Original Research

South African public hospital intrapreneurship culture: Unit nurse managers’ governance role

Thandiwe M. Letsie

Received: 23 Oct. 2023; Accepted: 21 Mar. 2024; Published: 17 June 2024

Copyright: © 2024. The Author Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Intrapreneurial public hospitals seeking reform, are favourable platforms enabling the unit nurse managers to promote innovative work cultures enhancing effective governance. The cost-conscious nurse managers consider scientific approaches to improve resources and services by securing seed funding.

Aim: To position skilled intrapreneurial unit nurse managers as effective governance leaders who can transform the risk-avert bureaucratic public hospitals’ culture into innovation centres to improve services.

Setting: The unit nurse managers from three public hospitals constituted the population of the study.

Methods: The qualitative study was explorative, descriptive, and contextual. The focus group discussions were convened at different hospitals’ private venues. A systematic analysis of data achieved through the Tesch technique culminated into themes and categories.

Results: The highly regulated top-down structured public hospitals’ culture, which is routine-based, denies potential intrapreneurs to constantly look for new approaches that could improve services through innovation. The four themes highlighted the following participants’ concerns: human resource issues, poor communication, concerns around the current incentivised performance, and hospital financial issues.

Conclusion: The findings shed light on some participants’ willingness to innovate. However, the extreme work pressure and inconsistent incentivised performance are demotivating. Furthermore, the lack of management support for innovative teams, and the lack of seed funding because of restricted budget contribute to a culture of apathy towards innovation.

Contribution: The study promotes a transformative intrapreneurial policy supporting favourable public hospital work innovative cultures through recognising the salient contribution of unit nurse managers positioned in the hub of clinical evidence, as potential intrapreneurs making evidence-informed decisions, improving quality care rendered.

Keywords: South Africa; public hospitals; culture; intrapreneurship; unit nurse manager; governance.

Introduction

Global public health care constantly under pressure to deliver health care services of value should adopt meaningful strategies that effectively address current realities like economic pressures, advancing technology – such as Fourth Industrial Revolution (4IR) – as well as unprecedented pandemics like coronavirus disease 2019 (COVID-19) (Chamba & Chaziren 2023; Moss, Hartley & Russels 2022; Nalubega & Uwizeyimana 2019). The rapid technological advancement and innovation, disruptive in nature, transforming socio-economic and political systems, challenge public healthcare policymakers and institutional leadership to consider new approaches like intrapreneurship, ensuring economic sustainability (Moss et al. 2022; Nalubega & Uwizeyimana 2019). The preferred strategy has numerous benefits, like the development of new products, services, technologies, improved business strategies, and advanced administrative techniques (Chamba & Chaziren 2023; Moss et al. 2022).

The South African healthcare system, transitioning towards Universal Health Coverage achieved through National Health Insurance, still faces several challenges like gross inefficiencies, inequities, and financial insecurity (Rispel et al. 2019). Effective measures aimed at tightening leadership and governance are needed, to pave the way for a favourable innovative culture within the reforming public hospitals (Ndebele et al. 2021).

Also, effective public hospital leadership should also prioritise pressing concerns like; corruption issues, brain drain, infrastructure degradation and the escalating statistics of incoming patients putting pressure on scarce health resources (Ndebele et al. 2021). The progressive public hospitals gravitate towards intrapreneurial organisational culture promoting shared assumptions, values and different beliefs determining how people behave (Eze et al. 2018). The shared values ignite intrapreneurial individuals internally and outside to innovate and improve performance through innovation (Eze et al. 2018). The purpose of this article endorses the crucial positioning of the skilled and knowledgeable intrapreneurial unit nurse managers being key in transforming the rigid South African public hospitals’ culture towards innovation.

Intrapreneurship orientation within progressive public hospitals promotes growth and development and enhances public value by advancing public–private partnerships (Antoncic & Hisrich 2011; Chamba & Chaziren 2023; Ekingen et al. 2018). The business-inclined initiative gradually gaining popularity in nursing comes with numerous benefits like increased revenue, profitability, product innovation, and new strategic business units. It also improves the business brand, increases the efficiency of the workforce, upskills teams to utilise scarce resources carefully, and improves the organisational system (Chamba & Chaziren 2023; Ekingen et al. 2018).

Positioning the intrapreneurial public hospital unit nurse managers as captains who can successfully spearhead positive innovation despite their tight work responsibilities is sensible (Armstrong, Rispel & Penn-Kekana 2015; Ekingen et al. 2018). Armstrong et al. (2015) give a detailed breakdown of unit nurse managers’ extensive responsibilities. These become a strong evidenced inclined basis where innovative nurse intrapreneurs could tap into and devise quality-improved innovative approaches. For instance, about 25.8% of the time is spent on direct patient care. Sixteen per cent is spent on administrative-related activities, 14% on patient administrative-related activities, and 13.4% on support and communication. Eleven-point five per cent of the time is spent on staff management, while education and stock and equipment management constitute 3.6% and 3.9% respectively. Lastly, the miscellaneous activities constitute about 11.8% (Armstrong et al. 2015). The crucial contribution of public hospitals’ intrapreneurial unit nurses in improving public hospital culture positions them as transformative stakeholders using their extensive clinical and theoretical knowledge and skills to deliver quality improved care (Moss et al. 2022). Their professional competency, humanitarian, and ethical obligation hold them accountable to integrate improved modalities bringing desired change in patient care (Moss et al. 2022).

Intrapreneurship as an emerging concept

Intrapreneurism as an evolving concept, coined by Pinchot in the eighties, is attracting growing interest from policymakers and healthcare executives (Pinchot 1985). Progressive scholars highly value intrapreneurship as a principle that could sustain high-quality and economically viable public health care services (Moss et al. 2022). Successful implementation of the bottom-up intrapreneurial approach within public hospitals relies on the unique characteristic of nurse intrapreneurs who are emotionally intelligent, and having extensive networking skills enabling them to work in multiple organisational domains ranging from product development to strategy building (Eze et al. 2018). Also, the talented nurse intrapreneurs are business developers, market researchers, and capacity developers (Eze et al. 2018; Prachi 2019). The senior management of progressive public hospitals promotes an intrapreneurial culture where improved technologies accelerate innovation that improves services (Letsie 2021). The enabling public hospital culture offers innovative team leaders who are not routinely inclined, to develop new products, services, administrative technologies, and strategies that improve the delivery of services (Letsie 2021; Gürsoy & Güven 2016). It is quite sensible for progressive public hospitals to nourish existing intrapreneurial talent sitting at the hub of evidence within units (Eze et al. 2018; Moss et al. 2022).

The conducive public hospital culture is a crucial cistern for idea generation, refinement, and implementation by skilled nurse intrapreneurs (Eze et al. 2018). The evidence-inclined nurse leader constantly looks for scientific solutions to problems encountered in clinical settings (Eze et al. 2018). The nurse intrapreneurs, as project leaders, seek peer and leadership support ideation to implementation (Eze et al. 2018). The motivated nurse intrapreneurs reflect on a tabled idea, and then make a thoughtful pitch, that is presented to relevant stakeholders and potential funders. The successful pitch brings in valued seed funding enabling intrapreneurs to embark on meaningful innovation that improves resources and services within public hospitals (Moss et al. 2022; Prachi 2019).

Public hospital culture fostering intrapreneurship

A systems-inclined intrapreneurship approach as a preferred business strategy for reform is unanimously gaining popularity at large public hospitals that are highly bureaucratic. The transformative initiative embraces the significant contribution of intrapreneurial nurse leaders in spearheading transformation in operations (Ortiz-hunt & Lerner, 2019). Intrapreneurship adopts a bottom-up approach by capitalising on the expertise of creative intrapreneurial unit nurse managers who are skilled, risk-takers relentlessly embarking on innovative solutions to improve services (Ortiz-hunt & Lerner, 2019). Many healthcare reforms in South African public health care are quite inclusive, and call for a collaborative team effort enabling communities to gain access to equitable and quality improved services (Rispel et al. 2019).

The specific norms, habits, behaviour, beliefs, and symbols influencing the behaviour of staff within progressive public hospitals depict inherent organisational culture enabling intrapreneurial individuals to constantly embark on creative and innovative initiatives (Eze et al. 2018; Gürsoy & Güven 2016). Aligning organisational philosophy to the existing organisational culture gets systems and processes ready for innovative individuals to bring new ways of improving services through collective consciousness within staff (Gürsoy & Güven 2016).

Strategic public hospitals survive internal and external pressures by preparing the work culture to be more receptive for an intrapreneurship practice (Ekingen et al. 2018). This ensures that there is an innovative vision and mission, autonomy, incentivised performance, flatter organisational structures enhancing open communication vertically or horizontally, and reasonable quality control systems (Ekingen et al. 2018; Muller & Bester 2017). Management support is needed to create favourable policies enabling constant innovation by risk-taking nurse intrapreneurs whose endeavours are recognised and rewarded accordingly (Ekingen et al. 2018; Neesen et al. 2018).

Oyebanji and Abiola (2013) argue that the advanced preparation of unit nurse managers at institutions of higher learning enables them to successfully drive transformative intrapreneurship policy favouring innovative culture. Their scientific problem-solving skills allow them to transform the units they lead into manageable cost centres (Ekingen et al. 2018; Muller & Bester 2017). The front-line leaders have acquired advanced financial management preparation enabling them to carefully prepare a thoughtful budget covering all the required resources including the seed funding for innovation (Ekingen et al. 2018; Muller & Bester 2017). This facilitates meaningful project kick-off through completion, without any restrictions (Ekingen et al. 2018).

Grazier (2015) asserts that futuristic intrapreneurial public hospitals have a meaningful social impact by offering services of significant value (Grazier 2015). Such institutions possess dual identities of commitment to quality service – being utilitarian and normative. The utilitarian identity is more business-inclined thereof product-oriented, whereas normative identity reflects the social commitment, and is more people-oriented (Grazier 2015). The hospitals rely on the expertise of outstanding innovative individuals to add value to the existing services or processes, through creating improved brands where quality-improved healthcare outcomes can be achieved (Eze et al. 2018). The knowledgeable unit nurse leaders are excellent communicators possessing unique clinical and administrative skills. They get support from peers and management on the tabled pitch of a prospective innovative idea bringing improved approaches benefiting the unit (Eze et al. 2018; Muller & Bester 2017).

Diverse public hospital culture

The salient diversity from multiple disciplines within large public hospitals represents teams of professionals with highly specialised skills, quite difficult to replicate (Grazier 2015). Public hospitals rely on favourable human resource recruitment policies giving preference to individuals carrying intrapreneurial characteristics like innovation, high achiever, risk-bearer, conflict-resolving skills, value creation, and ability to identify potential opportunities that could improve the delivery of services (Grazier 2015). The nurse leaders at the forefront advocate for quality improvement strategies offering client-centred care through creatively breaking routine patterns, taking calculated risks, and effectively organising and coordinating resources (Ortiz-hunt & Lerner, 2019). The team leaders carry substantial clinical knowledge, business, and evidence-based skills enabling them to tactfully lead teams in driving a strategic transformation effecting change (Eze et al. 2018).

Contextualisation on intrapreneurship

Different scholars assert that public hospital management should create a favourable intrapreneurial culture supporting innovation to adequately address pressing challenges like redundancy and vacancy freezes, gross staff shortages, graduate unemployment, and so on (Letsie 2021; Eze et al. 2018; South Africa Human Resource for Health Sector 2017). Integrating the skilled and knowledgeable intrapreneurial unit nurse managers and executive teams maximises the productivity of the innovative workforce, bringing in desired change within embattled acute settings (Eze et al. 2018; South Africa Human Resource for Health Sector 2017).

A call to transform the South African public hospital landscape is necessary to promote an innovative culture for teams on the ground (Eze et al. 2018; Rispel et al. 2019). According to the South African Lancet Commission (2019), progressive public health care needs to devise improved approaches to address the six key challenges like ethical leadership, poor quality care costing lives, increasing malpractice cases and medical litigations, human resource issues, health information gaps and fragmentation, and limited impact on quality care initiatives (Rispel et al. 2017). The progressive public hospital leadership should support innovative nurse intrapreneurs highly analytical and evidenced-inclined networkers to form meaningful project-inclined public and private partnerships coalitions services (Neesen et al. 2018).

The non-transformative culture associated with poor leadership at some South African public hospitals results in poor quality care rendered at these institutions. Also, the large acute settings deal with daunting challenges like fragmented services, infrastructure and security issues, poor referral systems, dysfunctional emergency services, staff shortages, management and leadership issues, poor accommodation for interns, dysfunctional information technology system, shortage of resources, cash flow challenges, and so on (Malakoane et al. 2020). The intrapreneurial unit nurse managers as lateral thinkers, can navigate the complicated bureaucratic and political barriers, and ignite transformative initiatives quicker and more effectively (Ortiz-Hunt et al. 2019). The excellent communication skills of the nurse lobbyists get them political will, supporting project-inclined funding, allowing them to expand innovative initiatives bringing in desired change (Gürsoy & Güven 2016). The cost-conscious nurse intrapreneurs integrate improved technology-based services, through aligning their vision to national and international standards, and bring in financial sustainability within the public health care institutions (Gürsoy & Güven 2016).

The non-receptive culture of intrapreneurship practice within public hospitals is associated with aspects like inadequate planning, unrealistic corporate expectations, insufficient corporate support, and miscalculation of markets (Ekingen et al. 2018). Also, gross shortage of resources, management, and quality care problems within clinical practice influence the desirable outcome of care (Rispel & Bruce 2014). The bottom-up intrapreneurial approach allows nurse intrapreneurs on the ground to integrate quality-inclined innovative strategies addressing the following issues: quality of care rendered, the cost of services, access and equity to meaningful health care, patient experiences, and safety of services and facilities markets (Ekingen et al. 2018; Malakoane et al. 2020).

Furthermore, the existing unstable hospital culture associated with shared skills between public and private hospitals, attainable through short-term arrangements like locums, affects the stability of the nursing workforce within concerned public hospitals (Rispel & Bruce 2014). The split loyalties between the public and private sectors because of agency work and moonlighting by some nurses affect desirable quality patient care in public hospitals. The protracted hours of work between the different healthcare establishments result in staff lacking accountability and being prone to making gross practice errors. The unappealing work setup frustrates creativity prospects from innovative teams. This results in team members lacking resilience in completing shifts because of extreme lethargy, leading to abuse of leave (Rispel & Bruce 2014). Yonder-Wise (2014) appreciates the personnel management skills of nurse intrapreneurs in predetermining the intensity of work performed within their cost centre. The team leaders plan for adequate resources to avert any shortfalls that could compromise envisaged quality care (Yonder-Wise 2014).

Several scholars assert that strategic public hospitals constantly striving for excellence, should adopt flexible structures, culture, systems, and processes to level the playground for innovative individuals to embark on new business ventures, product or service innovation, process innovation, self-renewal, and so on (Ekingen et al. 2018). The public hospital leadership needs to tap into the altruistic ability of intrapreneurial unit nurses to establish fruitful networks. Meaningful partnerships across the health care spectrum improve the development of products, services, technologies, administrative techniques, strategies, and competitive positions (Ekingen et al. 2018).

Research methods and design

Study design

The qualitative nature of the design is inductive and emerging in nature (Creswell 2014). It structures the collection and analysis technique of vast data to improve the quality of findings (Creswell 2014). The explorative, descriptive, and contextual nature of qualitative study sheds light on the contribution of unit nurse managers in fostering an improved intrapreneurship culture aimed at improving governance at South African public hospitals.

Study setting

The three different public hospitals in Bloemfontein operating at different levels of primary health care referral approach constituted the setting of the study. The public hospitals handling simpler conditions refer to more advanced public hospitals handling complex conditions through the integration of advanced skills and technology (Rispel et al. 2019).

Population and sampling

The purposive sampling method as a non-probability sampling technique considers the selection of the participants from the population, using non-random approaches (Burns & Grove 2016; Polit & Beck 2017). One hundred and four unit nurse managers from three public hospitals purposely selected, constituted the population of the study.

Data collection

The groups’ dynamics were considered in the planning of focus group interviews to improve equal participation (Polit & Beck 2017). Successful moderation of the focus groups’ interviews is influenced by open-mindedness, flexibility and responsiveness, patience, observance, and good listening (Boyce & Neale 2006). The different groups participating in the discussions were homogenous, and the selection of the participants was fair (Polit & Beck 2017). The venues at different hospitals were accessible to the participants (Burns & Grove 2016; Polit & Beck 2017). The discussions were conducted in English. As part of the briefing, the purpose of the study was explained to the participants. Participation was voluntary, and those willing to participate were requested to sign an informed consent form. Groups of about 6–10 participants from each public hospital formed part of the discussions. The different focus group sessions at each public hospital lasted about 1–2 h. The participants were given a fair chance to engage in fruitful discussions. The participants were asked this question: What is the unit nurse managers role in creating work cultures fostering intrapreneurial practice at South African public hospitals ? The neutral or non-directive probing technique used by the moderator improved meaningful interaction with the participants. The moderator as an active listener created inviting conversations with each participant. The skill of paraphrasing and reflection further improved the clarity of the conversations. For example, more inviting and neutral probes used were: Is there anything else? Go on and so on (Polit & Beck 2017). A debriefing exercise on the completion of each focus group interview created clarity on any outstanding issue. The discussions continued till saturation of data was reached (Burns & Grove 2016; Polit & Beck 2017).

Data analysis

The detailed ongoing analysis of qualitative data involves continuous reflection on transcripts and field notes to improve the quality of data under scrutiny (Creswell 2014). The consistent inductive reasoning and critical transformation process unfolded through careful synthesis of qualitative data. The careful process of analysis enabled the qualitative researcher to thoughtfully interpret existing data and create a bigger picture leading to the development of themes and categories through the eight steps of Tesch (Creswell 2014).

Trustworthiness

The qualitative inquirer constantly strives to integrate measures to improve the authenticity or rigour of findings by reflecting on the experiences or viewpoints of the participants (Polit & Beck 2017). The four approaches considered in this study to improve trustworthiness of findings include confirmability, dependability, credibility, and transferability. The researcher improved the quality of data elicited through prolonged engagement, peer debriefing, triangulation, audit trail, and organisation of raw data like field notes, transcripts, and reflective journals (Lincoln & Guba 2004).

Ethical considerations

Prior conduct of the qualitative study, appropriate gatekeeping initiatives were prepared for all parties concerned. The ethics clearance was granted by the ethics committee of the concerned University. Ethics clearance number is ECUFS NR 151/2011. The head of the Department of Health in the concerned province and the different public hospitals’ authorities offered permission. Participation in the study was voluntary. The participants signed the informed consent form. The study adhered to the following ethical considerations: beneficence, justice, and confidentiality.

Results

The prominent conversations coming out through consistent synthesis of qualitative data culminated into meaningful four themes each with relevant categories.

Human resource

Human resource management in health care is realistic through proper planning, provision, and utilisation of personnel and upholding appropriate measures of staff retention and development (Muller & Bester 2017).

Increase in advertising posts

The participants reflected on the reality and urgency of filling the vacant posts:

‘Filling of vacant post is quite urgent. Staff pass on, others go. for greener pastures, others go on pension while. others resign.’ (Participant C, female, unit nurse manager)

Appropriate staff allocation

The participants raised the concern of hospital CEOs being individuals with non-clinical expertise, only holding administrative related credentials:

‘The CEO of the hospital should be someone with a medical background, not a teacher because they are able to handle problems more efficiently since they are insiders.’ (Participant B, female, unit nurse manager)

Retention of staff through proper compensation

Participants echoed the importance of progressive human resource management policy taking heed of staff retention measures to motivate and improve staff competency:

‘To retain appropriate personnel, motivate staff through compensating them accordingly.’ (Participant B, female, unit nurse manager)

Improved communication

Effective communication within teams at public hospitals improves cohesion and morale and prevents conflicts (Muller & Bester 2017).

Improved communication between management and lower cadres

The participants emphasised the need to clear lines of communication with senior management to improve interaction:

‘There must be transparent communication from top-down. through open lines of communication to discuss any pressing issue timeously.’ (Participant B, female, unit nurse manager)

On-going departmental communication

The participants emphasised the urgent need to have uninterrupted internal communication to prevent miscommunication:

‘Consistent departmental communication engages all parties. and prevents any potential conflicts. If any conflict occurs, individuals need to communicate their grievances through proper channels, for the managements’ attention.’ (Participant C, female, unit nurse manager)

Poor signage in some hospitals

The participant raised the concern of existing poor signage within the hospitals which affects staff and visitors:

‘People get lost within the hospital because of lack of signage directing community members within the hospital departments.’ (Participant B female, unit nurse manager)

The participants felt that the public is not adequately informed on new developments taking place within the hospital:

‘We need to have slot in local radio stations where members of communities are updated on the existing programs within the hospital. I’m working at a paediatric ward, and there are still notable inconsistencies regarding vaccination of babies.’ (Participant B, female, unit nurse manager)

Award of incentives

The criteria used for motivating and rewarding nursing staff accordingly at large public hospitals take heed of the unique expertise of nurses in different areas of responsibility. For instance, the ability of nurses to adequately conceptualise and interpret their different roles is a crucial criterion considered (Jooste 2017).

Improving the current occupational specific dispensation

One participant echoed the importance of monetary incentives like Occupation Specific Dispensation to motivate nursing clinical specialists:

‘Attaching monetary incentives recognize the expertise of different members of nursing team and attaches responsibilities accordingly.’ (Participant A, female, unit nurse manager)

Different forms of incentives

The participants emphasised that offering different forms of incentives improves the work morale of teams:

‘Different forms of incentives in the form of money, Bursaries for career advancement and others pave the way for junior teams to consider innovative initiatives aimed at improving services if their efforts are recognized.’ (Participant A, female, unit nurse manager)

Financial management

At public hospitals, effective financial management strategy assists operational teams in controlling budgets effectively. Expenditure control and financial risk management also form the crucial components of financial management. It is the responsibility of unit nurse managers to ensure that teams are cognisant of expenditure control measures (Muller & Bester 2017).

Improved budget

One participant raised the concern of financial constraints:

‘Limited budget limits any meaningful innovation that could improve services. Sometimes one tries a new idea, but there is no money.’ (Participant A, female, unit nurse manager)

Availability of resources

One participant highlighted the concern of working within the public hospital environment with limited resources:

‘Poor financial management contributes to lack of resources. Constant lack of equipment jeopardizes desirable delivery of quality care.’ (Participant A, female, unit nurse manager)

Discussion

Meaningful transformation in acute public health care settings becomes realistic through incorporating measures that change the conventional cultures, inculcating routine-based operations into platforms of constant innovation (Oboirien et al. 2019). At large public hospitals, the existing diversity of cultures representing existing societal norms and values influences the employee cultural values to constantly consider new ways of improving services through constant innovation (Gürsoy & Güven 2016). The successful blending of multiple talents from a diverse workforce within the progressive intrapreneurial public hospital results in teams that are motivated to embark on constant innovation aimed at improving the quality of care rendered (Gürsoy & Güven 2016).

It is an urgent call for public hospital leadership to reconfigure the existing cultures by creating a more relaxed non-punitive hospital environment encouraging ongoing innovation to improve operations (Gürsoy & Güven 2016). The concerns raised by unit nurse managers painted a picture on the current state of the public hospital environment and its readiness to foster intrapreneurial work culture. Interesting discussions with nurse leaders culminated in four themes (Table 1): human resource issues, improved communication, the urgent need to award incentives for outstanding performance, and capacitating operational teams on good financial management principles.

The more structured human resource systems at public hospitals assist leadership at different levels to integrate progressive staffing practices (Grazier 2015; Rispel & Bruce 2014). Adequate provision of staff is a crucial component of the human resource role. Therefore, it is necessary to constantly merge the staff needs with the changing environment influenced by considering several aspects like changing disease patterns, demographic changes, and so on. Appropriate recruitment and advertising of posts, selection, appointment, and placement become critical to attract the right calibre of nurse leaders that spearhead transformative quality improved service delivery measures (Muller & Bester 2017). In South Africa, the enormous contribution of nurses in the delivery of healthcare services is notable because of their significant numbers compared to other healthcare disciplines. The large representation of nurses in healthcare impacts on promotion and provision of desirable quality improved healthcare services (Rispel & Bruce 2014). Several concerns experienced by the profession compromising the envisaged quality care include gross shortages, declining interest in the profession, a lack of caring ethos, ageing workforce, quadruple disease burden, multiple health reforms, gender stratification, and strong professional silos and hierarchies (Rispel & Bruce 2014). The participants voiced the existing staffing concerns impacting on the envisaged quality of care rendered: ‘Filling of vacant post is quite urgent. Staff pass on, others go for greener pastures, others go on pension while others resign’ (Participant C female, unit nurse manager).

The pressing healthcare demands call for proper planning of staff by considering the following factors: changing models of healthcare calling for an expansion of skill mix, demographic changes, advancing technology, and pandemics (Chamba & Chaziren 2023; Jooste 2017). Some of the pressing human resource concerns needing urgent attention include the highly polarised profession and ethical diversity with minimal interaction at public hospitals. This unconducive public hospital work environment affects work morale, productivity and staff competencies, and job satisfaction (Jooste 2017; Muller & Bester 2017). Pro-active staffing approaches attract high-calibre nursing personnel with clinical, advanced leadership and management skills (Daley 2013). Therefore, it is critical for interviewing teams to possess outstanding interactive skills enabling them to select outstanding candidates with business acumen (Daley 2013). The experienced interviewers need to establish if the prospective candidate’s value-laden and business-inclined philosophy merges with that of the organisation. Careful selection of more intrapreneurial candidates builds strong teams and improves employee relations in the long run, and this contributes to quality care (Daley 2013). Retention of staff within public hospitals is a critical human resource responsibility considered by intrapreneurial operational leadership to ensure sustenance of services at the unit level. The positive clinical work environment is constantly changing and stimulates teams on the ground to capitalise on existing informative evidence within units to improve treatment modalities for new diseases. Such an environment offers ample opportunities like ongoing education and, a flexible schedule for action research by individuals. It is necessary to recognise outstanding performance and establish strong mentorship programmes for upcoming nurse intrapreneurs (Daley 2013). The participants emphasised the need to avoid non-clinical stewardship at public hospitals: ‘The CEO of the hospital should be someone with a medical background not a teacher because they are able to handle problems more efficiently since they are insiders’ (Participant B, female, unit nurse manager).

The existing treatment modalities influenced by existing communicable and non-communicable disease patterns increase the staffing demands and impact the outcome of care (South Africa, Human Resource Strategy 2017). A meaningful human resource strategic plan constantly strives to build and maintain an experienced and stable team of nurses with knowledge and an appropriate skill mix (Daley 2013). The unit nurse manager designs staffing plans by using the existing staff and patients’ demographics to select, train, evaluate performance, and promote staff accordingly, to meet the needs adequately (Van Rensburg 2012). One participant highlighted the contribution of positive human resource policies promoting staff retention and productivity:

‘To retain appropriate personnel, motivate staff and compensate them accordingly.’ (Participant B, female, unit nurse manager)

South African public hospitals are undergoing major refurbishment to comply with the stipulated quality improved standards (Muller & Bester 2017). Therefore, many issues such as improved infrastructure, safety and signage form the heart of discussions from different levels of management (Muller & Bester 2017). The ongoing renovations at public hospitals make it difficult for the patients’ visitors, and staff to find the complex hospital departments easier (Masbool, Raju & Eunii 2016). The need to improve the layout of the hospital environment to improve the free movement of staff, patients, and visitors within hospitals is urgent: ‘People get lost within the hospital because of lack of signage directing community members within the hospital departments’ (Participant B, female, unit nurse manager).

Effective communication within intrapreneurial public hospitals offers the nurse leaders the needed autonomy to embark on proactive initiatives aimed at improving the delivery of services (Gürsoy & Güven 2016). Desirable communication turns the stressful environment into platforms of focused discussions intended to improve the meaningful delivery of services (Gürsoy & Güven 2016). The innovative vision and mission of public hospitals bring in new ways to improve operations. Therefore, it is necessary for senior management to support flexible time schedules and democratic communication to encourage creativity and innovation by intrapreneurial employees (Gürsoy & Güven 2016). The notion of democratisation of information is quite important and is achieved through constant interaction between different hierarchies on several issues affecting human resources. Prompt feedback on any issue previously discussed should be inclusive and hold each team member accountable for the decisions reached (Daley 2013). Internal communication within intrapreneurial hospitals should be goal-oriented and intentional to stimulate the self-driven innovative teams to take ownership of the organisation and become productive citizens who relentlessly consider new approaches improving the delivery of services (Daley 2013). The outstanding communication skills of intrapreneurial unit nurse managers enable them to go beyond prescribed roles and forge lasting project-related partnerships with team members internally or outside, through sharing innovative ideas and applicable implementation strategies with teams (Daley 2013). The participants emphasised the urgency of improving professional interaction between operating teams on the ground and senior teams: ‘There must be transparent communication from top-down through open lines of communication to discuss any pressing issue timeously’ (Participant B, female, unit nurse manager).

Open communication at public hospitals transforms the traditional perception of these public healthcare institutions and creates new settings for meaningful involvement with surrounding communities using media platforms like radio, to raise public awareness of new programmes offered by the public hospitals. The participants highlighted the urgent need for public updates on new disease developments and the functioning of the facility to avoid unnecessary confusion:

‘We need to have a slot in local radio stations where members of communities are updated on the existing programs within the hospital. I’m working at a paediatric ward, and there are still notable inconsistencies regarding vaccination of babies.’ (Participant B, female, unit nurse manager)

Intrapreneurial unit nurse managers constantly share the organisational vision with the team and create a relaxed non-punitive environment, allowing professional teams to be responsible and autonomous and satisfy the client’s needs through offering quality improved care (Daley 2013). The outstanding leader possesses management qualifications including training in best practices including human resource-related training. This exposes them to different government policies relating to human resource recruitment, induction, procurement, financial management, and so on (Albert & Randerstorf 2021). The research-oriented nurse intrapreneur has critical skills of judgement enabling them to have heightened power of perception giving them the added advantage of decisive judgement and preventing any potential conflict through team involvement (Carlson 2018). Participants echoed that engagement of junior teams and feedback from senior teams avert any potential conflicts:

‘Consistent departmental communication engages all parties and prevents any potential conflicts’. (Participant C, female, unit nurse manager)

Proper allocation of money and other resources at public hospitals impacts the desired outcome of care within units (Muller & Bester 2017). At public hospitals, financial management is engrained within extensive legislative frameworks like the National Health Act, principles of corporate governance, legislation and subsequent regulation, directives, regulations, and financial management policies (Muller & Bester 2017). Personnel, medicine, supplies, and equipment constitute the greatest expenditure at the health service unit. The unit nurse managers need to take responsibility and accountability by planning for sufficient funds on time to ensure that all necessary equipment, medicine, and other consumables are available (Muller & Bester 2017; Muller, Bezuidenhout & Jooste 2015). The budget cycle acts as an essential quality control measure, highlighting different stages of implementation, monitoring, reporting, analysis, and feedback strategies, determining how the stipulated performance indicators will be upheld (Muller et al. 2015; Naranjee, Ngxongo & Sibiya 2019). The clinical expertise and financial management skills of intrapreneurial unit nurse managers assist them in planning and defending budget extensions to incorporate seed funding and support intrapreneurial evidence-based innovation aimed at curtailing costs and improving the delivery of services (Albert & Randerstorf 2021; Hoying et al. 2021; Verghese 2018). The existing budget constraints at these public healthcare enterprises were raised by one participant who said:

‘A short fall in budget allocation limits any meaningful innovation that could improve services. Sometimes one tries a new idea but the is no money’ (Participant A, female, unit nurse manager).

Incentivising performance is one of the personnel retention strategies known to keep teams motivated within public hospital institutions (Ngozwana 2015). The highly regulated bureaucratic South African public health care has restrictive financial policies. This limits the desirable support from senior management allocating the seed funding aimed at improving the delivery of services by innovative individuals. However, progressive democratisation of systems within the South African public hospitals significantly influenced the Department of Health to relax financial resource policies to incorporate the Occupation Specific Dispensation (Ngozwana 2015). As a crucial government financial incentive, the Occupation Specific Dispensation is designed to attract specific skills from private into public health care by improving the career paths of nurses with specific skills by offering a better salary grade. The initiative has been an excellent starting point to incentivise performance to individuals with specific skills (Ngozwana 2015). A positive work climate reduces turnover and hiring costs, develops individuals, and promotes healthy competition within teams (Muller et al. 2015). It is an urgent call for the front-line leadership to think of progressive staff retention approaches for teams of nurses at the forefront working in a volatile public hospital environment. These nurses need to be recognised and rewarded for their outstanding skills and performance (Hoying et al. 2021; Verghese 2018). The rewards improve morale and add value to the significance of employees to the organisation. Different forms of rewards can be offered in the form of financial incentives, promotion, or improved lifestyle, and should be aligned with the organisational goals (Hoying et al. 2021; Verghese 2018).

The participants emphasised the urgent need for incentivised performance to outstanding team members:

‘Different forms of incentives in the form of money. Also, bursaries can be offered for career advancement, and other forms pave the way for junior teams to consider innovative initiatives aimed at improving services.’ (Participant A, female, unit nurse manager)

The crucial hospital cultural issues addressed in the findings reflecting a non-receptive culture towards intrapreneurship practice include aspects like the structural issues being highly centralised and drastically affecting desirable interaction between senior and junior teams. The highly task-oriented environment limits the potential to form strong project-related coalitions by innovative teams, internally and interdepartmentally to improve services. The non-inclusive policies where there is minimal management support on time allocation for innovation, and resource allocation through seed funding for innovative projects constitute a setback. Furthermore, the unfavourable recruitment policies aligning intrapreneurial employees to organisational culture for innovation are non-existent. The policies supporting incentive-based performance recognising and rewarding outstanding individuals for outstanding for innovation, still lack.

Interestingly, the findings reflect the conventional and restrictive bureaucratic walls as highly structured. The findings, seemingly underscore the business potential of an intrapreneurial unit nurse manager with advanced academic credentials from institutions of higher learning, possessing extensive clinical expertise coupled with advanced theoretical, practical, and research knowledge in influencing meaningful transformation at operations.

The article emphasises the urgency for public hospital management to support intrapreneurship norms and values aimed at improving the processes and outcomes of care. The leadership needs to prepare the hospital work culture and align plans to the constantly changing external environment impacting internal processes. The positive work culture encourages individuals to be productive, and take ownership of assigned tasks, inculcate good work ethics and commitment across different hierarchies inclusive of the bottom cadres. The responsible and accountable teams take calculated risks. Their collective consciousness influences business-inclined behaviour across the entire organisation (Gürsoy & Güven 2016). The unit nurse managers constituting the crucial human capital at public hospitals prepare the ground for exploitation of any potential opportunities internally and outside the organisation to augment the existing performance management systems (Grazier 2015). The outstanding characteristics of the unit nurse managers enable them to mobilise resources and start innovative projects by clearly defining the existing problem. The strong coalitions built internally and externally are realised through constant communication on the project’s progress (North 2015).

Managerial implications

Extensive nursing literature emphasises that there is minimal participation of nurses in health care policy reform, despite their significant numbers in health care. The non-progressive healthcare policies could be quite limiting to intrapreneurial unit nurse managers in face-lifting the traditional hospital work cultures by embracing improved ways of delivering services.

The study paints the current restrictive culture of innovation by nurse intrapreneurs at public hospitals and invites senior teams at public hospitals to innovate and allocate seed funding enabling intrapreneurial individuals to devise new approaches for improving care (Carlson 2018; Gürsoy & Güven 2016). Transforming the hostile public hospital work into a playground for constant creativity and innovation assists nurse intrapreneurs to lobby, network, raise funds, and embark on research that improves services.

The study acknowledges the extensive skills of intrapreneurial unit nurse leaders motivated to lead and manage intrapreneurial-related projects to completion (Gürsoy & Güven 2016). The outstanding leadership and management skills assist the nursing champions to prepare the unit environment adequately and allow responsible and autonomous teams to integrate evidenced and new technology-based approaches aimed at improving the outcome of care.

Limitations of the study

Intrapreneurship being foreign to nursing was not adequately understood by all groups. The response from the participants was uneven. Some participants dominated the discussions, and other participants did not participate at all. Examples of participation in innovative projects were minimal. The environmental challenges were overwhelming and were not seen as a hub for innovative change by unit nurse managers.

Conclusion

The highly layered bureaucracy makes the public hospitals quite complex requiring outstanding operational leadership to promote inclusivity through decentralised structures (North 2015). In South Africa, increasing non-communicable and communicable diseases’ burden, including the COVID-19 pandemic, causes a serious influx of patients in public healthcare facilities (Malakoane et al. 2020). The constant pressure experienced by these public healthcare institutions puts them under the spotlight for scrutiny from different stakeholders on critical issues like the general state of the facilities and the existing administrative and operational concerns compromising the quality of healthcare being offered.

The operational and administrative issues compromising meaningful service delivery include staff attitudes, long waiting times, unclean facilities, medicine stock out, inadequate infection control measures, and safety and security for staff and patients (Malakoane et al. 2020). The senior executive management as drivers of health care policy put functional systems in place to improve the quality of care rendered (Muller et al. 2015). This makes it easier for the service providers responsible for the technical aspect of care to consider aspects like adherence to treatment protocols, infection prevention measures and positive outcomes of care instrumental in the reduction of morbidity, mortality, or disability (Muller et al. 2015; Rispel et al. 2019). The challenging hospital work environment motivates intrapreneurial teams to innovate.

Based on the findings, the study recommends the following:

Improved human resource policy should address critical aspects like:

• Balancing intrapreneurial employees with organisational goals.
• Improving performance management systems.
• Recruiting candidates with advanced knowledge skills to ensure teams with the right skill mix whose attitudes and values are a good fit for the job.
• Reasonable staff development plan based on staff engagement on the current needs.
• On-going intrapreneurial leadership mentorship programme to ensure sustainable services in the future.

Improving clinical practice:

• Decentralisation of organisational structure to improve interaction between different hierarchies.
• Capacity development to operational teams on improved financial management skills.
• Creating a positive work culture in which different roles are clarified to avoid potential conflicts.
• Leveraging management and teams’ support for ongoing creativity and innovation.
• Management support on incentivised performance for intrapreneurial-related innovation.

Improving education:

• Alignment of the nursing curriculum with dynamic environmental influences through considering critical aspects like changing disease patterns, markets, technological advancement – 4IR, and so on.
• Collaborative research partnerships with different stakeholders aimed at improving clinical practice.

Acknowledgements

The author T.M.L., expresses heartfelt gratitude to the research office, School of Governance University of the Witwatersrand for support to publish this article.

The author declares that no financial or personal relationships inappropriately influenced the writing of this article.

T.M.L is the sole author of this article.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The data that support the findings of this study are available from the corresponding author, T.M.L., upon reasonable request.

The views and opinions expressed in this article are those of the author and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The author is responsible for this article’s results, findings, and content.

References