This section outlines the key components of step 3, assessment of context and readiness to change.
Context analysis asks the question, how ready is the organisation for change or evidence implementation? This is sometimes described as an organisation's readiness to change, (Harvey, G. & Kitson 2016) which encompasses whether there is a commitment to change (wanting to change) in addition to the ability to change (called change efficacy) (Weiner 2009). A context analysis is a diagnostic process, the purpose of which is to understand issues within the local context that are important to practice change, and to identify factors likely to influence the proposed change. Understanding change, or creating the case for change, requires data collection and engaging with key personnel to establish their support for the project.
Contextual analysis is key when trying to investigate whether a process of change in policy or practice is feasible. There are a variety of ways of undertaking a diagnostic/situational analysis; for example, a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis (Pickton & Wright 1998) can be a quick and effective framework at this stage. In any context, a situational analysis is vital when trying to stimulate a process of change in policy or practice. It recognises that interventions to promote change need to be tailored to the particular context. There are eight elements that should be covered in a good situation analysis. These elements are presented along with some guiding questions to help the assessment team think about what each element means. A SWOT analysis could be used and applied to each of these factors.
- Structure - To what extent does decision-making occur in a decentralised manner, and is there enough staff to support the change process?
- Workplace culture - To what extent is the proposed change consistent with the value and beliefs of the practice environment, and to what degree does the culture support change and value evidence?
- Communication - Are there adequate communication systems to support information exchange relating to the change and the implementation process?
- Leadership - To what extent do the leaders within the practice environment support (visibly and behind the scenes) the implementation?
- Resource availability - Are the necessary human, physical and financial resources available to support implementation?
- Knowledge, skills and attitudes - Do staff have the necessary knowledge and skills? Which potential group is open to change and new ideas, and to what extent are they motivated to implement the change?
- Commitment to quality management - Do quality processes and systems exist to measure results of implementation?
- Interdisciplinary relationships - Are there positive relationships and trust between the disciplines that will be involved or affected by the change?
There may also need to be cultural changes in the workplace to facilitate evidence implementation. The literature clearly indicates that culture and climate affect organisational performance, and in the context of healthcare, this can have serious effects on patient care as well as staff (Tillott, Walsh & Moxham 2013). This demonstrates the importance of being able to recognise, understand and subsequently develop effective cultures in the workplace. (Manley et al. 2011) The evidence indicates that although many tools exist to measure organisational culture and climate, many are not validated and the choice of tools will depend on the reason measuring organisational culture in the first place (Gerardi 2004; Jung et al. 2009).
Culture is deeply entrenched in an organisation, and changing it is complicated (Jung et al. 2009). The evidence base on strategies to change culture highlights this (Parmelli et al. 2011). Parmelli et al. conducted a systematic review investigating the effectiveness of strategies to change organisational culture to improve healthcare performance (Parmelli et al. 2011). Additionally, they also intended to assess the identified strategies in relation to different patterns of organisational culture. No high-quality studies met the inclusion criteria. The authors recommended further research, but noted that the lack of available evidence may be due to the lack of a clear definition of organisational culture and the ways to measure it.
Organisational culture interventions
Ng et al. (Ng et al. 2014) reviewed the evidence on organisational culture interventions across any setting. Interventions were grouped under the following categories: 1) organisational-wide culture interventions; (2) workplace civility and staff engagement interventions; (3) leadership interventions; (4) teamwork interventions; (5) anti-bullying interventions and (6) mindfulness and stress/burnout interventions.
Interventions relating to teamwork and mindfulness and stress/burnout represented half of the evidence located. The components and findings of each category are summarised in Table 3.
Table 3. Findings from a Literature Review on Organisational Culture Interventions (Ng et al. 2014)
Description of Intervention
Organisational-wide culture interventions
Large scale, complex and long term, comprising strategies at multiple levels across the organisation
Workshops, training, coaching to raise awareness
Increased communication (e.g. newsletters)
Codes of conduct
Small number of studies located but indicated carefully planned interventions that have strong support from senior management and good participation from employees resulted in positive changes
Workplace civility and staff engagement interventions
Purpose is to create/improve on a culture that values respect, collaboration and engagement
Most interventions used the Civility, Respect, and Engagement at the Workplace (CREW) program involving facilitated discussions, role play and action plans
Significant positive effects on workplace culture
Purpose is to create/improve on a culture that nurtures teamwork and collaboration
All interventions were based on Crew Resource Management (CRM), a set of training procedures that uses a participative approach such as debriefing, podcasts, communication and self-review
Improvements in positive behaviours and attitudes created culture change
Targeted at managers and leaders to upskill in managing culture change
Executive education and coaching
Reflective and visionary practice
Action-learning leadership development workshops
Leadership learning modules/interactive leadership
Simulations and role play
Improvements in trust in leadership, workplace health and safety, and workplace morale
Purpose is to reduce bullying behaviour, including preventive and reactive measures
Change frameworks to guide interventions
Small number of studies located that showed increased awareness in prevention
Mindfulness and stress/burnout interventions
Interventions focused on the individual; aims to modify response to stress and enhance well-being
Mix of strategies such as training and mindfulness practice; could also incorporate weekly homework and coaching
Some benefits seen but take time to feed into culture change; relies on individual compliance
After reviewing the findings, the process of changing/improving culture should be systematic and clearly communicated and implemented. The literature suggests that the following elements should be considered:
- Diagnosis of the problem/s:
- Identifying and understanding the current culture, as well as developing a vision on how to change it, is considered the first step in changing culture. As discussed previously, there are tools available and choosing the most appropriate will depend on an organisation's unique circumstances.
- Vision and support from leadership, working with active members who are engaged and supportive of change
- Brunges and Foley (Brunges & Foley-Brinza 2014) recommend that changing the culture requires full support from leaders within an organisation; they need to have vision and management tools in order to engage individuals into embracing change. Although open communication is considered vital in promoting a positive cultural message, it is also crucial that organisations demonstrate what they advocate. For example, if the tools needed to meet organisational expectations are not provided to individuals (such as providing adequate staffing), then the messages that were communicated will be seen as dishonest (Gershon et al. 2004). Periodically assessing the current culture/climate was also recommended in the literature (Gershon et al. 2004; Tillott, Walsh & Moxham 2013). This may prove to be of particular importance when there are major changes in management.
- A combination of interventions that are evidence-based
- Once the current culture/climate is identified, Brunges and Foley (2014) advocate that the organisation must clearly communicate their vision/plans to changing the culture and the reasoning behind doing so. Nilson (Nilson 1999) suggests introducing new values and behavioural norms in various ways, such as issuing policies and behavioural directives, and using training programs. It is also important to ensure that the new behaviours are rewarded through personal recognition and public acknowledgement. These values should be integrated into human resource systems, such as performance management, career development, succession planning, etc.
- Communication, communication, communication
- Clear communication is strongly encouraged in the literature. Gershon (2004) advises that if cultural aspects within an organisation are clearly expressed, there will be improved cohesion and stability regarding the collective behaviour of individuals. If they are not articulated clearly (i.e. they constantly change, are poorly communicated, are vague, are not reinforced and are not supported well administratively), inconsistencies in perception and behaviour will result, impacting patient care and safe work practices. The values and principles of an organisation also need to be clearly communicated to individuals. This allows individual employees to compare their own values and principles with that of the organisation.
- Use of an evidence-base and evaluative process
- Intervention strategies and implementation should be informed by the latest research and conducted within an organisation where change is most needed. An evaluative process should be incorporated into implementation projects, and should occur at different stages of the implementation project to determine effectiveness of the intervention and to ensure outcomes are achieved (Ng et al. 2014).
Lastly, an understanding that culture change takes time and a commitment to the long term are required. Culture change only happens because people want it to. Ng et al. (2014) recommend leaders identify units/areas that are ready to change and commence the intervention/s there first.
Once the topic of focus has been identified and an evidence implementation project is deemed feasible within the current setting, the JBI Implementation Framework can provide guidance to the implementation process.