The challenges of change processes for nurse leaders—a qualitative study of long‐term leaders' experiences over 25 years

Abstract Aim This study aimed to map what experiences nurse leaders have encountered concerning the change work that political decisions and reforms have created within the healthcare sector in the last 25 years. Design A qualitative design with a narrative approach was used. Methods A qualitative study involved individual interviews of eight nurse managers from Norway and Finland with more than 25 years of experience working in specialist and primary healthcare fields. Results Two main categories were observed: experiences of organizational challenges and experiences of personnel‐administrative challenges. The first main category included two subcategories: A: historical experience with culture and challenges in health services and B: historical experience with mergers and using welfare technology in health services. The second category included the following subcategories: A: historical experience of job satisfaction for leaders and employees and B experiences with interprofessional collaboration in health services.

organizations in Nordic countries in the 1990s. The nurse leader's role in the organizations was changed from the role of a clinical expert to a more non-clinical one. Leadership became largely based on strategic management, administration, development of content and work around training of the staff. Furthermore, non-clinical leaders were no longer engaged in direct contact with patients or played any active role in patient care, as clinical leaders did (Feitosa et al., 2021).
Other changes over the 25 years include the digitization and the priorities of open health care versus hospital care. The implementation of new health technology has also initiated a change process and has the potential to alter methods of working, organizing work and power relations in health organizations (Vaagan et al., 2021).
Digitization has been (and still is) a major challenge for health organizations (Vaagan et al., 2021). To create an alliance to ensure proper health care, leaders are required to develop leadership competencies that differ from the typical criteria associated with clinical and scientific excellence (Vasset et al., 2022;Ylitörmänen et al., 2019).
Leaders at all levels in health services experience major change, with challenges for both leaders and employees. Organizations merge into large units, with wide geographical spread and different cultures. According to Salmela et al. (2012) and Vasset et al. (2023), nurse leaders promote change by leading relationships, processes and culture and by using supportive, reflective and culture-bearing leadership that permits the realization of genuine and sustainable changes (Salmela et al., 2013(Salmela et al., , 2017Vasset et al., 2022Vasset et al., , 2023.
Leadership, which emphasizes innovation, creativity, competencies and the participation of employees in strategic planning, has resulted in the knowledge of rules or bureaucratic procedures becoming less relevant. Healthcare teams often work in uncoordinated environments, thus resulting in the duplication of processes, and increased costs and workload. Fast-paced, demanding working environments have led to increased medical errors and threatened patient safety. For decades, hierarchies between nurses and medical and financial leaders have existed. The role of nurse leaders has often been unclear (Yukl, 2019). In contrast to nurses, physicians are formal leaders who engage in direct contact with patients, and the role of nurses has been to indirectly create the conditions required for reasonable care (Huikko-Tarvainen, 2022;Vasset et al., 2021Vasset et al., , 2022. In order to lead change processes, an effective leader has to use different relationship-oriented behaviours to build commitment, mutual trust, collaboration, and identification with the team. Moreover, the leader builds and maintains a network of cooperative relationships with outsiders who are a valuable source of information, assistance and political support, and who also forge a coalition of internal and external supporters (Booher et al., 2021;Hemberg & Salmela, 2021;Salmela et al., 2017). This case study is a qualitative study based on individual interviews among eight nurse leaders from two countries, Finland, and Norway.

| BACKG ROU N D
Earlier research was conducted with the help of a systematic database search by using the following keywords: change processes, nurse leader and challenges in health services. Several concepts were found to be common to interprofessional and inter-organizational collaboration, such as communication, trust, respect, mutual acquaintanceship, power, patient-centredness, task characteristics and environment (Almås et al., 2018). Other concepts are of particular importance either to inter-organizational collaboration such as the need for formalization and the need for professional role clarification or to interprofessional collaboration such as identifying the role of individuals and teams. The promotion of inter-organizational collaboration was observed to face greater challenges, regarding matters such as the achievement of a sense of belonging among professionals when differences exist between corporate cultures, geographical distance, the multitude of processes and formal paths of communication span style (Karam et al., 2018).
Employees' reactions to changing processes can vary depending on the desire for change. Previous research has described employees' reactions to change in terms of threats, job satisfaction, problems and solutions (Holmström et al., 2021;Nilsen et al., 2016). Approximately 40%-80% of traditional change efforts result in failure, as reported by Nilsen et al. (2016). This failure may be due to the existence of multiple frameworks for understanding the types and the nature of change and a lack of conceptual clarity regarding the tasks of leading, managing and directing change. However, many change initiatives fail because of unfocused and insecure management and due to a lack of systematic project management (Holmström et al., 2021).
The effective nurse leader leads interpersonal relationships through an ethical approach of respect, trust and concern to preserve a trustworthy relationship with co-workers. Moreover, the nurse's leader is an interactive team player (Gjellebaek et al., 2020).
Changing processes benefit from effective nurse leaders who lead through an ethical leadership style characterized by respect, trust and consideration (Hemberg & Salmela, 2021;Holmström et al., 2021).
Leading change processes are not a new concept for nurses; however, the character of such changes is complex, and the processes are faster-paced than they were 25 years ago.
Collaborative practice has been highlighted as a necessary aspect of implementing change processes and addressing health problems in a complex municipality (Almås et al., 2018;Guraya & Barr, 2018;Vasset & Almås, 2017). Employees and leaders in health organizations must collaborate in an individual organization and among different organizations, countries and professions. These principles are similar across health professions and are often enumerated in terms of interprofessional collaboration, sharing, partnership, interdependency and power (Green & Johnson, 2015;Hove & Vasset, 2020;Karam et al., 2018;Lindquist, 2018).
A study by Vasset et al. (2022) demonstrates that nurse leaders have shifted from serving as clinical experts to performing purely administrative work. One of the most important tasks for nurse leaders is to develop their skills to lead and manage all the challenges that the change process requires (Hemberg & Salmela, 2021;Salmela et al., 2017).

The research question is as follows:
What challenges have nurse leaders had in terms of organizational change processes in their work over 25 years? 3 | ME THODS

| Design
In this study, we employed a qualitative narrative design (Kvale & Brinkman, 2015;Polit & Beck, 2017), which has been identified as being the most suitable method for exploring experiences and opinions and for gaining a comprehensive understanding of a leader's work history. The narrative design describes life in its entirety by recapitulating past experiences and matching a verbal sequence of causes to a series of events (Polit & Beck, 2017). The term 'history' is equivalent to 'narrative', thus indicating that the narrative is the primary form in which humans live.

| Sample
The study included participants from primary and specialist health services in Norway and Finland. The leadership role of the participants was largely based on strategic management, administration, development of content and work training. All participants had formal leadership and management position. The leaders' titles differ between the countries. In this study, we chose to use the term 'nurse leaders' synonymously to 'head nurses' or 'chief nurses which comprises that they were responsible for resource allocation, administration, staff and service quality at an intermediate level. Prior to the data collection, specialists and primary health service leaders were contacted and informed of the study via email. The intention was to recruit participants with long-term and profound experiences as nurse leaders in the context of healthcare services or specialist care. They should also have experience in leading change processes. The first eight nurse leaders who accepted the invitation to participate in the study were included, that is four nurse leaders from primary health services and four nurse leaders from specialist health services, for a total of four nurse leaders from each country. Table 1 shows a description of the informants' formal education, higher education, organizational affiliation, title and nationality.
Prior to the data collection, specialists and primary health service leaders were contacted and informed of the study via e-mail.
The intention was to recruit participants with long-term and profound experiences as a nurse in the context of. In other words, the informants were located through recommendations from wellknown healthcare professionals. The participants were required to

| Data collection
Data were collected through individual interviews with an open interview guide. The same number of interviews was carried out in both Norway and Finland. At the beginning of the data collection process, three interviews were carried out face to face; but due to the COVID-19 pandemic, some of the data was collected virtually. All the interviews were audiotaped, with the written permission of the informants. Additionally, the interviews lasted approximately 1½ h each and were completed in the spring-summer of 2020. The focus of the narrative interviews was on the depth of the conversations.
Background data are presented in Table 1. Table 1 highlights the level of education of the nurse leaders and demonstrates variation between the Nordic countries, which can possibly be explained by how nursing science as an academic discipline has developed in different countries (Hafsteinsdóttir, 2019;Vasset et al., 2021Vasset et al., , 2022.
The main question the participants were asked was, which challenges they had experienced during the changing processes.
The analysis process followed the four steps of text condensation suggested by Malterud (2017).
(1) Firstly, the transcripts were read by the first author and third authors to obtain an overall impression of the respondents' experiences.
(2) Secondly, a detailed reading of the transcripts was performed to identify relevant descriptions of experienced challenges during the change processes.
(3) Thirdly, the content of meaningful units was abstracted into concepts and coded into categories and subcategories. (4) Finally, the essence of each category and subcategory was summarized and used as a foundation for the result section.

| Ethical considerations
The Research Ethics Committee's approval for this study was obtained from the Norwegian Social Science Data Services. Informed consent was obtained from all the respondents in accordance with the rules stipulated by the Helsinki Declaration. We conducted eight narrative interviews with nurse leaders in healthcare institutions.

Moreover, the same number of interviews was conducted in both
Norway and Finland. The interviews were open ended to provide the informants with the opportunity to convey a complete picture of their careers. Dictaphones and virtual platforms were used during the interviews. Furthermore, the focus of the narrative interviews was on the depth of the conversations. After eight interviews had been conducted, we could observe similarities and differences in the informants' experiences. However, we could also observe clear themes emerging based on the interpretation and analysis processes.
The participants were informed that they could withdraw from the interview in 4 months but before the writing of the articles began.
The participants had been numbered and could be identified by the authors. The first author has an overview of the informants from Finland, and the third author has an overview of those from Norway.
The participants were provided with both written and verbal information regarding the purpose of the project. However, it was in the researchers' interest to protect the identity of the informants as far as possible. The audio tapes and data about the informants were kept apart. The informants were informed of this and asked to give informed consent to the accepted conditions before the survey.

| RE SULTS
The analysis process generated two main categories: (a) organizational challenges and (b) personnel-related and political challenges.

| Experiences of organizational challenges
The category related to organizational challenges was divided into The intention is that nursing and medicine should be equivalent, but it depends on the person, how you want to lead (N4).
In the 1980s, new models for treatment and caring were developed, which led to a need for new organizational and care models (i.e. a new nursing ideology or culture). The processes of nursing and caring would be developed in accordance with the patients' needs and adapted to contemporary norms and value systems, one informant stated.
The mindset that one must look after the client's needs and opportunities adapts the business to support the client. It taught me an incredible amount to be able to follow the rehabilitation process of a client (N4).
In addition to cultural changes, the informants also emphasized the need for quality insights into financial awareness. Patient or user TA B L E 2 Change process in health services. Based on the data, it appeared that political decision-making and economic realities often constitute motivations for change rather than aspects related to culture or quality, which professional managers cannot ignore. However, simultaneously, the economic reality does not exclude opportunities to work to provide high-quality services.
Then, it is economical. You have the money you must use that the municipalities give, and we always exceed it, but it is probably a constant struggle with finances (N2).

| Historical experience with mergers and the use of welfare technology in health services
Changes of various kinds have occurred throughout the participants' careers, but these changes are expected to occur more quickly and become more significant than the participants' discussions indicate. At the beginning of their careers, nursing leaders were leaders of small organizations, in which context they leader could oversee the work activity in detail. Today, organizations have expanded and have become too large and too complex to 'own' all the ongoing projects.
The merging of different hospitals is a substantial change that results in extraordinary challenges for leaders and employees.

Legislation and national recommendations in Finland and Norway
have highlighted the need for larger units, which would be more cost-effective and increase the quality of services.
The merger came, the Cooperation Reform came, the Hospital Reform came, and it became a health trust (N1).
An obvious problem that emerged in the data material was the sizeable geographical spread of the organizations, which complicates the developmental processes of the new organization. Contact in the organization often takes place via digital platforms, which is an approach that the informants experienced as being challenging with respect to contact creation and interaction.
New reforms-We spent a great deal of time creating a common culture and merged with AAA Hospital. This merger was not life changing. The problem was that we had collaboration problems from the first moment (N4).

| Experience of personnel administrative challenges
The second main category of challenges was related to personnel administrative challenges. The main category was related to two subcategories: (a) job satisfaction and motivation and (b) political and interprofessional collaboration.

| Historical experience of job satisfaction for leaders and employees in health services
The participants experienced reluctance to change. This reluctance is often rooted in various types of fears. Staff members are anxious about losing their jobs, the inability to cope with new tasks and having to move to another workplace that features new, unknown routines and people. Moreover, the participants noted that employees perceived mergers as threats. One frequently raised question was 'Whether I will be allowed to keep my job. Will I get new tasks that I do not master?' A challenge for nursing leaders pertained to the creation of security and trust and the task of listening to and informing employees. Furthermore, participants noted that displaying a cheerful outlook towards change work was a challenge.
Being motivated to work for change depends on one's own goals and expectations that the change must bring with it (F6).
As brought out by the informants, mergers among organizations resulted in changes in terms of leadership responsibilities. The leader was given greater responsibilities and additional employees to manage. Additionally, the personal relationships between leaders and employees were weakened. The leader did not 'know' their staff in the same manner as before. Moreover, the informants felt they became more distant from clinical work and began to serve as a fulltime administrator.
It was a merger of units, which met with resistance. I must listen to them, and there was a concern, will I be without work? I must move there (F5).
Several informants highlighted the fact that you must listen to employees, engage in discussion with them and motivate them to perceive new opportunities. Some employees shared that they did not always know if they could trust that they would be well cared for during the change process.
Some have difficulty making the change, depending on how you are as a person. However, you must understand them too. If they have been at a small place, they will be afraid to come to a larger place, afraid of not being able to do it, if it is too demanding, do I have the required knowledge, or will I be forgotten (F5).
A leader's task is to address fears and anxiety and to motivate change work. At present, leaders have fewer opportunities to inform employees of changes and to discuss that topic with the employees. The larger and more complex an organization grows, the more insecurity emerges among employees. The participants noted that they often did not know each other, which could be a challenge.
Moreover, the workplace was viewed as pleasing when employees exhibited certain traits. As one informant noted, 'they must like challenges and those who are going to start here must be independent and not focus on details all the time' (N1).
A prerequisite for successful change is that employees must feel as if they are involved in the change process and must understand why a change is necessary. Furthermore, attitude change requires time and many extensive discussions.

| Experiences with interprofessional collaboration in health services
Some participants expressed the notion that being the leader of an interprofessional team was appealing to them. 'We worked interprofessional with physiotherapists, occupational therapists, speech therapists and doctors in this department. It is a challenge to be an interprofessional leader and a leader of many vital professions' (N4).
The change affects people in both positive and negative ways. A leader should first ensure that employees are aware of the reason for such a change. That most of the changes were initiated by politicians without sufficient knowledge of the consequences that a decision had for the organization and the employees, was a common experience among the informants.
If you believe that you belong to a management group that pre- These quotes emphasize the idea that important questions need answers, and the questions may not be easy to answer.

| DISCUSS ION
Based on the two main categories, experiences of organizational challenges and experiences of personnel administrative challenges with subcategories, analysis and interpretation of the findings was carried out. The informants highlighted culture, quality of services and economics as essential issues that are relevant to change processes. In addition to cultural changes, the informants also emphasized the need for quality insights and financial awareness. The second category is related to job satisfaction and motivation and to political and interprofessional collaboration. Job satisfaction, motivation and political and interprofessional collaboration have been highlighted in earlier research (Salmela et al., 2017;Storbjörk et al., 2021).

| Organizational challenges from a historical perspective
The results confirmed that organizational challenges have been a reality throughout the careers of nurse leaders. New reforms have occurred, new welfare technology has been developed and mergers of health institutions have occurred because of political intentions and goals. Culture, quality and economy have been relevant themes in connection with the changes that have been relevant in recent decades (Huikko-Tarvainen, 2022;Nylenna, 2020).
In the early 1990s, these changes frequently pertained to new care models, service offerings and leadership issues. Political leaders have given considerable attention to quality assurance models, efficiency and productivity (Gjellebaek et al., 2020;Karam et al., 2018).
However, there is an obvious risk that such a focus on efficiency and productivity may become guidelines for health care, potentially at the expense of the well-being of employees and users. Changes occurred that emphasized outpatient care rather than institutional care. (Hemberg & Salmela, 2021). Additionally, all the participants highlighted the importance of high-quality nursing and caring.
Research, education, collaborative praxis and evidence-based praxis were some of the areas within nursing to which nurse leaders were required to pay attention throughout their careers (Vasset et al., 2022. The informants noted that the concept of a culture is not selfevident, and they spent a great deal of time developing a common understanding of the concept. A shared understanding of the concept of culture, economy and quality of service, and what this understanding means for the organization, can be a success factor for a new organization (Byrkjeflot & Jespersen, 2014;Salmela et al., 2013;Vasset et al., 2022). According to Salmela et al. (2012), nurse leaders inaugurate change by leading relationships, processes and culture and via supportive, reflective and culture-bearing leadership aimed at the realization of genuine and sustainable changes. These claims were supported by this study.
Change processes have created complex organizations due to cultural differences across organizations in terms of quality and economic realities (Gjellebaek et al., 2020;Guibert-Lacasa & Vázquez-Calatayud, 2022). Participants from Finland and Norway highlighted the shared culture of the organization, the optimal quality of care, treatment and a responsible economic policy focused on the patients' needs. The change processes created complex organizations, difficulties for personnel and political challenges. The ultimate purpose of public services is to produce what is beneficial to citizens (Nylenna (2020); Virtanen & Stenvall, 2010). One challenge to the provision of excellent service may be the geographical realities resulting from mergers between organizations. It is difficult to lead changes without conducting a meeting, as the informants stated.
The informants felt as if they were 'pictures on the wall' in the absence of face-to-face contact. Additionally, the constant need for change is a reality, which is partially due to changes both within and outside of organizations, not merely due to political recommendations and reforms, which have become accelerated in recent decades. Feitosa et al. (2021) highlighted the concept of 'political skills'.
Specifically, a leader in health care must collaborate with different people from different professions with respect to decision-making and strategic planning. Political skills can be defined as the ability to adapt to changing situations and the behaviour of others to align with personal or organizational goals (Bernstrøm, 2014;Feitosa et al., 2021;Nordquist & Grigsby, 2011). Traditionally, leadership tasks in the public sector have been rewarded when leaders display a strong work ethic and clinical competence, and less attention has been given to leadership competencies (Huikko-Tarvainen, 2022; Nylenna, 2020).
Effective leadership is critical for optimizing the cost, accessibility and quality of health care according to Hafsteinsdóttir (2019).

| Historical experience of personnel administrative challenges
In the modern world, health organizations have expanded, and or- as noted in the studies by Vasset et al. (2021Vasset et al. ( , 2022Vasset et al. ( , 2023.
The nurse leaders who participated in this study were satisfied with their work. but the employees perceived all mergers as threats.
This situation is difficult because employees do not always know whether they will keep their jobs. Health care has been transformed from a locally controlled effort to a highly fragmented national system facing unpredictable changes, which is a point that the informants discussed in the study (Feitosa et al., 2021;Nordquist & Grigsby, 2011).
Some delays occur during the change process; specifically, leaders inform employees, and the employees feel as if they have not received any information. Salmela et al. (2013)  People from different backgrounds plan the work process in the context of everyday work to allow them to meet each other.
Researchers have highlighted this fact (Bernstrøm, 2014;Feitosa et al., 2021;Nordquist & Grigsby, 2011). According to Nylenna (2020), NPM is intended to distinguish between political and professional leadership, highlight results and foster active communication with political and professional leaders. Several informants noted that they had become quite good at researching what was occurring regarding employees' feelings and new political guidelines. The changes led to nurse leaders being given leadership responsibilities for other areas associated with the profession (such as responsibility for employees in other locations or other hospitals).

| CON CLUS IONS
The challenges highlighted in this study were organizational and personnel changes occurring over several decades. However, new reforms have been implemented, new welfare technology has been developed, and mergers of healthcare institutions have occurred, which were often due to political intentions and goals. The implementation of change processes to ensure effective health care with high quality takes time.
Following a merger, it is difficult to create new organizations with interprofessional teams that are distant from one another over a short period of time. Mergers that blend different departmental and institutional cultures are tiring for employees. Moreover, interprofessional collaboration, political skills and employee motivation are essential for achieving the goals of the healthcare system. Political knowledge is essential for leaders in the healthcare system because they must collaborate with people from different backgrounds and plan the work process. Furthermore, the NPM intended to distinguish between political knowledge and professional leadership.

| LI M ITATI O N S
The data referenced in this study were collected during the pandemic, thus making face-to-face interviews unfeasible. Additionally, only eight participants were included in the study, but our opinion is that a certain degree of saturation is apparent in our results. Another weakness of the study is the fact that the survey group from Finland consisted entirely of Swedish-speaking leaders. We may have been able to account for more nuance in our results if both language groups had been represented.

AUTH O R CO NTR I B UTI O N S
Frilund has the main responsibility for the article. Vasset (lives in Norway) is responsible for the Norwegian data material. Frilund and Fagerstøm live in Finland and are therefore responsible for the Finnish data material. The introduction, background and analysis were carried out by Vasset and Frilund. All the authors read and approved the submitted article draft.

ACK N O WLE D G E M ENTS
The authors acknowledge AJE (www.aje.com) for language editing and Ordfabriken 2907812-7 Finland for re-editing (e-mail elisabeth. ekstrand@ordfabriken.net).

FU N D I N G I N FO R M ATI O N
There has been no funding.

CO N FLI C T O F I NTE R E S T S TATE M E NT
There are none to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
Not applicable.

E TH I C S S TATEM ENT
The Research Ethics Committee approval number and the name of the review board that approved the study of the Norwegian Centre