presented
earlier on. It is important to emphasize on the nature of the

49. research – it will involve an inquiry into the change
management practices in the healthcare sector to establish its
impacts, types of change, stakeholders, and implications among
other aspects.
A qualitative approach will be used for this study owing to the
fact that it will involve collection and analysis of qualitative
data. A qualitative research has been hailed as the best way to
explore various dimensions of social life, including the weave
and texture of the everyday life of the society (Mason, 2002, p.
1). The qualitative research can be defined as a systematic and
empirical inquiry into meaning (Ospina, 2004). Since the
qualitative research involves both naturalistic and interpretive
settings, it can be said that qualitative researchers are concerned
with studying the subjects in their natural settings as they try to
make sense of or interpret phenomena.
An institutional ethnographic design will be adopted for this
research. The ethnographic research is indeed a genre of
qualitative research developed out the anthropological
methodology (Shagrir, 2017). This type of research often seeks
to investigate cultures and societies through the examination of
the human, social ad interpersonal aspects. It is closely
associated with the core qualitative methods of observation and
interviewing. It is important to notice that ethnography emerged
and developed as a social science tool. The researcher in an
ethnographic research is a social scientific observer. Other

50. participants in an ethnography are the observed and the
audience to whom the reports (in the form of text) are made
(Naidoo, 2012, p. 1).
The institutional ethnography can simply be described as
ethnographic practices in specific institutional contexts.
According to Gerhard (2011), institutional ethnography is an
inquiry method describing the institutional situations in detail
and analysing the actions and interpretations of the people make
these situations recognizable institutional contexts. As an
institutional ethnography, this research will involve the
researcher (or the scientific observer) interacting with the
healthcare organizations or institutions to learn about the
change management practices.
Research participants
The research participants, besides the researcher, will be the
two organizations selected and their employees and
management/leadership. The people with whom the researcher
interacts with will be selected on the convenience criteria, the
rationale being that an organization with very many employees
might not be easy to make contacts and spend adequate time
with each employee. The researcher’s interest is on the change
management practices and their impacts on the various
stakeholders, a select few of which the researcher will interact
with to learn all that is necessary.
The targeted sample for this research will be 100 participants

51. from the various levels of the organization. The nurses, being
the greater focus of the research, will be allocated 40% of this
figure. The physicians and line managers will be allocated
another 40%, and the remaining 20% will go to the executives
and top management. Stratified random sampling method will
be used whereby the participants will be selected as per the
three groups, and randomly selected until the desired figures are
reached. Taking into account the voluntary nature of the
research, rejected requests will be replaced by other requests
until the researcher obtains a full 100 research participants.
Protection of participants
The protection of the participant will be facilitated through the
researcher observing the various ethical principles in a research.
The researcher will make sure not to harm in any way the
research participants, physically, mentally, or otherwise. The
anonymity of the responses will be maintained and the
researcher shall not link any employee or participant with any
observation or interview response. The personal information
shall not be disclosed to protect the privacy of the participants.
Lastly, the researcher will make sure to obtain consent of the
participants before engaging them in any research activity.
Data collection
Two methods of data collection will be used for this research –
observations and interviews. Much of the data collection this
design is collected through observation. In this method, a

52. checklist of the researcher’s expectations and hypotheses will
be used as the framework for data collection. The researcher
will make the relevant notes to keep record of all observations
related to the research. However, there are cases where it is not
easy to observe what is being done, especially during secluded
boardroom executive meetings where much of the change
management decisions will be made. This means that the
interview method will be of equal importance to the researcher.
The interviews will be conducted on face-to-face basis where
the institutional ethnographer will prepare a set of questions for
the interviews. Open-ended questions are preferred because they
allow the respondents to freely express themselves and provide
as much information as possible. There are more than one
occupations in a healthcare institution, and this means that the
researcher will have to prepare a different set of questions for
each occupation or level in the organizational hierarchy. These
questions will be aligned with the primary theme of the research
– that is, the change management practices and their
implications. The interviews will be tape-recorded for
reference.
Credibility
Credibility entails the truth of the data and/or the participant
views, their interpretations and representation. The researcher
will adopt various techniques to improve the research rigor.
Firstly, the research will adhere to the research guidelines and

53. ethics as prescribed. The researcher will also ensure that the
findings are valid and reliable, and this will mean overcoming
various challenges like consistency. The researcher will give the
research adequate time and resources, seek feedback where
necessary, and work within a specified framework that keeps the
study focused on achieving the research objectives. The
credibility of the research will be achieved through
demonstrating engagement, audit of trails and the methods of
observation. Sections of the recorded interviews and original
field notes will feature occasionally in the report as proof of the
information collected.
Dissemination of findings
The dissemination of the findings will follow a simple
procedure. The researcher will first understand the audience of
the findings and select the best tools and techniques for analysis
and presentation that yields results understandable by the
audience. The dissemination will be in the form of a research
report addressed to these audiences that will highlight the aim
of the research, the methods and procedures, and the results of
the research.
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for Organizational Change in Patient Safety Initiatives.
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Shagrir, L. (2017). Journey to Ethnographic Research.
Willian, N. (2011). Research Methods: The Basics. New York:
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cs.pdf

57. Qualitative Research in Psychology, 11:25–41, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1478-0887 print/1478-0895 online
DOI: 10.1080/14780887.2013.801543
Sampling in Interview-Based Qualitative Research:
A Theoretical and Practical Guide
OLIVER C. ROBINSON
University of Greenwich, Department of Psychology and
Counselling,
London, UK
Sampling is central to the practice of qualitative methods, but
compared with data
collection and analysis its processes have been discussed
relatively little. A four-point
approach to sampling in qualitative interview-based research is
presented and criti-
cally discussed in this article, which integrates theory and

58. process for the following:
(1) defining a sample universe, by way of specifying inclusion
and exclusion criteria for
potential participation; (2) deciding upon a sample size, through
the conjoint consider-
ation of epistemological and practical concerns; (3) selecting a
sampling strategy, such
as random sampling, convenience sampling, stratified sampling,
cell sampling, quota
sampling or a single-case selection strategy; and (4) sample
sourcing, which includes
matters of advertising, incentivising, avoidance of bias, and
ethical concerns pertain-
ing to informed consent. The extent to which these four
concerns are met and made
explicit in a qualitative study has implications for its coherence,
transparency, impact
and trustworthiness.
Keywords: case study; purposive sampling; quota sampling;
random sampling; recruit-
ment; sample size; sampling; stratified sampling; theoretical
sampling
Sampling is an important component of qualitative research

59. design that has been given less
attention in methodological textbooks and journals than its
centrality to the process war-
rants (Mason 2002). To help fill this void, the current article
aims to provide academics,
students and practitioners in psychology with a theoretically
informed and practical guide
to sampling for use in research that employs interviewing as
data collection. Recognised
methods in qualitative psychology that commonly use
interviews as a data source include
Interpretative Phenomenological Analysis (IPA), Grounded
Theory, Thematic Analysis,
Content Analysis and some forms of Narrative Analysis. This
article presents theoretical
and practical concerns within a framework of four pan-
paradigmatic points: (1) setting a
sample universe, (2) selecting a sample size, (3) devising a
sample strategy and (4) sam-
ple sourcing. Table 1 summarises the principle features of these.
All of the aforementioned
methods can be used in conjunction with this four-point
approach to sampling.
Point 1: Defining a Sample Universe

60. The first key concern in the four-point approach is defining the
sample universe (also called
“study population” or “target population”). This is the totality
of persons from which cases
Correspondence: Oliver C. Robinson, PhD, University of
Greenwich, Department of Psychology
and Counselling, Southwood Site, Avery Hill Road, London,
SE9 2UG, United Kingdom. E-mail:
[email protected]
25
26 O. C. Robinson
Table 1
The four-point approach to qualitative sampling
Name Definition Key decisional issues
Point 1 Define a sample
universe

61. Establish a sample universe,
specifically by way of a set of
inclusion and/or exclusion
criteria.
Homogeneity vs.
heterogeneity,
inclusion and
exclusion criteria
Point 2 Decide on a sample
size
Choose a sample size or sample
size range, by taking into
account what is ideal and
what is practical.
Idiographic (small) vs.
nomothetic (large)
Point 3 Devise a sample
strategy
Select a purposive sampling

62. strategy to specify categories
of person to be included in the
sample.
Stratified, cell, quota,
theoretical strategies
Point 4 Source the sample Recruit participants from the
target population.
Incentives vs. no
incentives, snowball
sampling varieties,
advertising
may legitimately be sampled in an interview study. To delineate
a sample universe, a set
of inclusion criteria or exclusion criteria, or a combination of
both, must be specified for
the study (Luborsky & Rubinstein 1995; Patton 1990). Inclusion
criteria should specify an
attribute that cases must possess to qualify for the study (e.g., a
study on domestic violence
that specifies that participants must be women who have
suffered partner violence that was

63. reported to the police or social services), while exclusion
criteria must stipulate attributes
that disqualify a case from the study (e.g., a study on exercise
that stipulates that participants
must not be smokers). Together, these criteria draw a boundary
around the sample universe,
as illustrated in Figure 1.
Homogeneity and Heterogeneity in the Sample Universe
The more inclusion and exclusion criteria that are used to define
a sample universe, and
the more specific these criteria are, the more homogenous the
sample universe becomes.
Sample universe homogeneity can be achieved along a variety
of parameters, such as
demographic homogeneity, graphical homogeneity, physical
homogeneity, psychological
homogeneity or life history homogeneity (see Table 2 for
descriptions of these). The
addition of exclusion or inclusion criteria in these different
domains increases sample
homogeneity.
One of these forms of homogeneity, psychological homogeneity,

64. is established if a
criterion for case inclusion is a particular mental ability,
attitude or trait. To make case
selection possible based on this kind of criterion, quantitative
data from questionnaires or
tests can be used as sampling tools (Coleman, Williams &
Martin 1996). For example,
Querstret and Robinson (2013) gained quantitative data on the
extent to which individuals
self-report having a personality that varies across different
social contexts, and used this
data to select individuals who were one standard deviation or
more above the mean for
Sampling in Interview-Based Qualitative Research 27
Sample universe
The total population of
possible cases for the
sample

65. Sample
The selection of cases
from which data is
actually collected
Inclusion criteria
Specify who/what is
permissible for inclusion
in the sample
Exclusion criteria
Specify who/what
cannot be included in
study

66. Figure 1. Sample universe, inclusion/exclusion criteria and
sample.
“cross-context variability.” These persons were then
interviewed for a qualitative study
about the motivations for, and experiences of, varying
behaviour and personality according
to social context.
The extent of sample universe homogeneity that a research
study aims at is influ-
enced by both theoretical and practical factors. Theoretically,
certain qualitative methods
have a preference for homogenous samples; for example
Interpretative Phenomenological
Analysis is explicit that homogenous samples work best in
conjunction with its philosoph-
ical foundations and analytical processes (Smith, Flowers &
Larkin 2009). By maintaining
a measure of sample homogeneity, IPA studies remain
contextualised within a defined set-
ting, and any generalisation from the study is made cautiously
to that localised sample
universe.

67. Conversely, there are approaches that aim to gain samples that
are intentionally het-
erogeneous, for example, the variation sampling technique of
Grounded Theory (Strauss
& Corbin 1998), or the cross-contextual approach described by
Mason (2002). The ratio-
nale for gaining a heterogeneous sample is that any
commonality found across a diverse
group of cases is more likely to be a widely generalisable
phenomenon than a commonality
found in a homogenous group of cases. Therefore, heterogeneity
of sample helps provide
evidence that findings are not solely the preserve a particular
group, time or place, which
can help establish whether a theory developed within one
particular context applies to other
contexts.
Cross-cultural qualitative research is another instance that may
call for a demograph-
ically and geographically heterogeneous sample. Such research
selects individuals from
different cultures in order to compare them and search for
similarities and differences.
An example of qualitative research conducted at such a scale

68. was the EUROCARE study;
the sample universe comprised persons caring for co-resident
spouses with Alzheimer’s in
14 European countries (Murray et al. 1999; Schneider et al.
1999). This influential piece of
28 O. C. Robinson
Table 2
Five types of sample homogeneity
Source of
homogeneity Description
Example hypothetical study and
sample requirement
Demographic
homogeneity
Homogeneity imparted by a
demographic commonality
such as a specific age range,

69. gender, ethnic or
socio-economic group
A study on menopause that
requires participants to be
women between the ages of
50 and 55
Geographical
homogeneity
Refers to sample that is all
drawn from the same
location
A study that evaluates Cognitive
Behavioural Therapy provision
in Birmingham
Physical homogeneity Occurs in a sample who must
share a common physical
characteristic
A study on coping with cystic
fibrosis that requires

70. participants who currently
suffer from the disease
Psychological
homogeneity
Similarity within a sample
imparted when participants
are selected based on the
possession of a particular
trait or ability
A study into gifted children that
requires participants to have an
IQ of over 150
Life history
homogeneity
Homogeneity resulting from
participants sharing a past
life experience in common
A study on motivations for
migration that requires

71. participants to have moved as a
migrant to the UK between the
ages of 20 and 40
research shows that cross-cultural qualitative research can be
successfully conducted with
a culturally heterogeneous sample universe, if resources are
available.
There are, however, challenges inherent in using a
heterogeneous sample. The
first is that findings will be relatively removed from real-life
settings, and the second
is that the sheer diversity of data may lessen the likelihood
meaningful core cross-
case themes being found during analysis. Therefore, all
researchers must consider the
homogeneity/heterogeneity trade-off for themselves and
delineate a sample universe that is
coherent with their research aims and questions and with the
research resources they have
at their disposal.
The sample universe is not only a practical boundary that aids
the process of sampling,

72. but it also provides an important theoretical role in the analysis
and interpretation process
by specifying what a sample is a sample of , and thus defining
who or what a study is about.
The level of generality to which a study’s findings is relevant
and logically inferable is
the sample universe (Mason 2002), thus the more clearly and
explicitly a sample universe
is described, the more valid and transparent any generalisation
can be. If a study does not
define a sample universe, or makes claims beyond its own
sample universe, this undermines
its credibility and coherence.
Sampling in Interview-Based Qualitative Research 29
Point 2: Deciding on a Sample Size
The size of a sample used for a qualitative project is influenced
by both theoretical and
practical considerations. The practical reality of research is that
most studies require a pro-
visional decision on sample size at the initial design stage.

73. Without a provisional number
at the design stage, the duration and required resource-
allocation of the project cannot be
ascertained, and that makes planning all but impossible.
However a priori sample specifi-
cation need not imply inflexibility; instead of a fixed number,
an approximate sample size
range can be given, with a minimum and a maximum.
Interview studies that have a nomothetic aim to develop or test
general theory are to a
degree reliant on sample size to generalise (Robinson 2012).
Sample size is by no means the
only factor influencing generalisability, but it is part of the
picture. O’Connor and Wolfe’s
grounded theory study of midlife transition, which was based on
interviews with a sample
of 64 adults between the ages of 35 and 50 (O’Connor & Wolfe
1987), illustrates this point;
the relatively large sample supports the nomothetic aim of the
study. A way of working
with larger sample sizes in qualitative research, which prevents
analytical overload, is to
combine separate studies together into larger syntheses. For
example, I recently combined

74. findings from a series of three studies on the topic of early adult
crisis into a single analytical
synthesis and article. One contributing study had a sample of 16
cases, the second had a
sample of 8 cases, and the third employed a sample of 26 cases.
These were analysed and
reported as separate studies originally, before being combined
into the synthesis paper with
a total sample of N = 50 (Robinson, Wright & Smith 2013).
Very large-scale qualitative interview projects include hundreds
of individuals in their
sample. For example, the aforementioned EUROCARE project
employed a sample size of
approximately 280 (20 persons of for each of 14 countries)
(Murray et al. 1999), and the
MIDUS study (The Midlife in the United States Study) is a
study that has involved more
than 700 structured interviews (Wethington 2000). While such
projects do require time,
money, many researchers and a robust purposive sampling
strategy (see below), they are
achieved by breaking up the research into smaller substudies
that are initially analysed on
their own terms before being aggregated together.

75. Interview research that has an idiographic aim typically seeks a
sample size that is
sufficiently small for individual cases to have a locatable voice
within the study, and for
an intensive analysis of each case to be conducted. For these
reasons, researchers using
IPA are given a guideline of 3–16 participants for a single
study, with the lower end
of that spectrum suggested for undergraduate projects and the
upper end for larger-scale
funded projects (Smith et al. 2009). This sample size range
provides scope for developing
cross-case generalities, while preventing the researcher being
bogged down in data, and
permitting individuals within the sample to be given a defined
identity, rather than being
subsumed into an anonymous part of a larger whole (Robinson
& Smith 2010a).
Case study design is often referred to as a distinct kind of
method that is separable
from standard qualitative method (e.g., Yin 2009). In relation to
interview-based case-
studies, a more integrative view is taken here in which the

76. decision to do a N = 1 case
study is a sample size decision to be taken as part of the four-
point rubric set out in this
guide. The resulting case study can then be analysed using an
idiographic interview-focused
method such as IPA. There are a number of different reasons for
choosing a sample size
of 1, and Table 3 lists six of these: psychobiography, theoretical
or hermeneutic insight,
theory-testing or construct-problematising, demonstration of
possibility, illustration of best
practice and theory-exemplification. All of these warrant a
sample size of one and require
associated sample strategies, which are discussed later in this
article.
Ta
bl
e
3
Si

77. x
fu
nc
tio
ns
of
an
N
=
1
sa
m
pl
e
si
ze

78. C
as
e-
st
ud
y
fu
nc
tio
n
D
es
cr
ip
tio
n
Ps

79. yc
ho
bi
og
ra
ph
y
Pr
ov
id
in
g
in
fo
rm
at
io

80. n
ab
ou
ta
n
in
di
vi
du
al
of
pa
rt
ic
ul
ar

81. in
te
re
st
or
si
gn
ifi
ca
nc
e,
by
us
in
g
ex
is

82. tin
g
th
eo
ry
an
d
co
nc
ep
ts
al
lie
d
to
ri
ch

83. de
sc
ri
pt
io
n
to
ill
um
in
at
e
an
d
in
te

84. rp
re
tt
he
ir
be
ha
vi
ou
r
an
d
th
ou
gh
ts
.E

85. xa
m
pl
es
of
th
is
in
cl
ud
e
th
e
ps
yc
ho
bi

86. og
ra
ph
ic
al
an
al
ys
is
of
G
eo
rg
e
W
.B

87. us
h
by
M
cA
da
m
s
an
d
Sc
hu
ltz
(2
01
0)
,o

88. r
E
ri
ks
on
’s
w
or
k
on
G
an
dh
i(
19
69
)

89. an
d
M
ar
tin
L
ut
he
r
(1
99
3)
.
T
he
or

90. et
ic
al
or
he
rm
en
eu
tic
in
si
gh
t
T
he
or
et

91. ic
al
in
si
gh
tg
ai
ne
d
fr
om
in
te
ns
iv
e
ex

92. am
in
at
io
n
of
a
si
ng
le
ca
se
ca
n
be
pu

93. tf
or
w
ar
d
fo
r
va
lid
at
io
n
in
ot
he
r
sa

94. m
pl
es
.A
n
ex
am
pl
e
of
th
is
is
th
e
re
se

95. ar
ch
by
N
ei
ss
er
(1
98
1)
on
th
e
tr
an
sc

96. ri
pt
s
fr
om
on
e
pe
rs
on
in
th
e
W
at
er
ga

97. te
Sc
an
da
l,
w
hi
ch
w
as
us
ed
to
ch
al
le
ng

98. e
an
d
ex
te
nd
m
od
el
s
of
m
em
or
y,
or

99. th
e
w
or
k
by
R
ei
ch
er
(1
99
6)
on
ri
ot
s

100. as
a
w
ay
of
st
im
ul
at
in
g
th
eo
ry
de
ve
lo

101. pm
en
ti
n
so
ci
al
an
d
cr
ow
d
pr
oc
es
se

102. s.
T
he
or
y-
te
st
in
g
or
co
ns
tr
uc
t-
pr
ob

103. le
m
at
is
in
g
A
ge
ne
ra
lt
he
or
y
or
hy
po

104. th
es
is
ca
n
be
te
st
ed
or
ch
al
le
ng
ed
by

105. re
co
ur
se
to
ev
id
en
ce
fr
om
on
e
ca
se
,b
as

106. ed
on
th
e
lo
gi
c
th
at
th
e
as
se
rt
io
n
‘a

107. ll
sw
an
s
ar
e
w
hi
te
’
ca
n
be
di
sp
ro

108. ve
d
by
fin
di
ng
ju
st
on
e
bl
ac
k
sw
an
(E
ys

109. en
ck
19
76
).
Su
ch
de
du
ct
iv
e
lo
gi
c
is
av

110. oi
de
d
by
m
an
y
qu
al
ita
tiv
e
ps
yc
ho
lo

111. gi
st
s
as
it
is
lin
ke
d
to
ob
je
ct
iv
is
te
pi

112. st
em
ol
og
ie
s,
bu
ti
n
fa
ct
qu
an
tit
at
iv
e

113. re
se
ar
ch
av
oi
ds
th
is
ki
nd
of
lo
gi
c
to

114. o,
fo
r
it
pr
ov
id
es
st
ro
ng
ju
st
ifi
ca
tio
n

115. fo
r
N
=
1
re
se
ar
ch
,w
hi
ch
is
al
m
os
tn

116. on
ex
is
te
nt
in
or
th
od
ox
qu
an
tit
at
iv
e

117. jo
ur
na
ls
.I
n
fa
ct
,c
as
e-
sp
ec
ifi
c
th
eo

118. ry
-t
es
tin
g
w
or
ks
w
el
lw
ith
in
a
qu
al
ita

119. tiv
e
ru
br
ic
,a
s
ev
id
en
ce
d
by
Fe
st
in

120. ge
r’
s
te
st
of
co
gn
iti
ve
di
ss
on
an
ce
th
eo

121. ry
th
ro
ug
h
a
ca
se
st
ud
y
of
a
U
FO
cu
lt

122. (F
es
tin
ge
r,
R
ie
ck
en
&
Sc
ha
ct
er
19
56

123. ).
D
em
on
st
ra
tio
n
of
po
ss
ib
ili
ty
A
ca
se

124. st
ud
y
ca
n
de
m
on
st
ra
te
th
at
a
ph
en
om

125. en
on
is
po
ss
ib
le
.F
or
ex
am
pl
e,
if
ju
st

126. on
e
pe
rs
on
w
as
fo
un
d
to
al
w
ay
s
sh
ow

127. ex
tr
as
en
so
ry
ab
ili
tie
s
on
re
pe
at
ed
oc
ca

128. si
on
s,
th
is
w
ou
ld
be
an
im
po
rt
an
tfi
nd

129. in
g
in
pa
ra
ps
yc
ho
lo
gy
,w
ith
or
w
ith
ou
tc

130. or
ro
bo
ra
tio
n
fr
om
ot
he
r
ca
se
s.
It
w
ou

131. ld
sh
ow
th
at
su
ch
ab
ili
tie
s
w
er
e
po
ss

132. ib
le
an
d
th
er
ef
or
e
th
at
hu
m
an
be
in
gs

133. ha
ve
th
e
re
qu
is
ite
ap
pa
ra
tu
s
fo
r
E
SP

134. (L
es
ha
n
19
90
).
Il
lu
st
ra
tio
n
of
be
st

135. pr
ac
tic
e
Pr
ov
id
in
g
in
fo
rm
at
io
n
on
th

136. e
pr
oc
es
s
of
pr
ov
id
in
g
co
un
se
lli
ng
,t

137. he
ra
py
or
ot
he
r
on
e-
to
-o
ne
he
lp
.T
hr

138. ou
gh
a
co
m
pr
eh
en
si
ve
ly
fo
rm
ul
at
ed
ca

139. se
st
ud
y,
be
st
-p
ra
ct
ic
e
ca
n
be
co
m
m

140. un
ic
at
ed
,w
hi
le
th
e
re
al
-l
if
e
co
nt

141. ex
ta
nd
ch
al
le
ng
es
of
de
liv
er
in
g
th
er
ap

142. y
ca
n
be
co
nv
ey
ed
.
T
he
or
y-
ex
em
pl
ifi

143. ca
tio
n
E
xe
m
pl
if
yi
ng
a
pa
rt
ic
ul
ar

144. th
eo
ry
or
co
ns
tr
uc
t,
by
sh
ow
in
g
ho
w
it

145. m
an
if
es
ts
at
th
e
in
di
vi
du
al
le
ve
la
nd

146. ho
w
it
he
lp
s
to
de
sc
ri
be
,i
nt
er
pr
et

147. or
ex
pl
ai
n
th
at
in
di
vi
du
al
(M
cA
da
m
s

148. &
W
es
t1
99
7)
.
30
Sampling in Interview-Based Qualitative Research 31
These case study objectives are not mutually exclusive. An
example of a paper that
evidences multiple aims is Sparke’s narrative analysis of the
autobiography of cyclist Lance
Armstrong (Sparkes 2004). It includes aspects of
psychobiography, hermeneutic insight and
construct problematising.

149. Pragmatic and Theoretical Justifications for Altering Sample
Size during
Interview-Based Research
In all qualitative studies, there are strong grounds for
monitoring data collection as it
progresses and altering sample size within agreed parameters on
theoretical or practical
grounds (Silverman 2010). Indeed, monitoring and being
responsive to the practical
realities of research is a key skill for the qualitative researcher,
as collecting in-depth data
leads to challenges that are never entirely predictable at the
outset of a project. Mason
(2002) refers to this skill as “organic” sampling. For example,
recruiting participants,
the final and fourth concern discussed in this article, is an
unpredictable business and if
it proves to be more difficult than anticipated, a reduction in
target sample size may be
required. Conversely, recruitment may lead to more potential
cases than was anticipated,
so the researcher may consider at this point expanding the target
sample size, if logistically
manageable. The other major practical reason for changing

150. sample size is if the availability
of resources, funding, time or researcher manpower lessens or
increases during the course
of a project.
Of all qualitative methodologies, Grounded Theory puts most
emphasis on being flex-
ible about sample size as a project progresses (Glaser 1978).
According to Grounded
Theory, as the researcher collects data, analysis should proceed
at the same time, not be
left until later. Simultaneous analysis permits a researcher to
make real-time judgements
about whether further data collection is likely to produce any
additional or novel contri-
bution to the theory-development process and therefore whether
further sample acquisition
would be appropriate or not (Strauss & Corbin 1998). Sample
size may be increased if
ongoing data analysis leads the researcher to realise that he/she
has omitted an important
group or type of person from the original sample universe, who
should be added to the sam-
ple in order to enhance the validity or transferability of the
findings or theory (Silverman

151. 2010). Alternatively, if the researcher judges that “theoretical
saturation” has been reached,
it is assumed that further data collection will not bring
incremental benefit to the theory-
development process (Strauss & Corbin), and data collection
will be halted. Guest, Bunce
and Johnson (2006) provide a useful set of guidelines for
determining theoretical saturation
when using interviews.
Point 3: Selecting a Sample Strategy
Once a sample universe is defined and an approximate or exact
sample number decided
upon, a researcher must then ask themselves the question: How
do I select cases for inclu-
sion in the sample? The strategic options available at this point
can be categorised into (a)
random/convenience sampling strategies and (b) purposive
sampling strategies.
Random and Convenience Sampling Strategies
Random sampling is the process of selecting cases from a list of
all (or most) cases within

152. the sample universe population using some kind of random
selection procedure. This pro-
cess is used in opinion polls and social research surveys, typical
methods include random
32 O. C. Robinson
selection of numbers from a phone book or of addresses from
the electoral roll. Quantitative
studies in psychology often claim to use a random sampling
procedure, even when they do
not. Instead they typically locate a nearby source of potential
participants who are con-
venient in their proximity and willingness to participate (i.e.,
psychology students) and
are in all likelihood not a random cross-section of the sample
universe (the sample uni-
verse is typically ‘people in general’). This is called
convenience sampling. It is used in
quantitative research and sometimes in qualitative research as
well. It proceeds by way of
locating any convenient cases who meet the required criteria
and then selecting those who

153. respond on a first-come-first-served basis until the sample size
quotient is full. The prob-
lem of using this approach in quantitative research is that
statistics function on the basis
that samples are random, when they are typically not. For
qualitative research, the danger
of convenience sampling is that if the sample universe is broad,
unwarranted generalisa-
tions may be attempted from a convenience sample. The best
way of justifying the use of
convenience samples in qualitative research is by defining the
sample universe as demo-
graphically and geographically local and thus restricting
generalisation to that local level,
rather than attempting decontextualised abstract claims. For
example, if the convenience
sample is psychology students at a particular university in the
United Kingdom, then by
making the sample universe “young university-educated adults
in the United Kingdom”
rather than “people in general,” the link between sample and
target population is enhanced,
while potential generalisation is narrowed and thus made more
logically justifiable.

154. Purposive Sampling Strategies
Purposive sampling strategies are non-random ways of ensuring
that particular categories
of cases within a sampling universe are represented in the final
sample of a project. The
rationale for employing a purposive strategy is that the
researcher assumes, based on their
a-priori theoretical understanding of the topic being studied,
that certain categories of
individuals may have a unique, different or important
perspective on the phenomenon
in question and their presence in the sample should be ensured
(Mason 2002; Trost
1986). Summarised below are stratified, cell, quota and
theoretical sampling, which are all
purposive strategies used in studies that employ multiple cases.
Following this I describe
significant case, intensity, deviant case, extreme case and
typical case sampling, which
are purposive strategies that are best employed when selecting a
single case study. All of
these are processes for ensuring that certain types of individuals
within a sample universe
definitely end up in a final sample.

155. Stratified Sampling
In a stratified sample, the researcher first selects the particular
categories or groups of cases
that he/she considers should be purposively included in the final
sample. The sample is then
divided up or “stratified” according to these categories, and a
target number of participants
are allocated to each one. Stratification categories can be
geographical, demographic, socio-
economic, physical or psychological; the only requirement is
that there is a clear theoretical
rationale for assuming that the resulting groups will differ in
some meaningful way.
If there are just two stratification criteria in a study, the
resulting framework can be
illustrated as a simple cross-tabulated table, as shown in Figure
2a. In this table, gender and
age provide the basis for the sample stratification of a
hypothetical study on the experience
of life following divorce. If more than two variables are used in
a sampling framework,
an alternative way of illustrating the stratification is using a

156. “nested table,” as shown in
Figure 2b (Trost 1986). Here, the variable of “with
children/without children” is added to
Sampling in Interview-Based Qualitative Research 33
a) Cross-tabulated table illustrating a sample stratified by two
variables: gender and age
b) Nested table illustrating a stratified sample with three
typological variables: gender, age and
presence of dependent children
Male Female
30Ð45 46Ð60 30Ð45 46Ð60
Dependent
children
No
dependent
children

157. Dependent
children
No
dependent
children
Dependent
children
No
dependent
children
Dependent
children
No
dependent
children
2 2 2 2 2 2 2 2
Male Female

158. Ages
30Ð45
4 4
Ages
46Ð60
4 4
Figure 2. Types of table used for illustrating stratified
sampling.
the divorce study sampling framework. It should be born in
mind from a practical view that
the more stratification criteria one includes in a sample frame,
the more complicated recruit-
ment becomes and the longer the process of finding
participants. Therefore researchers
should devise a sample strategy that takes into account how
much time they have and the
resources at their disposal.
As previously mentioned, to include a purposive sampling
stratification there must be

159. clear theoretical grounds for the categories used. For example,
in this hypothetical study on
postdivorce experiences that Figure 2 refers to, the theoretical
grounds for sampling men
and women could be that women are more likely to get custody
of children than men in
the United Kingdom, and thus a systematic difference between
sexes would be justifiably
expected. Age could be justified as a sampling criterion on the
basis that younger adults typ-
ically find it easy to re-partner than older adults, meaning the
postdivorce experience may
differ by age. The presence or absence of dependent children
could be included because
issues of child custody add a great deal of complexity and
potential stress to postdivorce
proceedings so those with and without children could be
expected to differ. In a real study,
such theoretical rationales for purposive criteria would ideally
have referenced sources.
Cell Sampling
Cell sampling is like stratified sampling insofar as it provides a
series of a priori categories

160. that must be filled when gaining sample. The difference
between cell sampling and stratified
sampling is that the latter employs categories that are discrete
and nonoverlapping; in the
former, cells can overlap like a Venn diagram (Miles &
Huberman 1994). As a hypothetical
example, a study on popular phobias may choose to purposively
select individuals who (a)
have a phobia of a certain animal, (b) have a phobia of heights
or (c) have both types of
phobias. This example is illustrated in Figure 3.
Quota Sampling
The process of quota sampling is a more flexible strategy than
stratified or cell sampling.
Instead of requiring fixed numbers of cases in particular
categories, quota sampling sets out
34 O. C. Robinson
Phobia of animal Phobia of heightsPhobias of both

161. N = 5 N = 5N = 5
Figure 3. A hypothetical example of …
6
Running head: IMPACT OF CHANGE MANAGEMNT IN
HEALTHCARE
Introduction
Change management is one of the pressing issues every
organization is confronted with especially in an environment
where change is associated with success or failure. The
healthcare organizations are not left out in this change frenzy as
they also seek to succeed through successful change
implementation. Rapid change is being recorded in the health
care organizations, mostly as they try to adopt new technologies
and improve the quality of patient care, as well as manage the
performance of the healthcare personnel. The best way to deal
with the change, as literature reveals, is helping the employees
adopt new ways of doing things (Campbell, 2008).
By definition, change management entails the process leading to
the realization of the ideal state of the organization. In other
words, change management in an organization entails
overseeing the transition from the current state to the desired
state. The process of change begins with the creation of a vision

162. for the change. This is then followed by empowering the people
responsible with the change to act as agents of the change and
help attain the change. The change management process often
involves many participants with roles that are clearly defined.
These may include the owners of the change, the managers of
the change, and the owners of the processes among others.
Change management often impacts on various people
differently. The stakeholders within change management are
varied which includes the participants to the change, and other
groups that are either affected directly or indirectly by the
change. In healthcare organizations, these impacts will be felt
depending on the type of change and the result of change. For
example, the change might be concerned with the introduction
of new technologies, and this will mean new skills for the
personnel and possibly a new structure for the entire
organization. Change management in healthcare organizations,
therefore, requires that the managers fully understand change
and its impacts before making efforts to implement the change.
Literature review
There are several major types of changes explained in the
literature that are experienced in the healthcare industry. In this
case, literature has revealed that technological changes,
strategic changes and innovations in pursuit of better patient
care are among the most influential ones. Change management,
it has been hypothesized, will entail managing the change

163. process itself and the people who most likely to resist the
change.
It is acknowledged that the healthcare managers today tend to
occupy an extremely challenging position requiring them to
maintain a competitive edge in a healthcare market while
leading the organization through a constant change (Campbell,
2008). Organizations today, regardless of the industry or
sector, are experiencing rapid technological change. The
healthcare organizations are also subject to this phenomenon
whereby technology is the key driver of change. The healthcare
organizations are adopting new technologies as they try to
implement quality improvement initiatives and performance
management initiatives such as pay-for-performance (Campbell,
2008). Technology can be disruptive in that it can completely
change the face and operations of the organizations, and the
change management in healthcare will need to take into account
that new models and structures might result. In such a case, the
biggest challenge is often preparing the nurses to cope with
such changes which could have huge impacts in the nature of
their careers. For example, they could not be required to have
IT skills for them to handle the new IT systems being
implemented.
Besides the technology changes, the change management in
healthcare is also concerned with the shifts in the environment
which tend to compel the healthcare organizations to change

164. their strategies (Caldwell, Chatman, O'Reilly III, Ormiston, &
Lapiz, 2008). Research in change management in healthcare has
revealed that strategic change often fails owing to the inability
of the individuals to adopt the necessary behaviors for the
successful implementation of the new strategy. The healthcare
management and leadership, therefore, are seen to be deficient
in terms of proper change implementation. A change in strategy
is something that would require a change in behavior, meaning
that the behavioral change should be the first thing to
implement. The behavioral change should lay the foundation for
the strategy change whereby everyone is brought on board.
Literature has established that this form of change requires a
unique approach. The hypotheses set out by Caldwell, Chatman,
O'Reilly III, Ormiston, & Lapiz (2008) include that the
management and leadership should gain support for the strategic
change and introduce norms for change readiness. According to
Klein, Conn, and Sorra (2001), a successful change
implementation will require an ‘implementation climate’, a term
defined as support for the specific change. Their study was
concerned with the application of advanced computerized
manufacturing technology, but the principle applies to all
organizational contexts. An implementation climate in a
healthcare organization would probably be that climate where
the organizational members are not only ready for the change,
but also support the change entirely.

165. Teamwork in change management in healthcare has also been
found to facilitate a successful change implementation.
Researchers like Markoczy (2011) have established that when
the members of the management team are in agreement or have
a consensus on the change direction, there is a greater
likelihood of success. This leads to another hypothesis that
there will be greater performance improvements where the
members agree on the nature of the new strategy. The healthcare
management is, therefore, presented with a challenge of
achieving this unity that will drive the speed and effectiveness
of the change process. Team leadership becomes a necessity
because, as research has established, the senior leaders may
have a critical role in the identification and implementation of
the new strategy, the middle managers leading the various
groups have the ability to enhance or undermine this
implementation (House & Aditya, 1997). This means that the
middle managers and the nurses collectively and individually
have an influence on the success of change implementation.
Each individual must be brought on board, a challenge for the
managers who need to overcome the resistance to change.
According to Kodama & Fukahori (2017), the nurse managers
are the first-line managers who are responsible for inducing
change in the clinical environment.
According to Al- Abri (2007, p. 9), the change management in
healthcare has to contend with the fact that the healthcare

166. professionals, including nurses, are obligated to acquire and
maintain the expertise requisite for their tasks as they will only
be given tasks falling within their individual competencies.
With the change occurring frequently, all these professionals
may be required to update continuously their expertise in order
to remain relevant to this sector. This is why researchers like
Al- Abri (2007, p. 9) argue that change management entails
managing the complexity of the processes – that is, planning,
evaluating, and implementing operations, strategies and tactics
that ensure that the change is relevant and worthwhile.
Managing resistance is especially important at the lower levels
where professionals like the nurses could face and resist a
change in the nature of their careers.
The pursuit of patient safety initiatives is another reason why
the healthcare organizations have to be worried about change
management. There are often some unintended consequences
when these organizations pursue patient safety without
undertaking effective change management (Ramanujam, Keyser,
& Sirio, 2005, p. 455). Herein, the management and leadership
in the healthcare organizations need to understand the inputs
shaping the strategy (both internal and external) before
developing strategies to achieve specified outcomes. According
to these researchers, the senior management and leadership has
an active role in the change initiation, and are also responsible
for energizing the process of change. This leadership must also

167. make sure that on board are senior administrators, clinicians,
nurses, and opinion leaders among others. In other words, all
members of the organization have to participate in the change
process.
The improvement of patient care has been a top priority in
almost all healthcare organizations and this exerts a lot of
pressure. Ducharme, Buckley, Alder, and Pelletier (2009, p. 70)
establish that among the challenges facing Ontario healthcare
organizations include overcrowding and long wait times that
degrade the quality of care. Innovative and timely solutions to
such challenges are a priority. A literature review presented by
Antwi and Kale (2014, p. 1) also indicates that the Canadian
healthcare organizations were in need for solutions to problems
such as long wait hour and timely access to care. This literature
review reveals that the patient care is a critical factor affecting
the changes in the healthcare. The pursuit of better patient care
means pursuing innovations in both systems, structures,
technologies, etc. These researchers express the need for the
managers and decision makers to understand how change occurs
in order for them to create a conducive environment for the
innovations.
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