Knowledge into Action
From Framework to Real Work: A Realist Evaluation of the Impact of Two Learning Activities on a Complex Adaptive System - PhD Study
What we know
Successful implementation of evidence-based innovations has been identified as offering the best outcomes for service users, communities, and organisations. A widening understanding of structures, processes and resources essential to the successful adoption of innovative practices has informed the development of implementation frameworks that seek to bring research users and providers closer together. Despite these efforts, best available research knowledge is still difficult to translate into innovations in practice at scale, requiring the investment and co-ordination of resources across interconnected social structures that can be resistant to change.
However, some changes do take hold and lead to new practices becoming integrated into organisational routines. Mobilising individual and collective knowledge have been identified as a key factor in delivering organisational changes. Research in this area has highlighted the role of complex, context dependent and power-laden organizational structures in relation to the spread and use of knowledge while the role of the individual as the agent of change within these organisational structures has received less attention.
This study considered how the ambitions of a Scottish Government Policy, Ready to Act (R2A) were implemented within the organisational setting of an NHS Scotland health board. The participants in the study were a group of Allied Health Professionals (AHPs) which included physiotherapists, occupational therapists, speech & language therapists, podiatrists and dieticians along with their leaders and representatives from the Scottish Government who had been instrumental in setting the overall direction of service redesign. The R2A policy aimed to break down professional silos to create a more integrated service delivery focused on early intervention and prevention approaches.
What this research explored
The qualitative longitudinal study adopted a realist approach to consider what works for whom and in what context in relation to implementing practice change in line with policy ambitions. Participants’ understandings of the change process and their attributions for successful changes were explored over a 17-month period.
The study considered two workstreams of AHPs who were collaboratively designing changes in practice which aligned with the ambitions of the R2A policy. The groups had different starting points in relation to their workstream tasks.
The overarching research aim was addressed in this context through the following research questions:
- What are the underlying mechanisms that enabled individuals to create, share and action knowledge to reconfigure services towards early intervention-prevention service delivery within this context?
- What underlying mechanisms facilitate and maintain the momentum and direction of change across diverse and dynamic agents within the system?
Context-mechanism-outcome (CMO) theory configurations were constructed and refined through three tranches of focus groups (4) , interviews (23), observations (50 hours) and documentary analysis (16 documents) to provide a robust explanation of how knowledge drawn from a learning activity was mobilised across a complex adaptive system of health and social care.
What this study adds
The findings from the study suggest that where knowledge is a catalyst for changes in practice, the scale-up and spread of change across a complex adaptive system is facilitated through micro-processes of feedback. These feedback loops are highly sensitive to context. Understanding how feedback loops evolve and influence the trajectory of change within specific contexts offers an opportunity to harness the feedback loop to create virtuous cycles of change, moving the CAS in the desired trajectory of change. Understanding how vicious cycles of undesirable change or status quo are being sustained through feedback loops offers formative opportunities to dampen the influence of these feedback loops.
The findings also suggest distributed and hierarchical approaches to leadership are both required within complex organisations. Although command and control structure are necessary to ensure the organisation is stable enough to function effectively, a distributed model of leadership is necessary to foster engagement and innovation. These different forms of leadership were not in competition but could be construed as operating as further feedback loops which influenced the direction of change.
Creating change across this complex system relied on the mobilisation of knowledge between engaged agents. This occurred within this study through respectful and empowering relationships which were based on a model of distributed leadership and an allocentric disposition. These factors took time to become established. Individuals and groups working to mobilise knowledge were supported when anticipated timeframes for projects and activities were extended to facilitate change processes, particularly in context where individuals and groups had no history of working together.
PhD awarded in 2020
The project was led by Dr Anne-Marie Craig, supported by colleagues from the School of Management at St Andrews University; in conjunction with Allied Health Professionals from NHS Scotland.
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