Identifying external influences and understanding factors creating pressure on hospital systems

Background: In today's fast changing environment, one of the major challenges for hospitals is to adapt to external demands while ensuring quality, safety and positive patient outcomes. It is not yet clear how the external environment affects the delivery of care. Health care research is currently following a normative approach when studying how environments affect hospital outcomes. External influences are theoretically conceptualised, which leads to inconclusive and non-comparable results. Research has yet to be conducted into how hospital staff experience external influences or external pressure. Thus, this qualitative study aims to assess how external influences are perceived by health care professionals in hospitals. Method: Open-ended, in-depth, semi-structured interviews were used to obtain a first impression of the topic. A total number of 8 interviews with health care professionals were conducted between April and June 2016 at a local public district acute hospital. Representation was sought across a variety of roles, fields and departments levels. A general inductive approach was used to identify the main themes and develop categories from the qualitative data. Results: Each hospital professional created their own subjective meaning of external influences. The perception of pressure was relative and shaped by identity and personality. There was no consistent understanding of 'internal' or 'external'. The interpreted boundaries were subjective and dynamic, depending on perception, professional accountability and work responsibility. The overall context and circumstances, the work-load, and time constraints also were connected to the perception of influences. Conclusion: Hospital staff experienced the external environment according to their own identity. External pressure and organisational boundaries, as understood by organisational theorists, had very limited relevance for most people working in the hospital.