BSBFLM309 Readings

Introduction

The healthcare sector is an ever evolving and changing environment and some of the key changes are largely driven through technology. It is therefore vital for healthcare organisations to continue to invest in people, by upskilling them in areas that will also give the company a competitive advantage. This includes training on technology and tools that seek to improve business processes and efficiencies. Knowledge management, training and development are the key attributes to organisational growth and development. Most entities develop policies and procedures around this, to ensure that there is continual training of staff on key aspects of the business.

Continued Training and Development

One of the most competitive advantages to a health organisation is its workforce, and thus continuous training and development is required, with efforts to respond to business demands. According to Maimuna, training and development is an instrument that aid human capital in exploring their dexterity as a result training and development is vital to the productivity of an organization’s workforce. Healthcare companies should continue to view training as a strategic investment, as it enhances and improves customer experience, throughout the value chain.

The identification of training needs at organisational level needs to be aligned to key strategic objectives and goals. Approaches such as Gap analysis, SWOT or a Risk Assessment framework are key in assisting the development of proactive strategies whereby a healthcare organisation can optimise their product offering and service delivery model. It further assists companies, based on needs assessments to identify the resources and the systems needed. Other methodologies of identifying gaps could be through conducting surveys; through using questionnaires which could comprise a series of questions and other prompts, for the purpose of gathering information from respondents. One typical example could be that an organisation wants to reduce costs associated with fraud, waste and abuse or by developing cost containment strategies, which could be achieved through proactive identification of potential culprits. This information could be obtained by conducting a survey where key questions are sourced for fraud, waste and abuse, that could be identified through assessing the responses.

Respondents could also propose new approaches and provide further pointers to new sources of fraud in healthcare and could also provide methods that could be used to pro-actively identify potential incidents of fraud.

Training Needs of Health Record Keeping

The keeping of medical records is a key attribute for the efficiency of a health system. In the main, it provides profiling and traceability of patients and customers. The keeping of medical records is also important for ensuring that there is adequate care coordination when a patient is transferred from one provider or facility to another. There are numerous studies that show that a lack of training in patient record keeping is more prevalent in the public healthcare sector where there are no systems nor suitable human resources to manage and monitor this function. Inadequate training is often stated as one of the reasons that impacts negatively on patients’ records processing.

There is also a culture issue, where there needs to be commitment and support from the top structure of a healthcare company. Marutha and Ngoepe investigated the role of medical records in the provision of public healthcare services. The study found that ninety percent (90%) of respondents lacked adequate training on policies, procedures, norms and standards for managing records and that only six percent (6%) of the respondents stated that they had received training in those areas. The other key feature regarding health records is data security; particularly where confidential patient information is concerned. Healthcare management companies should ensure that they put processes and training programs on data breaches and the proper guard of patient information in place, as these could negatively impact an organisation.

Training Needs on Supply Management

One of the main strategies to reduce cost and wastage in the healthcare sector is improved contracting and supply chain management processes. SCM is also regarded as one of the tools when effectively employed could have a significant impact on reducing costs and improving performance in health care organizations. A recent article by Mathew, John and Kumar depicts approaches to optimize costs in healthcare supply chain operations, which includes the virtual centralisation of supply chains, supply utilisation management practices, the use of RFID technologies, the use of analytics and streamlining workflow. The author further classifies stakeholders into three major groups, namely: producers, purchasers, and providers.

Producers (comprise medical and surgical supplies, medical devices, and pharmaceuticals) who distribute these to the purchasers (wholesalers, distributors and GPOs). Purchasers then distribute them to the providers (hospitals, IDNs, physicians, clinics, pharmacies, and nursing homes). Ryan further elaborates on the addition to the complexity of the system, where there is involvement and participation from governmental institutions, regulatory agencies, and insurance companies. All these key components of supply chain management need to be integrated into an effective healthcare management system.

Training Needs on Products Offered

Product simplicity in healthcare is a very difficult concept to quantify. There is also the issue of information asymmetry, where there is not enough detail about products. Health generally, is not considered a public good, because of non-paying individuals (without health insurance, healthy food, etc.), and this makes it even more complex than other products. Information in this regard is key for choice optimisation by consumers, when they purchase health insurance plans. For example, consumers who are often not aware of the potential for receiving subsidies for their premiums and cost sharing, might choose not to enrol in coverage. Similarly, consumers who enrol in plans with expected spending greater than alternative plans could end up spending far more on their health care requires, during the year, than they otherwise would have.

In a medical insurance setting, members enrol and purchase a product in the form of health care plans so to be able to access care. In the main, these products are often too complex for the purchasers to understand. The level of complexity is also twofold and it affects, both the member and the medical service provider. Various studies also show that the purchase of care by citizens who have low healthcare system literacy may result in a struggle for them to make key decisions. The more complex the product is, the greater the risk is of it not being fully understood by the purchasers.

During 2017, there were two hundred and seventy-eight (278) registered benefit options operating in eighty-one (81) medical schemes in South Africa; thus, choosing a benefit option remains a big challenge, as there are many benefit options are often not standardised. Kaplan and Ranchod contend that the number of benefit options available in the medical scheme market creates complex environment impacting decision making. An annual survey conducted in 2017 depicted that consumers were unsure of their own medical scheme details and of the benefits that they were entitled to.

The complexity of products offered by health insurance companies has a positive correlation with complaints and customer satisfaction scores. It is thus critical for health insurance and medical schemes to invest in programmes that will educate and train enrolees on the benefits and the products being offered.

Training Needs on Patient Centeredness and Customer Care

Effective patient-centred care has become a central aim for the nation’s health system, yet patient experience surveys indicate that the system is far from achieving it. Based on interviews with leaders of patient-centred organisations and initiatives, this report identifies seven key factors for achieving patient-centred care at the organisational level:

• Top leadership engagement;
• A strategic vision, clearly and constantly communicated to every member of the organisation;
• The involvement of patients and families at multiple levels;
• A supportive work environment for all employees;
• Systematic measurement and feedback;
• The quality of the built environment; and
• Supportive information technology.

The two main strategies that have been identified as necessary to overcome barriers and to help leverage widespread implementation of patient-centred care at both the organisation and at system levels.

There is comprehensive theoretical work being done on customer care, customer service, quality and how these impact on customer fulfilment, organisational performance and customer retention. According to Sheahan, customer service in health care is not the same as in other industries, because customers are the receivers of the medical services that are critical to their health. As such, healthcare industries must maintain a good customer service relationship with their customers.

Mosadeghrad highlighted ten determinants that could lead to better quality of service, which, in turn, will lead to better customer care:

• Reliability - consistency of performance and dependability.
• Responsiveness - the willingness or the readiness to provide service.
• Competence - having the required skills and the knowledge to perform the service.
• Access - approachability and ease of contact. • Courtesy - politeness, respect, consideration, and friendliness of contact personnel.
• Communication - keeping the customers informed in a language that they can understand and listening to them.
• Credibility - trustworthiness, believability, being honest.
• Security - freedom from danger, risk, or doubt.
• Understanding - knowing that the heath care provider is making the effort to understand the customer’s needs.
• Tangibles - the physical evidence of the service.

Knowledge Management

According to Chong, knowledge management is a broad subject with many facets, ranging from databases to patents, from the intranet to the mentor, from coldly technical to warmly personal concepts. Different academics and practitioners presented a review of the literature, which concluded that there is no clear definition and concept of knowledge management. Salleh and Goh agreed that it is difficult to define knowledge management since various perspectives and schools can define different dimensions and meanings of knowledge management. A different perspective on the concepts of knowledge can lead to different definitions of knowledge management

Knowledge management is crucial for enterprises to determine where they are going and for organisational survival in the long run; given that knowledge creation is the core competency of any organisation. The human resources function in organisations needs to drive knowledge management and create an enabling environment, thus by creating a knowledge-sharing culture, nurturing and “learning‐by‐doing” can yield to competitive advantage.

Financial Management in Healthcare

The primary role of financial management in healthcare organisations is to manage budgets and to ensure that financial risk is mitigated. Companies need to be able to have adequate systems to ensure that there is adequate working capital management, assurance on cost reduction and available funds, to ensure that the organisation runs effectively. Furthermore, the financial management staff of any healthcare or other form of healthcare organisation should ensure that the organisation can meet its strategic goals, through proper planning and budgeting processes. According to Deloof, financial management includes evaluation and planning, long-term investment decisions, financing decisions, working capital management, contract management, and financial risk management and risk; in a way that this helps to achieve the financial goals of the organisation. When a healthcare organisation has strong and organised financial management plans, which are also managed efficiently, they are able to provide efficient healthcare to all their patients.

Learning Organisation

The ‘learning organisation’ is a concept first described as an organisation where people continuously learn and enhance their capabilities to create the results that they really care about:

• Team learning
• Shared vision
• Mental models
• Systems thinking

Al-Abri and Al-Hashmi further elaborates that all five disciplines are dynamic, and they interact with each other. Furthermore, there are some educational concepts and theoretical models, which are of relevance to the learning organisation, and can thus provide a framework for managerial decisions. The aim of professional health care education is to educate health care personnel with up to date knowledge and skills; either by theoretical learning through attending courses or practically, through training programmes. The core purpose of health care education is to promote quality in health care services by providing competent and safe personnel. Health care managers are obligated to acquire and to maintain the expertise needed to undertake their professional tasks. Additionally, they are also obligated to undertake only those tasks that are within their competence and to acquire technical knowledge in their field of work.

 

Governance for Healthcare Managers:

Corporate governance involves more traditional managerial tasks of finances and budgets, procurement and supply-chain management, human resource management, and infrastructure. The principles underpinning corporate governance include fairness, accountability, responsibility and transparency. At a global healthcare ecosystem level, healthcare managers ranging from practice managers, policy makers to governments, need to ensure that there are enough two-way engagements and adequate communication, where corporate governance is concerned. Furthermore, there needs to be adequate access to information on corporate governance policies and continuous training and development in this regard. The ability to understand and to influence corporate governance issues in the healthcare space is complex, as most healthcare practitioners are mainly trained more to practise healthcare than in an oversight role. Studies have shown a clear distinction between clinical and corporate governance. Maxwell and Carswell depicts a clear linkage between corporate governance and clinical governance. The authors further depicts that the management team should implement clinical governance systems which ultimately get reported to the board. The table below depicts a distinction between corporate and clinical governance.

Conclusion

Healthcare management is a complex sector to manage, this is mainly due to the risks associated with it, ranging from financial management and sustainability, business improvement processes to the health and the safety of patients or customer involvement. The top structure of these organisations operates in a continually changing business environment, ever-evolving technology, complex regulatory requirements and changes in the profile of patients, such as an increasing age profile and the burden of disease.

All these require complex and demanding health management; in order to manage health organisations in an efficient, cost-effective, competent manner. Health managers require various leadership and managerial skills and they need to be familiar with the problems that exist in the health care system. Continued identification, analysis, and assessment of health management training needs are pivotal, for the survival of healthcare organisations.

Introduction

The provision of health care has evolved from applying a traditional paternalistic approach of ‘doctor knows best’ to a patient-centred care (PCC) approach. Under the traditional paternalistic approach, medical practitioners instructed and prescribed treatments with limited input from patients and families. Conversely, today, research studies recognise the importance of a PCC approach in the delivery of health care. Indeed, governments (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2011; National Health Service, 2005; US Department of Health & Human Services, 2008), the World Health Organisation (2000) and other health policy organisations (e.g., the National Research Corporation [NRC] Picker, 2008; Picker Institute, 2004) advocate and endorse the need for health care institutions to place greater emphasis on the individual. The major objective of PCC is to achieve a working partnership between patients and families in relation to the delivery of health care services.

There is no universally agreed upon definition of PCC; however, it is embedded within the paradigm of holism that views individuals as a biopsychosocial and physiological whole (Ekman et al., 2012). Holism seeks to ensure that the needs of individuals accessing health care services are met with respect and responsiveness and, in relation to the making of clinical decisions, it is a paradigm grounded in concepts of values, personal preferences and partnerships (Institute of Medicine, 2005).

The Picker Institute (1993) brought PCC to the forefront with its research that emphasised the need to respect patients’ preferences and values, psycho-physiological comfort, the importance of communication and the need to provide support and coordinated care that is inclusive of the patient and his/her family. Due to its ability to be flexible and tailored to meet individualised needs, this approach has enhanced the quality of health care and has become an independent measure of the quality of health care services being provided (ACSQHC, 2011). The idea of PCC is reflected in the presupposition: ‘nothing about me, without me’ (Delbanco et al., 2001).

Patient-centred care in preference to paternalism

The principles of PCC are reflected in the mission statements of many health service providers that espouse the qualities of respecting patients’ beliefs and values, open communication and support. In the Australian health care setting, PCC has been practised for over a decade and is reflected in the Australian Charter of Health Care Rights (ACSQHC, 2007) and the Australian Safety and Quality Framework for Health Service Standards (2011). These documents provide patients’ with information on the care standards that they can expect from an organisation and reaffirm the core PCC principle that an individual is central and integral to his/her care and should be consulted before any decisions about treatment are made. The primary principles underpinning PCC reflect the ethical paradigms of autonomy and the right to self-determination; however, it should be noted that some health care providers have grappled with the implementation of PCC focused approaches.

The traditional paternalistic approach to health care has received extensive criticism due to its focus on decisions being made by the medical fraternity (i.e., medical practitioners, positioned as experts around whom a health care organisation’s workflow is based and who define the constructs of an organisation’s perceptions of health care) (Rodriguez-Osorio & Dominguez-Cherit, 2008). Paternalism is characterised by a usurpation of decision-making power that gives little consideration to an individual’s preferences; rather, the decisions reached are primarily based the opinions and preferences of medical professionals (Buchanan, 2008). As an approach, it focuses on the disease and its management rather than the individual and his/her family and what they value as important (Lewin, Skea, Entwistle, Zwarenstein, & Dick, 2001). Itlacks parity between the doctor and patient and can compromise a patient’s rights to self-determination and autonomy. The tenets of these two principles; self –determination and autonomy, support the development of a therapeutic alliance based on respect for each individual’s competences, decision-making abilities and personal values and preferences (Entwistle, Carter, Cribb, & McCaffery, 2010; Mackenzie, 2008; Ryan & Deci, 2000). Recently, health care organisations and clinicians have become more receptive to PCC and have acknowledged its ability to enhance the safety and quality of care provided.

The benefits of patient-centred care

Supporting participation along with a greater emphasis on communication can lead to shared collaborations and decision-making processes. Rather than viewing a patient as a passive component of the medical process, PCC adopts a contractual view of health care under which a patient is viewed an active participant who should be involved in any decision-making processes (Leplege et al., 2007). The shift to PCC enhances concordance between health care providers and patients’ adherence to treatment plans (Roumie et al., 2011; Thompson & McCabe, 2012), improved health outcomes and increased patients’ satisfaction with healthcare services (Bertakis & Azari, 2011; Ekman et al., 2012). The adoption of PCC practices in primary health care has resulted in significant benefits for patients, as patients can better manage their health when they are informed and supported. Bertakis and Azari (2011) showed that a PCC approach significantly reduced patients need to access speciality care (p < 0.0209), hospitalisations (p < 0.0033) and required fewer pathology investigations (p < 0.0027). Similarly, the adoption of a PCC approach in the health management of patients with chronic hypertension led to an increase in medication adherence (RR 3.19, 95% CI 1.44, 16.23) (Roumie et al., 2011). Other benefits related to PCC, including improving patients’ self-perceptions, reducing stress and increasing empowerment, have also been reported in diabetes management (Anderson, Funnell, & Butler, 1995; Hermanns, Kulzer, Ehrmann, Bergis-Jurgan, & Haak, 2013; Kinmonth, Woodcock, & Griffin, 1998).

Programmes that employ established PCC approaches (e.g., in cardiac and respiratory rehabilitation) endeavour to empower patients to make lifestyle modifications, and improve their overall health and wellbeing. Conversely, traditional management strategies focused on illness, interventions and pharmacology and have limited strategies on how to optimise health. Adjusting the focus of clinical care to accommodate the needs of patients has reportedly enhanced patients’ experiences (Cegala Street, & Clinch, 2007; Coulter, Parsons, & Askham, 2008; Robinson, Callister, Berry, & Dearing, 2008), decreased the lengths of hospital stays and readmission rates, enhanced primary health care services and improved patients’ functional capacities (Anderson et al., 1995; Bertakis & Azari, 2011; Hermanns et al., 2013; Kinmonth et al., 1998). The outcomes attributed to PCC suggest that the approach benefits both consumers and health care organisations

Despite the benefits of PCC in relation to patients’ levels of satisfaction, concerns have been raised as how this approach affects evidence-based health care practices. The two approaches have been traditionally been viewed as being mutually exclusive rather than complementary (Pollock & Grime, 2003). However, proponents of the evidence-based health care approach concede that medical practitioners need to consider and recognise what is meaningful to patients. The importance of acknowledging patients beliefs has been increasingly recognised through the promotion of patient advocacy (e.g., respecting patients’ choices initiatives) that aims to promote communication in relation to advanced healthcare planning (APC). APC supports patient advocacy, the right to self-determination and permits patients to make decisions and have input into future health care decisions even, if in the future, they have a limited capacity to do so. Such initiatives reduce disparities in the judgement of patients, families and health care decision makers (Balsa, Seiler, Thomas, & Bloche, 2003).

Differences of opinions on medical treatment and a patient’s right to self-determination can be challenging and may cause patients to decline medical interventions and treatment in favour of alternative medicines (Verhoef & White, 2002). In such cases, health care professionals need to ensure that they provide the patient with the necessary medical information and support and understand that the patient’s decisions are reflective of his/her own values and preferences. Research suggests that many patients’ are subjected to treatments that are deemed futile, impose additional stress upon the patient and his/her family and can cause caregivers to feel morally distressed (Teno et al., 1997; Walling et al., 2010). The relentless pursuit of medical treatment and interventions could potentially compromise an individual’s perceptions of quality oflife and dignity at the end of life and thus should not be pursued at any cost.

Huynh et al. (2013) investigated the frequency of treatments provided to patients admitted to an intensive care unit (ICU) that were deemed futile and found that 20% of the patients admitted received treatments that did improve their overall survival rates or quality of life. Further, these treatments had financial repercussions for the hospital and also contributed to psychological distress experienced by the patients’ families. In Australia, a randomised controlled trial was conducted that compared the impact of APC to usual care and concluded that in circumstances where a patient had stipulated his/her wishes in APC, health care practitioners were significantly more likely to follow and adhere to the patient’s wishes (p < 0.001) (Detering, Hancock, Reade, & Silvester, 2010). Further, the family members of participants in the treatment group were significantly less stressed (p < 0.001) and depressed (p = 0.02) and indicated greater levels of satisfaction with the care provided (Detering et al., 2010).

The Australian Quality Framework for Health Care (ACSQHC, 2011) identifies PCC as a critical component of any safe and high quality health care system. The integration of PCC approaches in clinical areas has resulted in a number of changes to clinical services (e.g., in relation to clinical handovers and an increased presence of family members during medical rounds). Traditionally, clinical handovers occurred away from patients and patients were not viewed as being integral to their own health care. The introduction of bedside handovers promotes inclusive communication in relation to each patient’s clinical status and care planning and provides patients with an opportunity to participate and ask questions about their health. This ACSQHC (2007) and the World Health Organisation (WHO) (2007) identified this initiative as being key to improving patients’ safety. By including patients in the process of transferring information regarding their health and healthcare, it has enhanced the accuracy of information and communication (Lally, 1999; Philpin, 2006). Further, identifying errors and omissions in reported information has improved patients’ safety and enhanced the satisfaction of both patients and clinical staff (Cegala, Street, & Clinch, 2007; Coulter et al., 2008; Robinson et al., 2008). Thus, the PCC approach encourages partnerships and collaborations in care planning and decreases the level of suspicion and secrecy in relation to medical care and decisions. An Australian based study reported increased participation and involvement in handovers and noted that over 44% of staff perceived improvements in patient safety as a result of the handovers (Chaboyer et al., 2009). Further, discharge planning led to perceived improvements in patients’ outcomes, as patients were able to identify the key considerations being made in relation to the planning and coordinating of support services (Chaboyer et al., 2009). Thus, including patients in clinical handovers enhances treatment decision-making processes, increases feelings of empowerment, improves functional outcomes and reduces the use of subsidiary health services (Sidani, Epstein, & Miranda, 2006).

Australian based hospitals have implemented a variety of care programmes aimed at the early detection of deteriorating patients that further subscribe to the provision of PCC. These clinical processes aim to safeguard patients and acknowledge that families are often better equipped to identify subtle non-clinical changes in patients. These initiatives align with Standard 9.9 of the National Safety and Quality Health Service Standards (ACSQHC, 2012) that seeks to enable patients, families and carers to initiate escalated care responses. These programmes also seek to promote communication between families, patients and clinicians and acknowledge that early intervention is beneficial to both patients and family members. This programme allows families to express and communicate their concerns with nursing staff and, if required, have their concerns escalated to other medical staff (Care ACT Health, 2014). Patients who participate in their own care are more likely to observe, identify and communicate potential issues; thus, mitigating risks and increasing the safety and quality of care provided (Broom, Brady, Kecskes, & Kildea, 2013). Numerous escalation programmes have been established elsewhere in Australia; however, to date, no data on the clinical impacts of these programmes have been published.

Initial studies on these programmes indicate that collaborating with patients and families can lead to a mortality benefit for health care organisations. Gerdick et al. (2010) conducted research over a two-year period and noted that relatively few calls (n = 25) were family or patient-activated and the reasons for calls by family members or patients were not dissimilar to reasons cited by staff (e.g., shortness of breath, pain management issues and intuitive reasons such as ‘something just did not feel right’). The small number of non-clinician based calls does not suggest that the system is being abused; rather, the system appears to being used according to its intended purpose. The implementation of this strategy resulted in an organisational improvement in relation to patient outcomes and a significant reduction in the mortality rate (22.9 deaths per 1,000 admissions compared to 8.1 deaths per 1000 admissions, 95% confidence interval 5.4–13.8) and a significant reduction in emergency calls (from 25.2 per month to 17.4 per month) (Gerdik et al., 2010). Meterko Wright, Lin, Lowy and Cleary (2010) considered the effects of PCC on the outcomes of patients presenting with an Acute Myocardial Infarction and found a significant hazard reduction in the mortality rate over a one-year period (hazard ratio 0.992, 95% CI 0.986–0.999). In addition to enhancing clinical effectiveness and patients’ safety, the PCC approach improves patients’ levels of satisfaction and the performance of health care organisations (Doyle, Lennox, & Bell, 2013).

Patient-centred care approach to enhance service delivery

PCC has become a key theme in designing and redesigning health care services and clinical services. It acknowledges the valuable input that healthcare consumers can have in achieving clinical design features that enhance patients’ and consumers’ experiences. Recently, consumers have had an increasing presence on stakeholder and project committees. However, despite intentions to involve consumers in the redevelopment and redesign of projects, debate continues as to whether PCC approaches have been adopted or whether organisational needs remain paramount. Given the financial constraints faced by health care organisations, a compromise between the two perspectives of healthcare organisations and consumers has generally been sought.

Based on an experience-based design methodology, design science is a strategy that seeks to combine patient and staff input (Bate & Robert, 2006). It endeavours to improve services by integrating the differing roles and experiences of patients and staff and their interactions with the environment. Design science has been used to redevelop clinical areas such as ICUs and neonatal intensive care units (NICU). Recently, a NICU in the Australian Capital Territory (ACT) employed design science to design a unit that is not only clinically functional, but meets the needs of families. The stakeholders of this project involved a number of NICU consumers in shared decision-making process between parents and clinical staff. This collaboration led to a highly functional NICU; a clinical environment was designed that has a capacity for flexibility, protects and promotes privacy, allows parties to undertake breastfeeding and kangaroo therapy, maintains the visibility of neonates, enhances the safety for of consumers and staff and promotes a sense of community (Broom et al., 2013). The collaboration resulted in a NICU that has been benchmarked as leading design in the provision of supportive services (e.g., fold out beds, areas to store personal items, privacy and the opportunity for greater intimate and meaningful interactions) to family members (Broomet al., 2013). The NICUs design features also measurably reduced clinical noise, which in turns settles neonates, enables a greater capacity for sleep and improves growth (Broom et al., 2013). These mutually beneficial outcomes improved the health and welfare of the neonatal patients and their family members. Further, the PCC and collaborative approach improved clinical outcomes.

Operationalising patient-centred care approach in nursing

The current focus on PCC approaches endeavours to redress imbalances in health care and represents a shift from the previous approach that was medically dominated and disease orientated. The PCC approach seeks to establish collaborative partnerships and adopts holistic approach that seeks to meet and acknowledge patients’ values, enhance their engagement and involve them in decisions. This approach is inherent to many of nursing care theories such as Leininger’s (1988) theory of culture care, Boykin and Schoenhofer’s (1993) theory of nursing as caring and Roach’s (1987) conceptualisation of caring relationships.

Nurses have the capacity to support and assist in the meaningful improvement and operationalisation of PCC (McCance, 2003). Transformational leadership, innovative practices (e.g., respecting patients’ choices) and collaborative approaches have been adopted to meet the needs of patients and improve the provision of health care and consumers’ satisfaction with the care provided (Edwards, Staniszeswka, & Crichton, 2004). These approaches identify the critical humanistic role of nurses in collaborating with patients and promoting and advocating for their patients’ choices and represent a need to move beyond technical competences in the provision of health care.

Conclusion

PCC is important to the healthcare profession and can provide invaluable insights that help foster better working partnerships and provide health care services that meet consumers’ needs. Health care providers should readily acknowledge primary ethical principles to ensure that patients are provided with the information they need to make decisions and are supported in any decision-making processes. Extensive research has been conducted on the benefits attributable to PCC and indicates that PCC (in combination with evidence-based health care practices) can produce outcomes that benefit both patients and health care organisations. These benefits have important flow on effects for health care organisations (e.g., reducing costs, decreasing readmission) and individuals (e.g., affecting positive lifestyle changes). Thus, when provided with support, education and information, patients are capable of appropriately applying this information to better manage their health and evaluate their own health status.

Introduction

It has become a norm for organizations to engage in strategic change initiatives to remain competitive (Johansson & Heide, 2008). Nevertheless, characterized by uncertainties and ambiguities (Corley & Gioia, 2004), approximately 40%–70% of change initiatives fail (Burns, 2000). Organizational change not only costs time and money, but, when done inappropriately, also deteriorates employee morale and commitment, resulting in lower work efficacy and higher turnover rates (Chawla & Kevin Kelloway, 2004; Eby, Adams, Russell, & Gaby, 2000; Kotter & Schlesinger, 1979).

Organizational changes have increased pressure on organizational leaders, who play an important role in affecting organizational change implementation (Pawar & Eastman, 1997). An American Management Association survey indicated that leadership was the top determinant of successful change, followed by corporate values, and communication (Gill, 2002). Successful leadership not only develops vision, strategy, and culture for change, but also empowers and motivates employees in change engagement (Gill, 2002). Transformational leadership in particular has received a great deal of research attention in change management. Transformational leaders are viewed as charismatic and visionary leaders, and can garner identification, trust, and confidence from the employees. Research has consistently shown the positive impact of transformational leadership on employee outcomes across situations including organizational change (Herold, Fedor, Caldwell, & Liu, 2008; Paulsen, Callan, Ayoko, & Saunders, 2013). The power of transformational leadership to facilitate change implementation lies in its ability to create and communicate a strong vision, provide empowering opportunities, encourage employees to think beyond self-interests, and boost employees’ confidence in adapting to a new environment (Carter, Armenakis, Feild, & Mossholder, 2013; Herold et al., 2008).

Another major factor, which emerged from previous research, that impacts change management, is strategic internal communication. Change initiatives that lack strategic internal communication inevitably fail (Elving, 2005). In fact, it is through effective internal communications that change implementers provide employees with better understanding of the content and rationale of the change. Prior research shows that quality internal communication supposedly reduces perceived uncertainty related to the change and decreases employees’ resistance to change (Allen, Jimmiesons, Bordia, & Irmer, 2007; Elving, 2005). Specifically, this study evaluates communication transparency, a desirable characteristic of internal communication (Men & Stacks, 2014). Public relations scholars have consistently found that transparent communication contributes to various positive employee outcomes, such as employee trust (Jiang & Luo, 2018; Rawlins, 2008), corporate reputation (Men, 2014), and employee-organization relationships (Men & Stacks, 2014). However, limited research has been devoted to examining the role of transparent communication in facilitating organizational change. Therefore, this study also sets to explore the role of strategic internal communication, represented by transparent organizational communication, in affecting employees’ reaction to change. Specifically, the study evaluates employees’ openness to a specific change effort, which is arguably a necessary condition for successful planned change (Miller, Johnson, & Grau, 1994).

To fully delineate how leadership and strategic internal communication influence employee openness to change (Hill, Seo, Kang, & Taylor, 2012), the study proposes employee trust toward the organization as a potential mediating factor. Trust has been suggested at the core of organizational performance, success (Currall & Epstein, 2003), reputation (Yang, 2007), and organization-public relationships (Hon & Grunig, 1999). It has also been associated with various employee outcomes such as employee organizational citizenship behavior (Duffy & Lilly, 2013; Wat & Shaffer, 2005) and job satisfaction (Yang, 2014). Change puts employees in a vulnerable position and creates varying degrees of uncertainty around them (Allen et al., 2007; Bordia, Hunt, Paulsen, Tourish, & DiFonzo, 2004; DiFonzo & Bordia, 2002). However, employees’ organizational trust, potentially resulted from effective leadership and communication, can mitigate their uncertainty and psychological stress and lead to change acceptance (Rousseau & Tijoriwala, 1999). In other words, employee organizational trust likely mediates the impact of leadership and strategic internal communication on employee reaction to change.

Therefore, taken together, this study examines how transformational leadership and perceived transparent communication may interplay to influence employee openness to change through fostering employee trust during an organizational change event.

Literature Review

Organizational change is triggered by “a relevant environmental shift” that demands intentional organizational responses to accommodate new procedures, processes, values, and personnel (Porras & Silvers, 1991, p. 52; Seeger, Ulmer, Novak, & Sellnow, 2005). Change initiatives include a wide array of topics such as the introduction of new technologies, mergers and acquisitions, organizational restructuring, changes in organizational leadership, downsizing, and layoffs (Beck, Brüderl, & Woywode, 2008).

It is contended that many changes fail not due to their inherent flaws but because of the implementation issues (Choi, 2011). Research in change management has gradually shifted to examine “how change recipients react to organizational change” as a result of different approaches to change implementation (Oreg, Vakola, & Armenakis, 2011). The central role employees play in the successful implementation of a change initiative has been acknowledged both in management practice and scholarship (Armenakis, Harris, & Mossholder, 1993; Cummings & Worley, 2005; Fugate, Prussia, & Kinicki, 2012). Organizational change literature is abundant in explicating and investigating different employee responses to change initiatives (e.g., openness to change, commitment to change, readiness for change, resistance to change, cynicism about change) (Bouckenooghe, 2010; Jimmieson, Peach, & White, 2008).

Meanwhile, Choi (2011) encouraged researchers to focus on the conditions under which employees’ support for change can be fostered. For this study, we focus on transformational leadership and transparent communication as valuable organizational resources that can cultivate employees’ positive attitudes toward the change. Empirical evidence abounds that transformational leadership enhances employee job satisfaction, performance, commitment, and loyalty (Bass, 1999; Braun, Peus, Weisweiler, & Frey, 2013). The adoption of transformational leadership is particularly crucial in non-routine situations, such as during the adaptation-oriented period featured by a need for change (Pawar & Eastman, 1997). The substantial role that communication plays during organizational change is reflected in the strategic internal communication between the organization and its employees. As Ford and Ford (1995) stressed, “change is created, sustained, and managed in and by communication” (p. 560). Looking closely, strategic internal communication contributes to different facets of a change initiative; it can reinforce an organization’s strategic objectives and values (Barrett, 2002; Neill, 2018), articulate shared change visions (Fairhurst, 1993; Luo & Jiang, 2014), create emotional support of the change (Luo & Jiang, 2014), and enhance mutual understanding between decision-makers, implementers, and key users (Lewis, 1997).

Research on organizational change is abundant in psychology and management (Oreg et al., 2011). Nonetheless, given the paramount role communications play in change management, it is surprising to see a lack of public relations perspective and communication approach to organizational change (Johansson & Heide, 2008). This study fills this gap by proposing a normative model that links transformational leadership and transparent communication to employees’ attitudes toward change, represented by employee organizational trust and openness to change. Below, we first conceptualize the change outcome, openness to change, then review literature on employee trust as related to openness to change. Lastly, we conceptualize the two proposed antecedent factors of the study, namely, transformational leadership and transparent organizational communication during change, and discuss how they influence employee trust and openness to change.

Openness to change

Employees are active participants of change initiatives rather than passive recipients (Augustsson, Richter, Hasson, & von Thiele Schwarz, 2017). Therefore, employees’ beliefs, attitudes, and behaviors substantially affect change process and outcomes (Nielsen & Randall, 2013). Among these responses, employee openness to change is a “necessary initial condition for successful planned change” (Miller et al., 1994, p. 60). It is also “the most important element of organizational culture that leaders should look to build” during change (Ertürk, 2008, p. 463). Conversely, the lack of openness to change is “an ominous sign” that may well predict the failure of the planned change (Miller et al., 1994, p. 66).

While openness to change can be an individual trait characterized by flexibility and novelty (Fugate & Kinicki, 2008), this study treats it as a state that is largely determined by situational variables related to a specific organizational change and reflects one’s perception, evaluation, and experience with the change. Openness to change constitutes two components: positive affect toward the change outcomes and the willingness to support the proposed change initiatives (Miller et al., 1994; Wanberg & Banas, 2000). A positive affect is reflected in employees’ welcoming attitudes of the change, believing that the change will be beneficial to them. It warrants attention that openness to change only taps into employees’ behavioral intention and psychological preparedness to change (Augustsson et al., 2017) rather than actual behavioral support of change. In line with the theory of planned behavior (see Augustsson et al., 2017), the intention to perform a certain behavior guides the following behavior (Ajzen, 1991). As acknowledged in literature, openness to change may be a precursor to readiness to change (Axtell et al., 2002; Devos, Buelens, & Bouckenooghe, 2007), job satisfaction, and low intention to leave a job (Wanberg & Banas, 2000).

Employee organizational trust

Trust has been widely discussed in relational, organizational, and societal level (Cook & Schilke, 2010), and across disciplines in marketing, management, economics, political science, psychology, communication, law, and information systems (Schoorman, Mayer, & Davis, 2007; Yang & Lim, 2009). Earlier scholars defined trust from a trait perspective and examined individual characteristics that could predict their trusting dispositions (e.g., Rotter, 1967, Interpersonal Trust Scale). However, more recent discussions have emerged with a focus viewing trust as one aspect of organizational relationships (Hon & Grunig, 1999; Mayer, Davis, & Schoorman, 1995; McKnight, Choudhury, & Kacmar, 2002; Shockley-Zalabak & Ellis, 2006).

For instance, trust was defined as “the willingness of a party to be vulnerable to the actions of another party” (Mayer et al., 1995, p. 712) and “the decision to rely on another party under a condition of risk” (Currall & Epstein, 2003). This definition reveals two central components of relational trust: reliance (dependency) and risk (vulnerability), which are embedded in organization-public relationships (Currall & Epstein, 2003; Rawlins, 2008). Publics are in a vulnerable position when handing their relationships with organizations that possess more power than they do. If organizations prove to be untrustworthy, risks occur, and publics suffer from loss. Reliance refers to the positive expectation publics collectively cast on organizations, believing that organizations will fulfill their promise and behave with benevolence, honesty, reliability, and integrity (Currall & Epstein, 2003; Yang & Lim, 2009). Similarly, public relations scholars, such as Hon and Grunig (1999), defined trust as “one party’s level of confidence in and willingness to open oneself to the other party” (p. 2). They identified three underlying dimensions of trust: (1) integrity, which refers to the belief that the company is fair and just; (2) dependability, the belief that the company will do what it says it will do; and (3) competence, the belief that the company has the ability to do what it says it will do (1999, p. 3). Based on definitions provided by Rawlins (2008), and Hon and Grunig (1999), this study defines employees’ organizational trust as employees’ willingness to be vulnerable to their organizations’ actions based on the belief that their organizations have integrity, and are dependable, and competent.

As an important organization-public relationship (OPR) indicator, trust, along with five other OPR dimensions, have been validated and applied in many public relations studies (Ki & Hon, 2007). For instance, OPR outcomes, including relational trust, have been associated with organizational reputation (Yang, 2007), positive public attitude and behavioral intention (Ki & Hon, 2007), public engagement (Men & Tsai, 2016), and positive employee communication behaviors (Kang & Sung, 2017). Nevertheless, how organizations could utilize organizational resources, such as internal communication and leadership, to cultivate employee organizational trust, particularly during turbulent organizational change, has remained underexplored.

From an internal perspective, the extent to which employees trust their organizations determines their cooperation, communication, and productive relationships with the organization (Rawlins, 2008). Trusting employees believe their interests are aligned with their organizations, which is particularly crucial in the change environment. Research shows that the trusting relationship between employees and managers is the basis for change initiative success; specifically, trust in the management cultivates positive employee attitude toward the change (Devos et al., 2007; Ertürk, 2008), whereas a lack of trust leads to a decrease in the perception of the legitimacy of the change, less readiness for the change, and stronger behavioral resistance to the change (Oreg, 2006; Rousseau & Tijoriwala, 1999). Along this line of reasoning, we argue that employees who trust their organizations embrace the vulnerability of their positions while accepting the rationale and the legitimacy of the change decision made by organizations, thus being more open to change. Therefore, we propose:

H1. Employee organizational trust during the change is positively associated with employee openness to change

Antecedents to positive change outcome: a social exchange perspective

Cook et al. (2005) propose that the trust building process is essentially a social exchange process. Social Exchange Theory (SET; Blau, 1964), in which this study is grounded, centers on self-interest and interdependence between two parties. SET has been extensively applied to examine organizational behavior. In the work setting, employees receive economic and socio-emotional benefits from the organization. SET delineates that employees who perceive and benefit from organizational resources will experience a degree of indebtedness, which subsequently causes a sense of obligation to repay the organization. On one hand, employees reciprocate by demonstrating positive attitudes and behaviors (Greenberg, 1980), such as engaging in more work (Wayne & Green, 1993), demonstrating organizational citizenship behavior, external advocacy (Men & Yue, 2019), organizational commitment, and loyalty (Eisenberger et al., 2010); on the other hand, it is found that organizational support and care are important factors that elicit employees’ reciprocal behaviors. Organizational socio-emotional resources such as authentic leadership, transparent communication (Jiang & Luo, 2018; Jiang & Men, 2017), employee empowerment (Saks, 2006), and high-performance work system (Gong, Chang, & Cheung, 2010) have all been associated with employee positive attitudes and behaviors. In the change management context, this study specifically focuses on the role of transformational leadership and transparent communication in generating trust and employee openness to change. Bass and Riggio (2006) have claimed that “transformational leadership is, at its core, about issues around the processes of transformation and change” (p. 225). Additionally, transparent communication has been found as contributing to employee trust, work engagement, and organizational reputation (Men, 2014; Jiang & Luo, 2018; Jiang & Men, 2017; Rawlins, 2008) and could arguably facilitate change implementation (Men & Bowen, 2017). Therefore, these two factors should play irreplaceable role in the successful implementation of organizational changes.

Transformational leadership

Bass (1985) transformational leadership has been one of the most researched leadership styles (Bass, Avolio, Jung, & Berson, 2003; Wang, Oh, Courtright, & Colbert, 2011). Rather than stressing the role of rules, standards, and power in organizations, transformational leaders are “relationship-oriented, interactive, visionary, passionate, caring, and empowering” (Men & Bowen, 2017, p. 69), and therefore able to enhance “consciousness of collective interest among the organization’s members and help them to achieve their collective goals” (García-Morales, Jiménez-Barrionuevo, & Gutiérrez-Gutiérrez, 2012).

Transformational leadership is characterized by four features: First, transformational leaders exhibit idealized influence by communicating collective purposes and values, demonstrating confidence and determination, and acting as charismatic role models. Second, inspirational motivation is displayed when leaders envision a desirable future, motivate followers to perform at higher levels and achieve common objectives. Third, they serve as a constant source of emotional support and demonstrate personal care, empathy, sensitivity, and individualized consideration for the developmental needs of employees. Finally, intellectual stimulation is displayed when leaders stimulate employees to think outside the box, challenge old assumptions, and promote their intelligence, learning, and innovation (García-Morales et al., 2012; Men & Bowen, 2017; Wang et al., 2011). Transformational leaders generate trust, pride, and respect from employees and are consistently associated with positive employee attitudes and behaviors in the workplace (Bass, 1999; Braun et al., 2013; Herold et al., 2008).

In the context of organizational change, a transformational leadership style brings about more positive outcomes than a transactional leadership style (Bass, 1985; Eisenbach, Watson, & Pillai, 1999; Hill et al., 2012). Transformational leaders engage in creating a purpose, or a vision, that clearly states the strategic direction of the organization, while meeting the needs of employees by taking their concerns into consideration. Intellectually, they motivate employees to think differently and to embrace new opportunities by framing change as a chance for personal growth. They are also capable of assembling a team to provide coaching and guidance to ensure employees’ smooth transition to the new environment. Overall, rather than exacerbating change-induced uncertainty and dissatisfaction, transformational leaders transform the change initiative to be more appealing. Empirically, such leadership influence has been associated with positive employee attitudinal and behavioral reactions during the change (Herold et al., 2008). Specifically, transformational leadership increases employee change commitment (Herold et al., 2008), job performance (Detert & Burris, 2007), job satisfaction (Braun et al., 2013), and reduces employee change-related cynicism (Bommer, Rich, & Rubin, 2005).

Consequently, employees who perceive the personal care, emotional support, and inspirational motivation from transformational leaders will feel an obligation to reciprocate such support and therefore be more likely to trust their organizations during the change. Prior studies have showed a positive impact of transformational leadership on promoting employee trust and loyalty in the workgroup (Bommer et al., 2005) and trust in leadership (Braun et al., 2013; Kelloway, Turner, Barling, & Loughlin, 2012). In turn, employees with high organizational trust will make extra efforts, look beyond self-interests, and champion organizational change.

H2. Transformational leadership during the change is positively associated with employee organizational trust.

H3. Transformational leadership during the change is positively associated with employee openness to change.

Transparent communication

Effective leadership cannot function in its fullest capacity without communication. The adoption of transparent internal communication demonstrates organizational leaders’ genuine interest in maintaining or enhancing relationships with employees. Transparency is the opposite of secrecy and is characterized by openness (Rawlins, 2009). Transparent communication is an excellent characteristic of internal communication (Men & Stacks, 2014) and has received increasing prominence in strategic communication literature (Jiang & Luo, 2018). For instance, communication scholars have found that transparent communication induces organizational trust (Jiang & Luo, 2018; Rawlins, 2008) and increases perceived corporate reputation (Men, 2014) and employee-organization relationships (Men & Stacks, 2014). Transparency consists of informational, participatory, and accountability transparency. These three elements “work together but are analytically distinct” (Balkin, 1999, p. 393). First, informational transparency necessitates the disclosure of “truthful, substantial, and useful” information” (Rawlins, 2008, p. 6). It should be noted that informational transparency is distinct from mere disclosure. In fact, organizations’ disclosure of overabundant information can cause confusion rather than clarification. In real life, an organization can claim to have disclosed “all legally releasable information” to employees by flooding them with meaningless documentations and emails (Rawlins, 2009, p. 74); however, in this case, the organization has no true or sincere intention to provide employees with relevant and key information. In the context of change initiative, top management’s incapacity to implement informational transparency can cloud employees’ understanding of the content, purpose, and implementation process of the change initiative. Participatory transparency is an organizational effort to involve employees in identifying the most relevant and concerned information to meet their informational needs. Without consulting employees and asking for their feedback, an organization is not able to provide the substantial and relevant information that employees want and need to know. As Cotterrell put it, transparency is the enabling of the information receivers’ “active participation in acquiring, distributing and creating knowledge” (Cotterrell, 1999, p. 419). Therefore, management should strive to solicit employee feedback regarding what information they hope to learn and create an environment where change-related information can be easily accessed. The accountability dimension of transparency concerns the inclusion of both positive and negative information. Organizations ought to reveal both sides of a story, and by doing so, avoid any attempt to manipulate employees’ perceptions and interpretations of the organizational action. When communicating the change initiative, an organization that values accountability would disclose both benefits and threats of a change initiative. Otherwise, hiding negative ramifications of the change initiative will breed rumors and misinterpretations, cause misunderstanding and distrust, and heighten employee uncertainty, insecurity, and anxiety (Men & Bowen, 2017). It is worth noting that not all change-related information will be transparent and complete; however, informing employees beforehand that the provision of information will be incomplete and providing them with a timeline for additional information is conducive to reducing employees’ uncertainty and anxiety (DiFonzo & Bordia, 1998). The same approach is articulated by Gergs and Trinczek (2008), who pointed out that “withholding information during phases of radical change is one of the worst mistakes in change management” (p. 152).

Empirical studies reveal that employees’ positive perception of internal communication fosters trusting relationships with their managers (Jo & Shim, 2005). Furthermore, Rawlins (2008) and Jiang and Men (2017) found a direct positive relationship between transparent internal communication and employee trust toward organizations. Along this line, we argue that an organization’s effort in engaging in transparent communication sends out a signal to employees that the organization is frank, honest, open, and would take employees’ concerns and feedback in consideration during the change. In the words of Rawlins (2008, p. 3), “a key part of reciprocal trust is an organization’s efforts to be transparent,” thus, the belief that organizations can cultivate employees’ confidence and trust by virtue of transparent communication is reinforced. Likewise, under the premise of understanding the goals and purposes of the change, employees would be more open to the change event.

H4. Transparent communication during the change is positively associated with employee organizational trust.

H5. Transparent communication during the change is positively associated with employee openness to change.

As one of the most important factors influencing organizational success, trust has been empirically established as a mediator between transformational leadership and employee attitudes (Dirks & Ferrin, 2002), job satisfaction (Pillai, Schriesheim, & Williams, 1999), and team performance (Braun et al., 2013; Schaubroeck, Lam, & Peng, 2011). Additionally, trust also results from effective internal communication and in turn affects employee behaviors and overall organizational outcomes (Shockley-Zalabak & Ellis, 2006). As previously argued, transformational leadership and transparent communication during the change contribute to employees’ organizational trust. In turn, when employees trust organizational abilities to implement the change, they are more likely to believe that the change is beneficial and well-intentioned, and therefore demonstrate greater openness to change. In this process, trust serves as a key mediator through which the power of transformational leadership and transparent communication is manifested. This leads to the final hypothesis:

H6. Employee organizational trust mediates the positive relationships between transformational leadership (H6a), transparent communication (H6b), and employees’ openness to change.

Method

The hypothesized model (Fig. 1) was tested through an online Qualtrics survey with a random sample of employees working across a variety of industries in the United States in a 2-week period in August 2018. Survey Sampling International (SSI), a global sampling service firm, assisted us in recruiting participants through its patented online sampling platform. Utilizing stratified and quota random sampling strategies, we obtained a representative sample with comparable genders, age groups, and organization sizes across various income and education levels. The final sample included 439 employees with 42.8% males and 57.2% females who qualified the screening question, which asked whether their company is currently undergoing a company-wide change or has gone through a company-wide change in the past two years and the respondents experienced the change. The average age of participants was 40 (SD = 13.11). Regarding their level of position, middle-level management comprised 32.6% (n = 143), followed by 31.7% non-management (n = 139), 24.8% lower level management (n = 109), and 10.9% top management (n = 48). More than half participants (n = 230, 52.4%) held at least a bachelor’s degree. The income range with the first and second largest number of participants were US$30,000 to US$49,999 (n = 92, 21%) and US$50,000 to US$69,999 (n = 90, 20.5%).

Measures

All the key constructs were measured using items derived from established studies and revised to fit into the change context. The survey instrument included questions measuring the antecedent variables (transparent communication, transformational leadership), one mediating variable (organizational trust), and one outcome variable (openness to change). Specifically, transparent communication was assessed by 16 items adapted from Rawlins (2009) and Men and Bowen (2017). Measures for three dimensions of transparent communication demonstrated good reliability (α = .92 for participation, .94 for substantiality, and .91 for accountability). Transformational leadership was assessed using 11 items developed by Rafferty and Griffin (2004). Four underlying dimensions of this construct had acceptable reliability: .84 for idealized influence, .85 for inspirational motivation, .83 for intellectual stimulation, and .91 for individualized consideration. Openness to change was examined using four items adapted from Wanberg and Banas (2000) (α = .87). Six items adapted from Rawlins (2009) and Hon and Grunig (1999) were used to measure employee organizational trust (α = .92). All items used a seven-point Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree).

Discussion and conclusions

The roles of transformational leadership in inducing positive employee attitudes (e.g., trust and satisfaction with leaders, organizational commitment) and behaviors (e.g., in-role performance, organizational citizenship behavior, creative performance) have been widely established in literature (Bass, 1999; Braun et al., 2013; Wang et al., 2011). This study supports and extends this line of research on transformational leadership with a specific focus on its role in organizational change events, a much-needed but underexplored scenario. The result demonstrated that transformational leadership played a positive role in engendering employee organizational trust. Grounded in SET (Blau, 1964), this study suggests that when the leaders appeal to the higher-order needs of employees, show individualized consideration to employees (e.g., tend to individual difference, coach employees individually), stimulate employees intellectually (e.g., teach them problem-solving skills), and show emotional support to employees (Bass, 1985; Wang et al., 2011) during organizational change, employees tend to exhibit trust toward the organization. These socio-emotional resources provided by transformational leaders are especially valued and appreciated by employees who are facing heightened anxiety and uncertainty during the change. For instance, the emotional links transformational leaders create with employees during the change induces employees’ awareness, acceptance, and commitment to a shared purpose and vision of the organization. Such leadership also encourages employees to overcome internal and external obstacles posed by the change and provides venues, in the form of change-related workshops and training, for employees to succeed. In conclusion, this finding points to the key role of transformational leadership and contextualizes its positive impact on eliciting employee trust during the organizational change.

This study also found a positive association between perceived transparent communication and employee organizational trust. Many scholars have acknowledged that effective communication is an important, but underdeveloped concept in organizational change literature (Johansson & Heide, 2008). Extant literature has examined change communication in terms of the perceived information and communication quality (Allen et al., 2007; Miller et al., 1994), perceived communication satisfaction (Bull & Brown, 2012), and sources of communication (Allen et al., 2007). This study provided additional evidence on the importance of transparent communication in successful change implementation. The concept of communication transparency has been closely tied to trust and credibility as seen in both professional (Edelman Public Relations, 2018) and academic literature (Rawlins, 2008,2009). For instance, empirical studies revealed that transparent internal communication is constructive in fostering employee trust, corporate reputation, and employee-organization relationships (Men & Stacks, 2014; Men, 2014; Rawlins, 2008). This study has further reinforced the notion that as organizations increase its communication transparency, they will become more trusted from the perspective of employees (Rawlins, 2008). Specifically, open, honest, and ethical communication can narrow the information gaps between employees and organizations, diminish change-related misinformation and rumors, and reduce employees’ anxiety and stress. Employees upon sensing organizations’ sincere interest in looping them in the change plan will be more likely to trust organizations’ intention and capability in implementing the change. In addition, organizations’ efforts in soliciting feedback from employees allow employees to voice out their interests and concerns, and more importantly, give them a sense of control and ownership of the change.

Impact on employee openness to change: the mediating role of organizational trust

This study confirmed a strong positive association between employee trust toward organizations and their openness to organizational change. Specifically, the more employees trust their organizations during the change; in other words, they rely on their organizations’ words and actions, hold faith in organizational justice, fairness, and competence in surviving the change, the more likely they develop a welcoming attitude toward the change and support change. The result pointed out the central and direct role of trust in eliciting positive employee attitude and behavioral preparedness during times of uncertainty. In addition, our emphasis on one important manifestation of employee change support (i.e. openness to change) embraced the notion that employees are active participants of organizational change; thus, their attitudes and behaviors during the change significantly impact the change outcome (Fugate et al., 2012). In this sense, this study filled the research gap by highlighting the direct linkage between employee trust and reaction to change and provided empirical evidence for organizational leaders to focus directly on cultivating employee trust to facilitate change implementation.

Much of prior research focused on the direct effects of leadership and communication on employee’ support for the change. This study also indicated that organizational trust plays a mediating role between transformational leadership, transparent communication, and employees’ openness to change. Trust has been linked with a variety of employee behaviors and organizational performance. For instance, employee trust in organizations leads to high job satisfaction and performance, low employee turnover, and high organizational commitment (Shockley-Zalabak & Ellis, 2006). The conclusion that trust fully mediates the influence of transformational leadership and transparent communication on employee openness to change emphasizes the indispensable and immediate role of trust. This finding provides empirical support for the notion that trust is pivotal in the uncertain and rapidly changing environment (Oreg, 2006; Rousseau & Tijoriwala, 1999) and can be fostered by transformational leaders and a transparent communication environment.

However, the results did not confirm direct positive associations between transformational leadership or transparent communication, with employee openness to change. This finding stands in contrast to previous literature that showed a direct influence of transformational leadership on employees’ change commitment and support for the change (Burke, 2002; Herold et al., 2008). The discrepancies may be attributed to the fact that trust is a more immediate and relevant factor eliciting employees’ positive attitude towards change than their perception of leadership behaviors and communication styles.

Theoretical and practical implications

As one of the first empirical attempts to examine the impact of corporate communication and leadership during change on employee reaction to change, the findings provide important theoretical and practical implications. Theoretically, by showcasing the influence of communication transparency featured by information substantiality, participation, and accountability on employee change attitudes, namely, trust during change and openness to change, the study contributes to the change communication literature from an internal public relations perspective. The findings provide theoretical insights into how transparent communication works in facilitating change implementation and extends the application of the strategic transparent communication strategy into the organizational change management context.

Also, the study demonstrates how organizational leadership interplays with communication factors to influence change outcomes. Transformational leadership in the context of organizational change has been extensively studied in previous literature; yet little is known how it affects employee reaction to change when the factor of strategic internal communication is taken into consideration simultaneously. The current study fills this research gap by demonstrating that transformational leadership and transparent internal communication play equally important roles in generating employee organizational trust during change, which subsequently leads to employee openness to change. Lastly, by focusing on employee reaction to change as a critical change outcome, the study assumed employees’ active participant role during change. It also delineates how employee openness to change is impacted by leadership and strategic internal communication by highlighting the critical mediating role of employee trust toward the organization.

From a pragmatic perspective, the findings provide important practical insights for public relations professionals, change communication managers, and organizational leaders. Essentially, to effectively manage change and generate positive employee affect and support for change, public relations and change communication managers should advocate an open and transparent communication climate. In particular, employees should be provided with complete, truthful, and unbiased change-related information in a timely manner, such as being fully informed about the rationale for change, what the change entails, and how it may impact employees’ job. Change communication managers should promote employee feedback and participative communication, proactively listen to employees’ voice opinions, and concerns, as well as seek for understanding of employees’ information needs. Change communication should also demonstrate the organization’s accountability, willingness to admit mistakes and reveal both sides of the story (i.e., benefits and threats) related to the change initiative.

Organizational leaders should communicate a clear and compelling vision for the change which can help unify employees, guide them in the right direction, and portray a shared purpose that motivate employees to support change (cf. Men & Bowen, 2017). Leaders at various levels should demonstrate confidence and determination in their communications and actions, and act as role models to advocate and support for the change. They also ought to challenge employees to think outside of the box and be creative and innovative, capitalizing on the transformative opportunity that change brings about. Most importantly, leaders should recognize employees’ legitimate feelings such as anxiety and uncertainty toward change and demonstrate genuine care and consideration for employees’ concerns, feelings, needs, and welfare. Overall, effective change communication requires collaborative efforts from public relations, human relations management, as well as leaders across different levels.

A system that incorporates strategic corporate and leadership communication should be in place to breed employee organizational trust, especially during the turbulent change process. The 2018 Edelman Trust Barometer reveals that trust in the U.S. has experienced an unprecedented crisis. Respondents claim that building trust should be the CEOs’ No. 1 job. This study further evidenced that trust is most critical in fostering employees’ openness to change and successful change implementation, and therefore urge companies to propel trust-building as a top business issue.

Limitations and future research directions

Despite the above-stated contributions, the study has encountered several limitations that should be acknowledged and addressed in future research. First, the study examined transparent communication and transformational leadership using self-reported data from single employees’ perspective. Without incorporating the communication managers and leaders’ perspectives, only employee perceptions as opposed to true leadership and communication behaviors were measured. Future research could utilize other methods, such as ethnography approaches, and incorporate the change communication managers’ and organizational leaders’ insights to provide a more in-depth, complete, and balanced understanding of how leadership and communication factors influence employee change outcomes. Second, a cross-sectional design is limited in establishing causality between the predictor and outcome variables. Although the use of structural equation modeling partially remedied the case, a true causal relationship can hardly be built without an experimental or longitudinal design or perhaps a longitudinal quasi-experimental design. Third, the study utilized a generalized approach to examine organizational change, which did not specify the change type. Future research could specify the model proposed in the study in specific change contexts, such as merger and acquisition, leadership or culture change. Finally, to delimit the scope of the study, the model only included transformational leadership and transparent communication as predictors of employee change attitudes. Other effective leadership styles (e.g., authentic leadership, ethical leadership, transactional leadership, and strategic communication strategies (e.g., symmetrical communication), messaging, and emerging channels (e.g., social media) in relation to employee reaction to change could be examined in future studies.