Nursing Inquiry 2015

Feature

Transforming a conservative clinical

setting: ICU nurses strategies to
improve care for patients relatives
through a participatory action
research
Concha Zaforteza,a Denise Gastaldo,b Cristina Moreno,a Andreu Bover,a Rosa Mir
oa and Margalida Mir

oa
aUniversity of Balearic Islands, Balearic Islands, Spain, bUniversity of Toronto, Toronto, ON, Canada

Accepted for publication 3 May 2015

DOI: 10.1111/nin.12112

ZAFORTEZA C, GASTALDO D, MORENO C, BOVER A, MIRO
R and MIRO
M. Nursing Inquiry 2015
Transforming a conservative clinical setting: ICU nurses strategies to improve care for patients relatives through a
participatory action research
This study focuses on change strategies generated through a dialogicalreflexiveparticipatory process designed to improve the
care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital
in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth
interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institu-
tionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-
centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between
physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to
change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit.
The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they
enhanced the care offered to patients relatives and patient safety. Transforming conservative settings requires capacity to nego-
tiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to
micropolitics, transformative proposals can be implemented and sustained.

Key words: action research, critical care, family, intensive care units, power, quality improvement, relatives, social change.

There is international recognition of the need to transfer
research results into clinical practice and to promote equita-
ble quality care (Sudsawad 2007; Davison and National Col-
laborating Centre for Determinants of Health 2013).
However, little is known about how to promote change in
clinical practice (Grimshaw et al. 2001; Simpson and Doig
2007), and there has been ongoing debate about which are
Correspondence: Concha Zaforteza, Department of Nursing and Physiother-
apy, Critical Health Research Group, University of Balearic Islands, Campus
Universitario, Cra. Valldemossa Km 7 5, 07122 Palma de Mallorca, Balearic
Islands, Spain. E-mail: <concha.zaforteza@uib.es>
the best strategies to transform health services, especially in
complex practice settings (Brown and McCormack 2011;
Michie, van Stralen and West 2011; Slater and Kothari 2014).
Scholars who have examined this issue have highlighted the
relevance of contextual factors in shaping the possibilities
for change (Dijistra et al. 2006) and the importance of strat-
egies developed by local actors to sustain change processes
(Brown and McCormack 2011).
Transforming health-care is particularly challenging in
places historically structured by conservative values, where
patriarchal and physician-centered relations dominate daily
decision-making. Until the 1970s in Spain, power relations

2015 John Wiley & Sons Ltd

C Zaforteza et al.
were anchored in the hierarchal superiority of most male
physicians over patients and other healthcare professionals
(Mir
o 2008; Mir
o et al. 2012) and, even today, establishing
collaborative practice and tackling physicians privilege
remains a challenge (Ruiz-Quiles 2008; Codorniu et al.
2011).
It is in this context that we decided to explore the dis-
crepancy between the needs of relatives of intensive care unit
(ICU) patients and the care they receive (Zaforteza 2010).
Internationally, ICUs are characterized by an emphasis on
the treatment of pathological physical manifestations, with
special interest in controlling measurable parameters, due to
the severity of patients conditions, where open unit policies
and family support remain a challenge (Capellini et al.
2014). However, in southern European countries, and in
particular in Spain, professionals prioritize a biomedical
approach that almost exclusively focuses on physical condi-
tions in detriment of communication and social dimensions
of health (Giannini 2007; Anzoletti et al. 2008; Rich-Ruiz
2011). This conception of health-care excludes family mem-
bers and disregards the scientifically proven benefits that
their presence produces for the patient (Fumagalli et al.
2006; Happ et al. 2007).
Usually, Spanish ICUs have restrictive norms related to
the access and presence of family members, which assigns
them an external and passive role (Velasco et al. 2005;
Escudero, Vi~ na and Calleja 2014). In our previous studies,
we found that nurses did not feel adequately trained to
handle emotional aspects of family support, experiencing
distress (Zaforteza et al. 2003). They also did not know
which kinds of information they could provide to families
without triggering conflict with other professionals, and
acknowledged that there was an unwritten rule that nurses
should not be present during visitation (Zaforteza et al.
2003, 2005). Concomitantly, we encountered nurses who
wanted to change this situation in order to provide consis-
tent routine care to patients relatives; however, they did
not know how to challenge the status quo in conservative
clinical settings (Zaforteza et al. 2004).
Identifying this interest in promoting change led us to
develop a participatory action research (PAR) project. We
selected this methodology because, in addition to translating
evidence into clinical practice, this approach focuses on trans-
forming structural conditions within a context that is adverse
to change (International Collaboration for Participatory
Health Research 2013a). In addition, PAR seeks to empower
those professionals who wish to adapt care to the needs of
healthcare users (Waterman et al. 2001; Hughes 2008).
In this study, we explore the results related to a specific
objective of a larger study. The general research question
2 2015 John Wiley & Sons Ltd
that guided that larger project was: How to generate changes
in an ICU to improve the care delivered to the relatives of
critically ill patients? In Table 1, we present a summary of
the key changes achieved through the entire project. The
specific objective addressed here is to understand which
change strategies are generated through a dialogicalreflex-
iveparticipatory process in an ICU setting.
METHODOLOGY
We utilized a qualitative PAR design. This design is recognized
as an appropriate methodology for health service intervention
and evaluation (Waterman et al. 2001; Delgado-Hito and Gast-
aldo 2006; Hughes 2008), and it has been used in different
projects for changing clinical practice, both in the Spanish con-
text and in the broader international context (Delgado et al.
2001; S
anchez et al. 2009; Crozier, Moore and Kite 2012).
The process was guided by critical theory (Denzin and
Lincoln 2000; Sayer 2009), particularly that of authors who
explore dialogic and reflexive processes. First, we drew on
the ideas of Paulo Freire on how dialogue and reflection are
engines for social change and for the empowerment of par-
ticipants in the process (Freire 1970, 2002, 2004). Second,
we adapted the model proposed by Kemmis and McTaggart
(1988, 2005) on transforming reality, which suggests that
successive cycles of reflection and action promote change.
This dialogic dynamic had already been used successfully in
the ICU of another Spanish hospital (Delgado et al. 2001).
Third, we used the notion that complex social processes
can be studied by introducing changes in them and observ-
ing their effects (Baskerville 1999). In this sense, PAR gener-
ates a privileged epistemological position to understand how
social processes that reproduce or transform the status quo
work in different contexts, such as a conservative clinical set-
ting in this case. While trying to implement change, it simul-
taneously allows for the study of how actors, such as
healthcare professionals, justify their actions; the logics used
to implement strategies to persuade others or themselves;
and processes that aim to achieve consensus or those that
generate confrontation (Gaventa and Cornwall 2004; Reason
and Bradbury 2008; Gooden and Gastaldo 2009). Therefore,
PAR supports knowledge generation about structural and
everyday practice changes, which can then be used by practi-
tioners and researchers in other contexts.
This PAR study was structured in five phases: (i) diagno-
sis of the needs and care provided to the families of critically
ill patients; (ii) selection of proposals for change, (iii) design
of proposed changes; (iv) implementation of changes; and
(v) evaluation of the process and its impact on the unit. The
research was conducted in an ICU of a tertiary hospital in
 Transforming a conservative clinical setting

Table 1 Key changes achieved through a PAR process in the ICU

Before PAR process After PAR process

New assets and
skills for ICU
(Garc
a et al. 2010;
Zaforteza 2010)
Changes in how
ICU health
professionals perceive
the critically ill
patients relatives
(Zaforteza
et al. 2010, 2015)
Changes in clinical
practice toward the
relatives
(Zaforteza 2010;
Zaforteza et al. 2010)
Changes in healthcare
team dynamics
(Zaforteza 2010;
Zaforteza et al. 2015)
Absence of a continuing education plan
on therapeutic relationship and family-
centered care
Absence of consensus on how to care for
the relatives of critically ill patients
Absence of any written information
tailored to patients relatives
ICU health professionals thought that
the relatives hinder their work (caring
for the patient)
ICU health professionals stated that
family
presence at the bedside might be
harmful
for the patients
Visit schedule: 8:15 am8:45 am, 1 pm
1:30 pm, 8 pm8:30 pm
Existence of rigid rules for visiting and
accessing the ICU
Relatives were not allowed to be present
during the death process
Healthcare team members held different
views on how to care for the relatives.
These different postures raised conflict
among team members
A continuing education plan was
implemented to improve family-centered
care, including care in grief processes,
communicating bad news, and strategies
for therapeutic relationship
The Caring for the Critically Ill Patients Family
Guide was developed (a pocket edition was
given to all the ICU healthcare
professionals)
An informative poster was designed to meet
some of the relatives information needs.
It was placed at the waiting room and used
at the first contact with the ICU
The ICU health professionals considered
that the relatives might be an asset for the
patient. In addition, they considered that
the relatives needed care to withstand the
situation
The ICU health professionals recognized
that that family presence at the bedside
could be beneficial for the patients
Professionals increased the visit time in two
hours per day: the last visit began at 6 pm
instead of 8 pm
Nurses valued the benefit of a broader visit
policy. Rules for access and visit were
flexible and case-sensitive
On a case-by-case basis, the health team
appraised possibility for the family to be
present during the process of death
A shared postured became dominant and
the conflicts disappeared

the Balearic Islands (Spain). This unit had 30 beds and 205
employees and treated 1300 patients per year. The project
had 60 participants (53 nurses and nursing assistants, three
hospital attendants, two physicians, and two social workers).
The sampling was intentional (Coyne 1996; Fossey et al.
2002), aiming at recruiting a maximum representation of
employees. We publicized the project through various clini-
cal sessions, distribution of information through posters,
and used a snowball technique for recruitment (Fossey et al.
2002). Two levels of participation were offered in light of
potential time limitations that participants could have. We
called those who assumed a greater degree of participation
representatives (11), and these were members of the group
discussions (described below). We called those who assumed
a lesser degree of involvement participants (49), and their
work was to convey their reflections to a representative.
To grasp the complexity of the phenomenon under
study, various qualitative methods were used to generate
data (Denzin and Lincoln 2000; Curry, Nembhard and
Bradley 2009). In Table 2, we describe the data generation

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C Zaforteza et al.

Table 2 Outline of the data generation methods employed

1st phase 2nd phase 4th phase 5th phase

Research methods diagnostic proposals for change 3rd Phase design implementation evaluation
Group discussions 3 3 3 2
(opinions of
participants and
representatives)
Field diary of the Yes Yes Yes Yes Yes
principal investigator
(reflexivity and
decisions about the
process)
Field diaries of the Irregular Irregular Irregular Yes Very irregular
coinvestigators
(reflexivity and some
data about the process)
Field diaries of the Yes Irregular
representatives
(reflexivity and change
processes in the unit)
In-depth interviews with 5
professionals from the
unit (experience of the
change and impact of
the change on the
unit)

strategies and their distribution throughout different
phases of the project.
The discussion groups were always composed of the same
11 representatives (eight nurses, two nursing assistants, and
one social worker) and moderated by the principal investiga-
tor (Morgan 1996; Barbour 2005). Each representative dia-
logued and reflected with a small team of participants, and
their contributions were presented in the group discussions,
which captured the views of all 60 participants.
Regarding the field notes, while the principal investiga-
tor captured the context, decisions being made about the
process, and reflexive notes (Hughes 2000), participants
field notes were used to encourage reflection about the care
provided to families of critically ill patients (Elliott 1997;
Hughes 2000; Stringer and Genat 2004).
The interviews conducted in the evaluation phase were
used to complement the data emerging from the group dis-
cussions. At that point, the group discussions were insuffi-
cient to describe individual experiences of change, and five
in-depth, semi-structured interviews were conducted (Kvale
and Brinkmann 2009).
To meet the objective, which was to discover change strat-
egies generated by a dialogicalreflexiveparticipatory pro-
cess, we analyzed participants narratives through PARs two
streams of analysis, which are process analysis and content
analysis. In the analysis of process, we sought to understand
how the dynamics of dialogue, reflexivity, and participation
resulted in changes at three levels: in language, relationships,
and activities (Kemmis and McTaggart 1988, 2005). In the
thematic analysis, we explored the transformation or repro-
duction of understandings, feelings, and power relations in
ICU care-giving (Zaforteza 2010; Zaforteza et al. 2015).
Initially, we analyzed the data generated by each method
in each phase, to create codes and subcategories, which,
when organized into categories, would explain the phenom-
enon of change. Codes and subcategories were reflected on
a grid, under each of the phases in which they were gener-
ated. Second, a cross-sectional analysis in chronological
order was undertaken, generating codes and subcategories
for strategies that maintained or changed the status quo.
That is, we tracked how themes emerged, disappeared, per-
sisted, or were modified as the dialogicalreflexiveparticipa-

4 2015 John Wiley & Sons Ltd


tory process moved forward, and as changes proposed by the
representatives and participants were implemented.
The trustworthiness of the study is based on several pro-
cesses: first, through the joint reflexivity and dialogue
between researchers and participants (McTaggart 1998)
which acknowledged different expertise among group
members, that is more specialized knowledge of research-
ers on methodology and the more applied and contextual
knowledge of participants and representatives (Freire 2002,
2004); second, the individual reflexivity of the principal
investigator (first author CZ), which was supported
through an exploration of her theoretical position and the
information emerging from the research (Bover 2013), and
verification of the initial coding scheme by other investiga-
tors (McTaggart 1998); third, the triangulation of methods
and sources used as an analytical strategy, critically contrast-
ing the findings from various techniques, not to generate
consensus, but to understand, for example, why certain
codes were dominant in individual or collective data, and
subsequently contrasting findings with those of other stud-
ies, looking for similarities and developments within the
existing body of knowledge (Denzin and Lincoln 2005);
and finally, there were also PAR-specific criteria, such as
sense of personal and group development among partici-
pants, evidence of progression toward change (Kemmis
and McTaggart 2005), increased understanding of the con-
ditions under which they executed their practice, and
participant adherence to the project (International Collab-
oration for Participatory Health Research 2013a).
The study has three limitations that should be taken into
account. First, it does not capture the discourses of all
healthcare providers. Physicians were underrepresented,
despite being encouraged to participate. The principal inves-
tigator held several meetings with the unit medical director,
and recruitment sessions were organized to fit physicians
schedule. In addition, although the researchers proposed to
include patients relatives in the study, healthcare providers
did not feel they could share their views with the families.
For this reason, inputs from the intended beneficiaries were
not included. Finally, PAR generates contextualized informa-
tion which can be transferred to other contexts, if social, cul-
tural, and political differences are considered.
This project was approved by the Hospitals Research
Commission and the Balearic Islands Clinical Research Eth-
ics Committee (CEIC-IBComit
e Etic  dInvestigaci
o Cl
nica
de les Illes Balears). In the informed consent, participants
were informed that their identity would remain confidential
in all project publications. However, participants were also
advised that due to the participatory nature of the project,
other employees and managers would be aware of their
2015 John Wiley & Sons Ltd
Transforming a conservative clinical setting
involvement. Finally, ethics was handled as a process requir-
ing collective decision-making by all involved in the study
(Ramcharan and Cutcliffe 2001; International Collaboration
for Participatory Health Research 2013b).
RESULTS
Four main change strategies were created during the study:
(i) Institutionally supported practices were challenged by
participants who attempted to make the whole unit shift its
professional-centered work to a more inclusive, patient-cen-
tered approach; (ii) traditional power relations were chal-
lenged to decrease the hierarchical power differences
between physicians and nurses; (iii) consensus was built
about the need to shift from an individual to a collective
position in relation to change; and (iv) consensus was built
about the need to develop a critical attitude toward the con-
servative context of the unit, rather than support the nave
acceptance of the status quo.
From professional-centered to patient-centered
care
In the first group discussion and in the field notes, in the first
phase (diagnosis of the care given to families of critically ill
patients), professionals spoke about their problems with fami-
lies, their conflicts with other colleagues, or about shortcomings
in providing care to family members. In their field notes, they
used language that was emotionally charged, reflecting the diffi-
culties nurses faced when dealing with these situations.
Today my patient is much worse. At the visit time, it was horri-
ble. There were more than 15 people crying and kissing him.
I went into the room for a brief moment. I felt unwell and
powerless; I dont know how to help in this grieving phase.
(Representative 9, field notes, phase 1)
As the process progressed (phase 2), professionals
reflected, exchanged ideas, and recognized their responsibil-
ity to respond to the needs of patients and family.
Representative 2: (. . .) the first thing to do is to consider
family members as care recipients.
Representative 8: Exactly, any of us could have gone outside
[waiting room] to tell the family all is well, but no, it took
us two hours to let them know the patient was fine. Ufff, I
felt really bad.
(Group discussion 5, phase 2)
However, these changes were partial. As soon as their
more transgressive propositions were confronted by the most
reactionary positions by those who were not involved in the
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C Zaforteza et al.
project, they chose a compromise between the two positions.
Thus, in the third phase, when designing interventions, in
the first group discussion participants proposed more ambi-
tious changes, while in the third group discussion more con-
servative changes were articulated. In the case of extending
visiting hours, participants at the beginning of the third
phase proposed to change the initial visiting hours (three
30-minute: 8:158:45, 13:0013:30, and 20:0020:30) to one
in which the family could remain in the unit for the entire
afternoon (8:158:45 and 13:0020:30). Upon reflecting on
successive group discussions and sharing this proposal with
other colleagues, participants reconsidered this proposal,
fearing that it would generate significant conflict or opposi-
tion that would ultimately impede the implementation of
this change. For this reason, the final visiting hours estab-
lished extended the initial visitation schedule only by two
hours (8:158:45, 13:0013:30, and 18:0020:30).
Power differentials among professionals
The second strategy was to reduce the power differentials
between physicians and nurses. When thinking about the
context of this unit, the participants and the representatives
perceived that it was physicians who decided or vetoed
initiatives.
Representative 3: (. . .) to provide medical information
before the visit? We will see, because to tell them [physi-
cians]: look, you have to provide information before the
family members come into the unit, we can propose that,
but it means we are looking for trouble.
(Group discussion 4, phase 2)
However, many participants evolved throughout the pro-
cess and, in the evaluation phase, referred to challenging
the status quo of reporting relationships and starting to dia-
logue with their medical colleagues. They managed to affirm
their judgement when they thought their proposals for rela-
tives care responded to users needs and gave greater impor-
tance to their professional role (of nurses and assistants).
Yes, if I want the family in the unit, I have to fight for it. I
have to earn doctors respect. I need to have very clear
points and tell: the patient is like this and that and I believe
his care requires actions A, B, and C.
(Interview 1, evaluation phase)
This balance in hierarchical relationships occurred when
participants felt confident about the position they took, par-
ticularly when it was supported by evidence, by a critical mass
of colleagues, or after they have developed new negotiation
skills. Another explanatory factor behind the change was
resilience, as there were professionals who stopped giving
6 2015 John Wiley & Sons Ltd
importance to conflict and gave priority to their professional
role as caregivers.
[A nurse is talking about the PAR project] For me, it has
given me arguments to silence those who were against it
[either flexible visit hours or expanding hours]. The con-
flict goes on, but I was always embarrassed and rarely felt
proud of things I do here, but now I got to the conclusion
that my ideas are as valid as the doctors ideas. So, now I
practice what I think.
(Interview 3, evaluation phase)
However, as happened in the first strategy, some partici-
pants reproduced previous practices despite the PAR pro-
cess. At this level, change was dependent on the individual
capacities and not on the structure of everyday relations
within the unit. Another aspect related to the reproduction
of the primacy of physicians over other professionals was that
when change proposals were raised during the second
phase, participants immediately dismissed those proposals
which involved modifying physicians routines.
Individual to collective position
One of the steps taken by the study participants was to move
from individual to collective posturing in relation to change.
Two phenomena supported such change. The first was a
mutual discovery, through dialogue, that colleagues shared
similar views. As the process progressed, participants stopped
talking about individual ideas, discovered what other partici-
pants and representatives thought, and proposed strategies
for change that other team colleagues agreed with.
The second phenomenon, derived from the first, was
observed in the evaluation phase. In general, there was an
improved level of care for the families and decreased con-
flict. This became particularly evident when professionals in
the same work shift found themselves defending the same
ideas. This led to collective synergies to maintain the change
in their clinical practice, and synergies which extended to
other professionals who were less committed to change.
Representative 1: The relationship with the colleagues who
have attended the continuing education classes [an out-
come of the project] has improved considerably. In my shift,
there are people who think like me [referring to providing
care to patients relatives], but I didnt know it! This is very
positive when I work with them. The quality of care has
improved.
(Group discussion 10, evaluation phase)
[A nurse reflects on a situation where many children were
taken to the unit to visit their grandfather. Initially, the rule
indicated that children under 12 were not allowed to access
the unit] (. . .) and I said Oh! All these children, do they
want to visit their granddad? Lets do like that, you are going

to get in, one by one, say hello, and then leave [there were
some 15 children]. . . and people [she refers to her shift col-
leagues] accepted it. No one complained and said children
are not allowed! or why did you allow them in?. No one
complained.
(Interview 3, evaluation phase)
Nave to critical attitude
With respect to the potential for change in clinical practice,
participants moved from a nave to a critical attitude
anchored in the context of their unit. At the beginning of
the first phase, participants were perplexed, hesitant about
their ability to influence the context, displayed hopelessness,
and utilized a highly sentimentalized discourse. Toward the
end of this phase, these discourses disappeared, and the dis-
course that was consolidated was that change was possible.
In an exchange of three representatives (Group discussion
3, phase 1), they described themselves as being reflexive,
changing attitudes, gaining awareness, and changing as
good and positive.
In the second and third phases, the change from a nave
to a critical posturing was different. At the beginning of the
second phase, participants generated many ideas for change.
As the process progressed, particularly in the third phase,
participants initiated a detailed analysis of their context:
They explored the potential barriers to change, sought alli-
ances with people who held formal power in the unit, ana-
lyzed the feasibility of different proposals, selected some,
discarded most, nuanced selected proposals, and adapted
them to their context to make them viable.
Representative 6: The problem with information. . . I con-
sider we should reach an agreement with each unit head,
present a proposal, and think how to implement it. It can
be done, if we negotiate alternatives.
(Group Discussion 9, phase 3)
DISCUSSION
This study shows that the development of a dialogicalreflex-
iveparticipatory process can lead to changes that promoted
family- and patient-centered care as well as learning critical
analysis skills that can be widely employed in healthcare
work. However, such process was not able to fully transform
and overcome some well-established practices that justified
family exclusion and disregarded potential benefits for
patients.
During this process, we identified four change strategies
held by participants. In analyzing the dynamics of change, it
is visible that these strategies operate differently, that they
2015 John Wiley & Sons Ltd
Transforming a conservative clinical setting
disrupted the status quo to different degrees, and that they
generated different consequences for the unit, patients, fam-
ily members, and professionals. We have grouped these four
strategies under two main approaches: consensus-dependent
strategies and institution-dependent strategies, as discussed
below.
Institution-dependent strategies
The institution-dependent strategies were as follows: (i) the
shift from a professional-centered work to a patient-centered
perspective; and (ii) a reduction in hierarchical power
between physicians and nurses. These strategies resulted in
more conservative transformations due to a higher degree of
difficulty for implementation than consensus-dependent
strategies.
The difficulty in breaking the status quo stems from the
fact that these strategies were highly permeated by institu-
tional norms, its history, values, and language. In this case,
we recognize that within the Spanish healthcare system,
there are tensions between different ways of conceiving care,
despite the domination of the biomedical approach (Rich-
Ruiz 2011). Within this perspective, the user is patient, a
passive recipient of health-care, while the professional is the
expert in solving physical problems, the medical specialist is
placed at the center of the system (Dwamena et al. 2012;
Hesselink et al. 2012; Reeve et al. 2013), and power relations
are organized around physicians decision-making (Mir
o
2008).
There are multiple consequences for this particular mix
of values and relationships. In our case, changes in clinical
practice have been produced (see Table 1), which
responded to users needs, but not all forms of control prac-
tices and exclusion of relatives were eliminated. In part, the
difficulty in breaking hierarchical power derives from the
fact that nurses reproduced the discourse of the superiority
of physicians. For instance, in the group discussions, nurses
discarded proposals that required significant changes in phy-
sicians routines because they doubted they could persuade
to them to do so.
Authors who work on quality of care and patient safety
warn about the consequences of playing down a person
(Berenholtz and Pronovost 2003). They also caution against
the risk of working with depleted teams, where the knowl-
edge of its members is not fully used for the health benefit
of the user (Parker and Gardner 2004; Curtis et al. 2006;
Hills, Mullett and Carroll 2007). Still worse, health teams
with little cohesion and strong hierarchical relations can
threaten users safety because they reinforce practices based
on routines and hinder the protective effect of collaborative
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C Zaforteza et al.
and critical practice (Newman, Papadopoulos and Sigsworth
1998; Makary et al. 2006).
Although changes achieved were limited, we consider
their consequences to be of paramount importance because
the user clearly benefited from them. In this study, clinical
practice evolved toward scientific evidence recommenda-
tions, as professionals responded to the need of close prox-
imity between relatives and the patient by extending visiting
hours (Pardavila and Vivar 2012). This was possible in part
because teams worked best when, in the same shift, there
were professionals who were empowered by the reflexive
process and shared the same ideas about the best way to care
for the family.
Consensus-dependent strategies
The consensus-dependent strategies were as follows: (i) the
shift from an individual to a collective posturing; and (ii) the
transition from a nave acceptance of the status quo to a criti-
cal attitude. These strategies, unlike the aforementioned,
achieved greater transformation of the status quo.
What explains this increased transformative capacity was
that these strategies operated in the interstices of the micro-
politics and the daily ICU practices. These strategies
depended more on individuals and groups rather than on
the opposition to established values. They were related to
learning new skills, such as collaborative practice and critical
awareness. The participatory nature of the methodology cre-
ated opportunities for dialogue and reflection among pro-
fessionals, who, until then, had not shared their concerns
regarding patients relatives care. As team members worked
to incorporate this form of care into their practice, profes-
sionals, who until then had not felt able to transform their
context, begun to critically review their clinical work and
transform it.
We argue that consensus building is a fundamental abil-
ity for healthcare professionals working in complex settings.
Teams that establish collaborative practices are able to
improve safety, quality of care, and health outcomes (Pun-
tillo and McAdam 2006; Reeves, Nelson and Zwarenstein
2008; Zwarenstein, Goldman and Reeves 2009). Some exam-
ples are the reduction of errors, nosocomial infections, and
surgical mortality (Zwarenstein and Bryant 2000; Zwaren-
stein and Reeves 2000; McCallin 2005; Sirota 2007; Nembh-
rad et al. 2008).
Collaborative practice also contributes to the improved
perception of professional autonomy and job satisfaction,
reducing, among others, the presence of chronic fatigue syn-
drome or occupational stress, such as burnout, harassment,
or professional exhaustion (Ajeigbe et al. 2013; Paradis et al.
8 2015 John Wiley & Sons Ltd
2013). As a result, professionals improve their clinical prac-
tices and avoid leaving their workplaces (Lindeke and Sieck-
ert 2005).
In addition, the emergence of a critical position among
professionals can potentially be a benefit to the healthcare
system. People with nave attitudes tend to perceive any
change as either impossible or beyond their capacity (Freire
2002). They may fail to recognize how they are part of the
system, critical social actors enmeshed in it (Freire 1970).
Feelings of belonging and the ability to promote change are
related to increased job satisfaction and diminish turnover
(Hills et al. 2007; Kalisch and Lee 2010; Parmelli et al.
2011). Through the dialogicalreflexiveparticipatory pro-
cess, practitioners established viable and lasting changes,
adapted to their context, which enhanced care without gen-
erating much stress on the system.
CONCLUSION
Faced with an opportunity to transform clinical practice
through a dialogicalreflexiveparticipatory process, health
professionals were able to generate change strategies and
incorporate recommendations from scientific evidence. The
strategies proposed were both transgressive and conservative;
however, when compared with the initial situation, they
enhanced the care offered to patients relatives and patient
safety. Furthermore, they had deeper implications for service
delivery and skills development. Patients are the ultimate
beneficiaries, given that the literature indicates that such
transformations improve their safety and well-being (Dwame-
na et al. 2012; Hesselink et al. 2012; Reeve et al. 2013).
However, this transformative process was not spontane-
ous and required considerable effort, as professionals had to
challenge institutional power relations and reactionary ways
of thinking. PAR should be seen as a learning opportunity
where participants acquire critical awareness about their con-
text and discover the game rules. Such understanding
allowed participants to use micropolitical strategies (such as
consensus building) as levers to implement transformative
proposals. Thus, participants learned how to develop change
strategies adapted to a specific context. In addition, this pro-
cess builds capacity for future engagement with issues partici-
pants may deem as challenges (Gooden and Gastaldo 2009).
Our findings suggest that change processes developed
collectively can occur even within conservative contexts. Our
environment was initially averse to change, strongly rooted
in traditions that placed the professional at the center of the
system and which organized the provision of health-care
within a hierarchical structure. Our position is that, in many
cases, waiting until conditions become ideal implies missing

opportunities for change that would improve the quality of
care provided.
Finally, one of the challenges for knowledge translation
studies is to demonstrate how different institutional, team,
and individual factors influence change processes (Lemelin,
Hogg and Baskerville 2001; Dijistra et al. 2006). Our project
sheds light on this issue. We acknowledge that transforming
conservative settings requires great effort, capacity to negoti-
ate positions, and outcomes may not be ideal. However,
when change is collectively articulated at the level of micro-
politics in everyday practices, and capacity is built in this
process, the potential for transformation is substantially
improved.
ACKNOWLEDGEMENTS
The project has been funded by the Fondo de Investigaci
on
Sanitaria, Instituto de Salud Carlos III, Ministerio de Sanidad
y Pol
tica Social, Gobierno de Espa~ na (Health Research
Fund, Institute of Health King Carlos III, Ministry of Health,
Spanish Government), Grant number PI06/90156.
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