Change management in hospitals: a way to learn from climate change

. Resolutely a complex and multidisciplinary organization, the hospital is undergoing several inevitable changes. Faced with so many changes and the risk of disappearing, it must transform, rethink and redefine its structures and strategies. Given this, change management is a critical factor in the success of organizational transformation strategies. In this respect, several change management practices have been proposed. Although applicable to any organization, these models and approaches require a perfect understanding of the reality of hospitals, as a change in hospitals is laborious and complicated. The change process in hospitals is still strongly marked by several constraints that handicap the management of change and make it challenging to implement changes. Rightly so, change management in a hospital may be hampered by technological, regulatory, organizational, managerial, or human resource constraints. Change management promotes continuous improvement where each actor must be considered a factor in the transformation of the hospital organization. To achieve this, the path to be followed must include more interaction and questioning, which encourage the learning of actors for the benefit of a learning hospital.


INTRODUCTION
The health sector is increasingly subject to change and has undergone countless multidimensional reforms and restructuring in recent years. However, it still faces several significant challenges, including implementing these reforms 1 . Indeed, reform is mainly a process of change to improve policies and adjust programs and practices by changing priorities and regulations, improving the managerial and organizational structure of health care institutions, or renovating financing systems. In this sense, the hospital world is under continuous pressure 2 . Rightly so, the hospital, a complex and multidisciplinary organization, is undergoing several inevitable changes that constantly force professionals to rethink their practices to keep up with the demands of the often multiple and profound reforms 3 . Faced with so many changes and the risk of disappearing, hospitals must transform, rethink and redefine their structures and strategies 4 . Change in hospital institutions is therefore essential but ineluctably laborious and complicated. Moreover, the literature is unanimous about the difficulty of implementing change regardless of the type of organization 5 . Change management is required, but the most worrying aspect is how it is carried out. Changes are often costly in the face of results that are not always satisfactory, and the hospital is obliged to transform itself to offer safe and quality services, optimize the use of resources, and control expenditure better. It must also respond adequately to the many transitions simultaneously experienced at the demographic, epidemiological, and political/socio-economic levels. It is now time to question the best managerial approach for hospitals to follow to introduce changes better. It is necessary to innovate and consider new methods without forgetting to consider the particular characteristics of hospitals in the conduct of all the evolutions and reforms of the health sector. By embracing change management practices, hospitals can effectively learn from climate change and adapt their operations to mitigate risks, optimize resource utilization, and improve overall sustainability. This proactive approach not only enhances the resilience of healthcare systems but also contributes to the broader goals of climate change mitigation and environmental stewardship.
The objective of this research is to clarify the importance of change, especially the change management within hospitals, which must take into consideration all the particularities linked to them to counter the constraints that can hinder the implementation of the desired transformations and also integrate learning into any change process within these rather complex institutions.

METHODS
Based on a synthetic review of the literature, using a selection of international literature, namely literature reviews or scientific articles, and by interpreting and analyzing all these data, the objective of this research is to highlight the importance of change, significantly change management within hospitals, which must take into consideration all the particularities linked to them to counteract the constraints that may hinder the implementation of the desired transformations and also integrate learning in any change process within these rather complex institutions. The research was conducted on different databases in English and French. Two hundred fifty studies were reviewed, and their relevance was assessed in terms of validity and eligibility to select the studies relevant to our research objective by including articles and books dealing with the subject of our research and excluding articles, reports, and personal interviews dealing with a subjective opinion, as well as all articles that have not been subjected to a validation process. The 30 selected documents, which had strong reliability and validity parameters, were exported and managed by Zotero. The parameters included in the grid for measuring the quality of the reviewed references included the definition of the study protocol, adherence to the study protocol, clarification of the research question, accurate description of the analysis methodology adopted, use of objective and unbiased measurement criteria, presence of single or double-blinding where appropriate, mention of conflicts of interest, and presentation of the study limitations.

Change management
Change management is becoming increasingly crucial for any organization to survive and succeed in a constantly evolving and often destabilizing environment. Above all, make the desired transformations operational and develop the capacity to change, reactivity, and adaptability 6. Thus, the ability to lead, manage, and control change is considered a real challenge 7. Indeed, change is defined in terms of its intentionality (imposed change-voluntary change), its pace (radical change-incremental change), and its motor (reactive or proactive) 8. Change refers, in fact, to any modification in the structures and behaviors of the members of the organization resulting from an adaptation to the environment or from a voluntary action by the leader to ensure the maintenance or growth of the organization in its environment 9. That said, change is, above all, a planned and structured process in which a series of interventions are decided upon and implemented to bring the organization and its actors from a current point (A) to the desired point (B) 10. Change is, in fact, part of the life of organizations, either to maintain balance, reproduce or transform 9. Whatever its nature, change can be analyzed as a gap between two situations. Hospitals can adopt sustainable infrastructure and practices to reduce their carbon footprint and enhance resilience. This includes implementing energy-efficient technologies, renewable energy sources, water conservation measures, waste management systems, and green building design principles. These initiatives not only contribute to climate change mitigation but also optimize resource utilization and operational efficiency. Therefore, managing change implies managing a process by considering the decision to change, the approach to managing change, the actors, and failure factors. Autissier and Moutot 11 examine change as a rupture in functioning when several elements are changed, namely: practices (ways of doing things), working conditions (material environment), tools (IT and management tools), the organization (areas of power and functional boundaries), the job (the organization's know-how), the strategy (the collective goals pursued and envisaged), and the culture (the value system). These elements subject to change can be classified along two axes depending on their individual or collective characteristics and the time required for their transformation. Lewin 12 conceives change as a path formed by progressive stages and three successive phases: unfreezing, moving, and freezing. The first phase implies the appearance of inertia and a dismantling of the logic of ideas in the individual. This leads to change. The second phase is change, which represents a period of fusion and transitions of new ideas or ideas that have emerged due to the dismantling of old ones. The third phase is the formation of a new logic. The crystallization of the new ideas makes it impossible to go backward. Kotter 13 goes so far as to advise that change should be implemented in eight stages. These stages allow the implementation of a fundamental change to be monitored at the organization's operational level. To do this, a sense of urgency must be established by linking the organization's current situation with the realities of the external environment (actual and potential crises, opportunities, etc.). Then, he advocates the formation of a strong coalition of individuals capable of circumscribing the change and bringing together the other actors to achieve it. But again, it remains essential to have a clear vision of the change process to achieve the desired outcome. The organization and its stakeholders need to know where they are going and where they want to go. Change is an essential lever for success in a world impacted by change and successive evolutions. It is also a symbol of development, adaptation, resilience, and collective intelligence. Given this, change management is defined as the entire process that goes from the perception of an organizational problem to the definition of a framework of actions allowing for the development, choice, and implementation of a solution in optimal conditions for success 11 . Change management is a critical factor in the success of organizational transformation strategies. It is an art that facilitates projection and transition while identifying the practices necessary to make change possible. In this respect, several change management practices have been proposed, in particular those of Autissier and Moutot 14 , of which there are three: 'Instrumented' change management: the best known, which enables large-scale changes to be dealt with through deployment kits, training and communication kits. Psychosociological" change management: the most complex, which makes it possible to understand the culture of the players, to characterize the organizations (agency, region, company), and to analyze resistance and its root causes, motivational factors, and management methods, and social relations between groups. And the "project management" change management: the most "complete," allows the intermediate stages of the change to be paced and the implementation of the transition to be monitored. It takes the form of a batch in a project with its actions, planning, and budget.

Hospital specifications
Although applicable to any organization, these models and approaches require a thorough understanding of the hospital's reality, which is necessary for successful change 15 . In this sense, the hospital has several properties, as it is a specific organization in terms of status, management methods, and legal structures. As a result, how these organizations operate and are managed remains delicate. The hospital is ultimately a complex organization because of the multiplicity of roles, actors, techniques, and the often-contradictory expectations of the public and the supervisory authorities 16,17 .

Figure 2:
The 4 worlds of healthcare organizations 18 Indeed, according to Glouberman and Mintzberg 18 , this diversity of roles is associated with four worldviews of hospitals: cure, care, control, and community. The "curative worldview" is specific to doctors who, each in their specialty, treat and care for patients while taking little interest in administrative work. Nurses, who spend much of their time with patients and value patient-centered care, have a "caring worldview." The "control world view" is related to managers, who, through their supervisory authority, will value control, stability, and compliance with procedures. Then, the 'community worldview' is held by the board of trustees, who have managers to account for and exercise their power by limiting the allocation of resources. These boards are often put in place by councils, the media, and politicians. In short, a hospital organization can be understood as construction where different professional, social, and human interactions are considered in their complexity. 19,20 . Consequently, to better analyze the management of change in a hospital, it is prudent to consider the specific characteristics of this organization while focusing on the feedback of information thanks to operating indicators; the management of material and immaterial flows; the management of processes; the adequacy of resources and risk management 19 . Therefore, hospitals are required to provide a faultless quality of service to patients on the one hand and optimize their resources on the other. This, knowing that political, economic, and socio-cultural changes in the health sector have an undeniable impact on the process of change within these establishments 21 . This is why it is necessary to consider the hospital context's internal and external particularities in implementing change.

DISCUSSION
Faced with the increase in health sector expenditure, several countries have implemented a wave of changes in health care establishments, among other things, through implementing a certain number of management and management tools taken from the industrial world 16 . This is almost an attempt to 'industrialize care,' control health expenditure, and improve practices to enhance the quality of patient care. Given this, the process of change in hospitals is still strongly marked by three main difficulties: the high expectation of external solutions on the part of internal actors, the demand for immediate solutions giving rise to another problem in projecting into the medium and long term, and the failure to respect the stages of change, which disrupts the smooth running of the mission 22 . As changes are undertaken, the hospital experiences several constraints that hinder change management and thus make it challenging to implement changes. Rightly so, changing direction in a hospital can be hampered by technological limitations. Technology is changing at such an accelerated pace these days. Also, it affects all levels of the organization and is becoming increasingly sophisticated and especially expensive. However, using more sophisticated technology always implies a change like work. This requires a greater or lesser proportion of staff to change their working habits, learn new routines, and even new skills 23 . Not to mention that hospitals are often unable to commit adequate resources and face difficulties and budgetary constraints in their change projects 24 . However, it should be noted that in hospitals, a state-of-the-art technological platform and IT infrastructure are necessary for the implementation of the desired internal processes and even condition the sharing of information and even knowledge between staff 25 .
As far as legal constraints are concerned, the hospital is, moreover, an entity with limited autonomy in the achievement of a certain number of objectives, especially as it is often subject to a regulatory and institutional framework imposed by the authorities in the process of rationalization of the hospital system which is increasingly taking place in a context characterized by growing tensions between professional and economic logics 26 . The incentive to change for hospitals has been essentially prescription-based through various laws, decrees, and orders 27 . The supervisory authorities even go so far as to define in the texts the managerial methods that establishments must implement 28 . The hospital often undermines these legal prescriptions, which unfortunately remains subject to several budgetary constraints and difficult trade-offs in terms of attention and allocated resources 24 . Other constraints are organizational, so much so that Boiteau and Baret 4 justify the failure of several change movements by the multiple organizational and contextual brakes that reign over the hospital environment, and they place particular emphasis on the pluralistic organization (several logics, objectives, actors, etc.) which compromises the success of change processes. In other words, the hospital integrates within its perimeter a very high diversity of activities carried out by distinct and autonomous services and a very high diversity of professions, skills, and categories: management, support functions, medical staff, and carers 28 .
Thus, this fragmentation is accentuated by cultural diversity resulting in the existence of parallel worlds 28. Within the hospital, there are, in fact, four worlds (Community, Control, Cure, and Care) that condition the behavior and actions of the actors with several contrasting values references 18 . Not forgetting that the changes have sometimes imposed generalized mergers of hospitals or even unions of services, this hospital reorganization has often transformed the very structure of the team, often upsetting power relations and compromising teamwork within the hospital, thus making change even more challenging 5 .
Thus, the success of implementing changes also depends on all sorts of phenomena related to the characteristics, functioning, and management that make up the hospital structure. Although organizational factors are decisive, individual elements are conclusive. The whole is intertwined and acts to facilitate or hinder the conduct of change 24 . However, the hospital staff bears the most challenging responsibility of promoting the patient-centered approach and moralizing professional practices. In addition, there are several human resource constraints that hinder the implementation of change 29 . Change usually starts with changing the behavior of individuals 30 . When they are not involved, individuals often change and experience it not as an opportunity for improvement but rather as several types of loss: loss of security, skills, relationships, power, territory, etc. This leads them to resist any change. This leads them to fight for change 11 .
For Lewin 31 , resistance to change appears particularly in two cases: first, when the change affects habits, customs, and rituals; individuals cling to their old value system because it becomes such a group norm that they reject new ones. Secondly, people resist when they do not understand the reasons for changes or innovations that the organization wants to introduce. Individuals do not prefer that "things change" and have difficulty understanding the rational justification for changing routines that "normally" reassure them. In this sense, the hospital has many specific characteristics, such as the withdrawal of staff into their corps and department, the weight of tradition, the low interest of the team in cross-disciplinary organizational projects, and difficulty in adhering to and using projects and approaches to improve quality or performance, given the additional workload that these changes imply 24, 26 .
Also, hospital staff has experienced many changes in their practice and employment conditions in recent years, demotivation, weak interprofessional collaboration, counterproductive power struggles, and a lack of organizational learning. These things lead to managers, professionals, and other employees' disengagement and are now an additional obstacle to change management 24, 25 . Paradoxically, the hospital staff is the driving force behind change, and no change can be achieved without their input 21 . Indeed, the individuals will enrich, improve, give meaning to things, and ensure that the changes bring the expected results. However, they often resist because they prefer to be consulted and involved in the change process. In this respect, change management can also be handicapped by certain managerial constraints related, in this case, to the quality of management and leadership. The need for improvement often drives change, but the most crucial question is whether or not the organization and its members are ready for it. The hospital's strategy is concretely focused on realizing the strategic themes defined by the governing authority 25 . Change management can be hampered when the organization's reality is not examined and when the expectations of change are not considered.
At the hospital level, this translates into decision failure when the perceived need for change does not lead to a decision to implement it, implementation failure when the decision to intervene does not lead to adequate implementation of the change, or intervention theory failure when the excellent performance does not produce the expected effects 5 . Also, opaque leadership and poor communication hinder the understanding of change and the ability to facilitate its successful implementation. Indeed, a lack of communication, participation, facilitation, and negotiation on the part of the manager leads to resistance to change 32 . For the hospital to succeed in implementing its objective, it is vital to establish performance measures that represent precisely what it intends to achieve while modeling the perception of change management by hospital stakeholders to get them on board, involve them and help them build a consensus through a participatory approach 10 . Ultimately, Kanter and al 33 identified three important actors in the conduct of change processes: the strategists who conceive the change, the organizers who implement it, and the receivers who are the recipients of the change and who are the first sources of resistance. Three main levers are accepted to initiate and implement change in organizations, including communication, training, and support 14 . However, the hospital is an organization where internal actors are of sustained importance due to the hospital configuration. The latter has been described by Mintzberg 34,35 as a professional bureaucracy dominated by its operational center and characterized by a dual hierarchy where managers at the top have formal authority over administrative staff but limited control over the behavior of professionals. It is also characterized by many professional silos separating doctors from nurses and other staff. In other words, medical and nursing staff have a certain autonomy and strongly influence change, given the importance of interprofessional collaboration in hospitals 36 . Also, the hospital staff is characterized by their diversity, varying between a profile with specialized medical knowledge and a profile with purely technical and administrative expertise 10 .
The change process is inexorably conducive to interactions, continuous adaptations, and questioning that promote 'double loop' learning 37 . When this process achieves knowledge, it allows the organization to develop and modify its modes of operation to integrate new ones compatible with its culture, systems, and structures. Therefore, it is worth noting that organizations that can adjust their management styles to structural changes will be suited to the emergence of an organizational learning process. The so-called learning organizations fall into this category 38, 39, 40 . This is why looking at change management is helpful, especially to better understand the critical role of the human factor, which is a 'driver of change' that can be mobilized through learning, motivation, and communication 41,42, 43,44 . Hospital staff, who have a certain amount of autonomy 35 due to the organization of the hospital into clusters and departments, have a strong influence on change 21,46,45 .

Limitations of the study
There are, however, limitations to this review, which are related to the extensive literature on the subject of the study, which could not be fully considered, and the lack of contextualization at the level of a hospital structure. These could have provided more information necessary for a complete understanding of hospital change management with regard to learning.

Declaration of interest
In conclusion, this contribution aims to support a new understanding of change. It has been argued that change is a solution to managing all the developments that an organization needs to integrate to learn, sustain and grow. Therefore, change management is the way to achieve this aspiration. This analysis also clarifies that successful change management is successful within the hospital. This is because of the complexity of the structure and the profound and continuous changes that are taking place. In this sense, successful change in the hospital requires that each actor be considered a factor of transformation while encouraging collective learning based on experimentation, trial, and error. Without a shadow of a doubt, this review will need to be reinforced by other studies to deepen the appreciation of the role of change management in the construction of hospital organizations capable of better embracing change.