Theme 1: Change Process

Similar to case studies 1 and 2 the first thematic network explores the ‘change process’ (figure 6.11, p.126). This thematic network appears to show opposition and no motivation to change i.e. the situation stays frozen.

126 Change process Tasks and processes Importance of training

Valuing Care Aims Ineffectiveness Subjectivity Choice Training and engagement Task focussed Paperwork Leadership and vision Inconsistent

training Care Aims is _difficult

Previous approach preferred

Key

Basic theme TCI Organising theme Global theme

The team finds time for developing new and improved ways of doing

things. Team members

actively influence each other

Team members often provide useful ideas and help and frequently build upon the ideas of other

team members. The team professes

support for innovation

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Care Aims was described as being no better than the systems and approaches the team were currently using and as not effective for their team (figure 6.11, p.126). Care Aims was perceived as being time consuming and the team felt their own triage form for example was much better. However goal setting with patients was described in more positive terms. Care Aims was not seen as being part of the team’s vision for the future which appeared to be reinforced by the team leader. AHP 1 described repeated discussions at team meetings about what was and was not working and making adaptations to the model and related paperwork. She then recalls the team leader’s reaction to the feedback from the team about Care Aims not working and their understanding of this:

“Give it a go; see you how you find it. So it was quite open” (AHP 1, p.4, line 15) (basic theme 6, table 6.8, p.125).

Care Aims was described as being subjective which appeared to cause difficulty in

accepting the approach as it was described that this could vary greatly according to which clinician assessed and also the patient’s response. In addition there was a perception that the tools were not specific to their team which also added to the subjectivity of the

assessing clinician. Care Aims was viewed as a case management approach and a series of tools and processes which could be adapted or abandoned: parts of the approach used and others which the team felt did not work for them or were not suitable dropped. AHP 1 said:

“I think we’re using more of an alien version of Care Aims.” (AHP 1, p.9, line 27) (basic theme 2, table 6.8, p.125).

Both AHP 1 and AHP 2 described participating in training but the extent of this appeared to vary significantly with AHP 1 observing:

“I think the people who’d had the longer training were probably more, I don’t know the right term, more up for it really and more involved in trying to get it to work rather than myself and ____(name removed to protect anonymity). We were just dragged along afterwards and we were sort of ‘we can either make this work or we can’t use it really. It doesn’t make that much difference”. (AHP 1, p. 8, line 34) (basic theme 10, table 6.8, p.125).

Lewin (1947) identified that there had to be a motivation to change to ‘unfreeze’ the status quo. Schein (2010) building on this identified three processes which all have to be present to unfreeze the situation. These are enough disconfirming data to create and stimulate a desire to change: a connection with the disconfirming data to cause anxiety or guilt in that

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if change does not occur then something bad will happen; sufficient psychological safety to overcome learning anxiety so that the new way of working is seen as achievable; and the learning process will not be too difficult.

Unlike case study 1, in case study 2 it would appear that none of these factors were sufficiently present to create motivation to change. The team felt that Care Aims was no better than their current way of working and the team did not describe their performance in any negative way and this appeared to be supported by the positive responses from patients i.e. there was no disconfirming data. The team appeared to suggest they could control how much if any of Care Aims they implemented indicating no anxiety or guilt about not implementing Care Aims. Learning anxiety appeared to be expressed in the basic theme (table 6.8, p.125) ‘Care Aims is difficult’ and described as “time consuming” (Team Questionnaire 1) suggesting insufficient psychological safety.

Pettigrew and Whipp (1991) identified eight receptive contexts for change some of which resonate with Schein’s (Schein, 2010) theory of managed change previously described. Whilst the TCI suggested a climate supportive of innovation (figure 6.2, p.93) other factors did not appear to be present such as the quality and coherence of policy and the

availability of key people leading change.

Weiner (2009) identifies that organisational readiness for change is a critical precursor to the successful implementation of complex changes in healthcare settings and states that a receptive context may not readily translate into readiness to change and that the content of change matters as much as the context. For example AHP 1 stated that:

“They’re pretty good at introducing things or trying new things” (p.2, line 31) (basic theme 19, table 6.8, p.125).

However in this instance the team appeared to be resistant to introducing this change.

Weiner (2009) suggests the conditions that promote readiness for change are team members wanting and valuing the change enough to committing to its implementation and having a sense of confidence they can implement the change (based on task demands, resource availability and situational factors) similar to Schein’s theory of managed change previously described (Schein, 2010). In this case study certainly the first factor and partly the second factor were not present.

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It is also possible in case study 2 that there was an element of ‘groupthink’ which

influenced the implementation of Care Aims. Janis describes groupthink as a group where “loyalty requires each member to avoid raising controversial issues” (1982, p.12). Janis (1982) identified that certain conditions tended to be present when groupthink arises. These included that the group was a highly cohesive group of individuals more concerned with maintaining cohesiveness than decision making. Whilst the work of Janis, particularly in relation to the influence of group cohesiveness was not fully supported by other studies (Park, 2000, p.873), Steiner (1982) suggested it was the desire for cohesiveness rather than the actual presence that was influential. In this case study whilst the team had different perceptions about the present team culture, the dominant preferred culture was clan, suggesting aspirations for improved team working. This and the high social

desirability scores could indicate the team’s priority for cohesiveness rather than decision making. This is supported by Anderson and West (1996) who noted that social desirability may correlate with aspects of group consensus. For example a very high social desirability response may manifest in a dysfunctional team as group think.

The other factors Janis (1982) identified were that the group insulated itself from

information and opinions from outside, the group rarely engaging in any kind of systematic search and going with the first available option on which there is consensus and the group is under pressure to make a decision. AHP 1 recalled:

“It was pretty much every time we got together as a team, we’d look at how it was working, what was working, what wasn’t and make adaptations at each meeting and see how that’s run on for the next one really.” (AHP 1, p4, lines 16-18) (basic theme 2, table 6.8, p.125).

This global theme appears to support the findings of Bate et al (2002) who reviewed the effectiveness of a series of improvement projects in the NHS and concluded that:

“proper implementation is key and may even make the difference between failure and success in all aspects of development” (p. 108).

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