ORGANIZATIONAL CHANGE MANAGEMENT AND WORK FLEXIBILITY IN TURKISH HEALTHCARE: COMPARATIVE EVIDENCE FROM PUBLIC AND PRIVATE HOSPITALS

Abstract

The COVID-19 pandemic accelerated organizational transformations in healthcare globally, particularly regarding work arrangements, yet systematic evidence on change management effectiveness remains limited in emerging market contexts. Drawing on Kotter's eight-step change model, this study examines relationships between change management practices and work flexibility adoption in Turkish healthcare organizations. We surveyed 652 healthcare professionals across 24 hospitals in three provinces , employing hierarchical regression and multi-group analyses. Results reveal significant positive associations between change management effectiveness and flexibility adoption (β=0.54, p<0.001, ΔR²=0.28). Supplementary analyses with organizational agility as an additional outcome confirmed similar patterns (β=0.51, p<0.001). Among Kotter's eight steps, employee empowerment (β=0.32, p<0.001) and institutionalization (β=0.24, p<0.001) emerged as strongest predictors, while vision (β=0.14, p<0.01) showed modest effects and communication was non-significant. Private hospitals demonstrated substantially higher change management effectiveness (M=67.5 vs. M=58.2, Cohen's d=0.81), with largest gaps in coalition building (d=0.83), empowerment (d=0.89), and institutionalization (d=0.88). The association between change management and flexibility adoption was stronger in private (β=.61) versus public hospitals (β=.48; interaction β=.09, p=.011). These findings reveal a hierarchy among Kotter's steps: structural enablers (empowerment, institutionalization) show substantially stronger relationships with flexibility adoption than rhetorical strategies (vision, communication). Public sector organizations require targeted policy interventions addressing bureaucratic and cultural barriers constraining change implementation.

Keywords

• Change management
• Kotter model
• Work flexibility
• Healthcare administration
• Turkey
• Public-private comparison
• Organizational agility

Türkiye Sağlık Sisteminde Örgütsel Değişim Yönetimi ve İş Esnekliği: Kamu ve Özel Hastanelerden Karşılaştırmalı Kanıtlar

Abstract

COVID-19 pandemisi, özellikle çalışma düzenleri açısından, küresel ölçekte sağlık sektöründeki örgütsel dönüşümleri hızlandırmış; ancak değişim yönetimi uygulamalarının etkinliğine ilişkin sistematik kanıtlar, özellikle gelişmekte olan ülke bağlamlarında sınırlı kalmıştır. Bu çalışma, Kotter’ın sekiz adımlı değişim modeli çerçevesinde, değişim yönetimi uygulamaları ile iş esnekliği benimsenmesi arasındaki ilişkileri Türkiye’deki sağlık kurumları örnekleminde incelemektedir. Üç ilde yer alan 24 hastaneden 652 sağlık çalışanıyla gerçekleştirilen anket verileri, hiyerarşik regresyon ve çoklu grup analizleri ile değerlendirilmiştir. Bulgular, değişim yönetimi etkinliği ile iş esnekliği benimsenmesi arasında anlamlı ve güçlü ilişkiler olduğunu göstermektedir (β=0.54, p<0.001, ΔR²=0.28). Ek analizlerde örgütsel çevikliğin ek bir çıktı değişkeni olarak modele dâhil edilmesi benzer sonuçlar ortaya koymuştur (β=0.51, p<0.001). Kotter’ın sekiz adımı arasında çalışanların güçlendirilmesi (β=0.32, p<0.001) ve kurumsallaştırma (β=0.24, p<0.001) en güçlü yordayıcılar olarak öne çıkarken; vizyon adımı daha sınırlı bir etki göstermiş (β=0.14, p<0.01), iletişim ise anlamlı bulunmamıştır. Özel hastaneler, kamu hastanelerine kıyasla toplam değişim yönetimi etkinliğinde belirgin biçimde daha yüksek skorlar elde etmiştir (M=67.5 vs. M=58.2, Cohen’s d=0.81). En büyük farklar ise koalisyon oluşturma (d=0.83), güçlendirme (d=0.89) ve kurumsallaştırma (d=0.88) adımlarında görülmüştür. Ayrıca değişim yönetimi ile iş esnekliği arasındaki ilişki özel hastanelerde (β=.61) kamu hastanelerine göre (β=.48) daha güçlüdür (etkileşim β=.09, p=.011). Bulgular, Kotter modelindeki adımlar arasında belirgin bir hiyerarşi olduğunu göstermektedir: Yapısal kolaylaştırıcı adımlar (güçlendirme, kurumsallaştırma), söylemsel stratejilere (vizyon, iletişim) kıyasla iş esnekliği benimsenmesiyle çok daha güçlü ilişkiler sergilemektedir. Kamu hastanelerinde bürokratik ve kültürel engellerin değişim uygulamalarını sınırladığı görülmekte olup, bu alanlarda hedeflenmiş politika müdahalelerine ihtiyaç vardır.

Keywords

• Değişim yönetimi
• Kotter modeli
• İş esnekliği
• Sağlık yönetimi
• Türkiye
• Kamu-özel karşılaştırması
• Örgütsel çeviklik

References

1. Allen, T. D., Johnson, R. C., Kiburz, K. M., & Shockley, K. M. (2013). Work–family conflict and flexible work arrangements: Deconstructing flexibility. Personnel Psychology, 66(2), 345–376. https://doi.org/10.1111/peps.12012
2. Appelbaum, S. H., Habashy, S., Malo, J. L., & Shafiq, H. (2012). Back to the future: Revisiting Kotter's 1996 change model. Journal of Management Development, 31(8), 764–782. https://doi.org/10.1108/02621711211253231
3. Barrero, J. M., Bloom, N., & Davis, S. J. (2021). Why working from home will stick. NBER Working Paper No. 28731. National Bureau of Economic Research. https://doi.org/10.3386/w28731
4. Bloom, N., Liang, J., Roberts, J., & Ying, Z. J. (2015). Does working from home work? Evidence from a Chinese experiment. The Quarterly Journal of Economics, 130(1), 165–218. https://doi.org/10.1093/qje/qju032
5. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates.
6. Deci, E. L., & Ryan, R. M. (2000). The "what" and "why" of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01
7. Donaldson, L. (2001). The contingency theory of organizations. Sage Publications.
8. Dyrbye, L. N., Shanafelt, T. D., Johnson, P. O., Johnson, L. A., Satele, D., & West, C. P. (2019). A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses. BMC Nursing, 18, Article 57. https://doi.org/10.1186/s12912-019-0382-7

9. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41(4), 1149–1160. https://doi.org/10.3758/BRM.41.4.1149
10. Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E. (2010). Multivariate data analysis (7th ed.). Pearson.
11. Hill, E. J., Grzywacz, J. G., Allen, S., Blanchard, V. L., Matz-Costa, C., Shulkin, S., & Pitt-Catsouphes, M. (2008). Defining and conceptualizing workplace flexibility. Community, Work & Family, 11(2), 149–163. https://doi.org/10.1080/13668800802024678
12. Horwitz, J. R. (2005). Making profits and providing care: Comparing nonprofit, for-profit, and government hospitals. Health Affairs, 24(3), 790–801. https://doi.org/10.1377/hlthaff.24.3.790
13. Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
14. Kniffin, K. M., Narayanan, J., Anseel, F., Antonakis, J., Ashford, S. P., Bakker, A. B., Bamberger, P., Bapuji, H., Bhave, D. P., Choi, V. K., Creary, S. J., Demerouti, E., Flynn, F. J., Gelfand, M. J., Greer, L. L., Johns, G., Kesebir, S., Klein, P. G., Lee, S. Y., ... van Vugt, M. (2021). COVID-19 and the workplace: Implications, issues, and insights for future research and action. American Psychologist, 76(1), 63–77. https://doi.org/10.1037/amp0000716
15. Kotter, J. P. (1996). Leading change. Harvard Business School Press.
16. Kotter, J. P. (2012). Leading change (New edition). Harvard Business Review Press.
17. Langer, M., & König, C. J. (2023). Introducing a multi-stakeholder perspective on opacity, transparency and strategies to reduce opacity in algorithm-based human resource management. Human Resource Management Review, 33(1), 100881. https://doi.org/10.1016/j.hrmr.2021.100881 Langley, A., Smallman, C., Tsoukas, H., & Van de Ven, A. H. (2013). Process studies of change in organization and management: Unveiling temporality, activity, and flow. Academy of Management Journal, 56(1), 1–13. https://doi.org/10.5465/amj.2013.4001
18. Menard, S. (2002). Applied logistic regression analysis (2nd ed.). Sage Publications.
19. Ministry of Health, Republic of Türkiye. (2023). Health statistics yearbook 2022 (Publication No: 1264). Ministry of Health.
20. Montgomery, A., Spânu, F., Băban, A., & Panagopoulou, E. (2015). Job demands, burnout, and engagement among nurses: A multi-level analysis of ORCAB data investigating the moderating effect of teamwork. Burnout Research, 2(2–3), 71–79. https://doi.org/10.1016/j.burn.2015.06.001
21. O'Brien, R. M. (2007). A caution regarding rules of thumb for variance inflation factors. Quality & Quantity, 41(5), 673–690. https://doi.org/10.1007/s11135-006-9018-6
22. Peugh, J. L. (2010). A practical guide to multilevel modeling. Journal of School Psychology, 48(1), 85–112. https://doi.org/10.1016/j.jsp.2009.09.002
23. Podsakoff, P. M., MacKenzie, S. B., Lee, J. Y., & Podsakoff, N. P. (2003). Common method biases in behavioral research: A critical review of the literature and recommended remedies. Journal of Applied Psychology, 88(5), 879–903. https://doi.org/10.1037/0021-9010.88.5.879
24. Raišienė, A. G., Rapuano, V., Varkulevičiūtė, K., & Stachová, K. (2020). Working from home—Who is happy? A survey of Lithuania's employees during the COVID-19 quarantine period. Sustainability, 12(13), Article 5332. https://doi.org/10.3390/su12135332
25. Rousseau, D. M. (1995). Psychological contracts in organizations: Understanding written and unwritten agreements. Sage Publications. Rudisill, C. (2023). The welfare state and handling health challenges. In Welfare States in a Turbulent Era (pp. 112-126). Edward Elgar Publishing. https://doi.org/10.4337/9781803926841.00015
26. Sharifi, H., & Zhang, Z. (1999). A methodology for achieving agility in manufacturing organisations: An introduction. International Journal of Production Economics, 62(1), 7–22.
27. Turan Kurtaran, A., Aydın, A., & Yeşildağ, A. Y. (2024). Glass ceiling syndrome: A perspective of women working in health institutions. Ege Academic Review, 24(1), 71–84. https://doi.org/10.21121/eab.1349010
28. Tretiakov, A., Jurado, T., & Bensemann, J. (2023). Employee empowerment and HR flexibility in information technology SMEs. Journal of Computer Information Systems, 63(6), 1394-1407. https://doi.org/10.1080/08874417.2022.2158962
29. Turkish Statistical Institute. (2023). Regional GDP statistics, 2022. Turkish Statistical Institute.
30. Yeşildağ, A. Y., Sayar, B., & Dalgiç, Z. (2024). Assessment of hospital managers' sustainable leadership levels. Ege Academic Review, 24(4), 593–606. https://doi.org/10.21121/eab.20240407
31. Waldman, J. D., Kelly, F., Aurora, S., & Smith, H. L. (2004). The shocking cost of turnover in health care. Health Care Management Review, 29(1), 2–7. https://doi.org/10.1097/00004010-200401000-00002