Motivating change: a theory to achieve large-scale sustainable change

Large-scale Sustainable Change
Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK

What we know

Initiating and sustaining effective change and replicating successful improvements in healthcare is a recognised challenge.  To address this, a wide range of theories and frameworks have been developed to support the implementation, scale up and spread of improvement initiatives.  However, despite the increase in large-scale improvement programmes and approaches, the challenge of achieving large-scale sustainable change continues and with it a need to develop a greater understanding of the processes that influence implementation and maintain practice innovations.    

Study Aim

The aim of the project was to explore and capture learning from experienced improvement organisations to provide a conceptual level explanation of the conditions necessary to facilitate and sustain improvement at scale. 

What this research explored

Working with staff from three leading change organisations in the UK – spanning health, education and social care; theories were co-developed using a participatory grounded theory approach – a research method for generating theory directly from empirical experience.  Consultation events were designed to facilitate the sharing of experiential knowledge, drawing upon the expertise and personal theories of managers and front-line staff involved in delivering large-scale change.   

What this study adds

The co-created theory of Motivating Change describes the psychosocial-structural conditions for large-scale, sustained change from the perspectives of front-line staff.  The theory suggests that change is more likely to be sustained at scale if there is synergy between staff’s perceived need and desire for improvement, and the extrinsic motivators for change. Witnessing effective change is motivating for staff and positive outcomes provide a convincing argument for the need to sustain improvement activity. As such, evidence of change becomes evidence for change. This is only possible when there is a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity. When these conditions are in place, organisations can generate self-proliferating improvement. The findings reflect the need to place motivational processes at the centre of the change process and highlights the value of humanising the improvement process, by learning from the experiences of individuals and organisations who have delivered sustained improvements.

Benefits and impact

The theory adds to and extends the existing evidence base on how to create large-scale sustained change and promotes the shared expertise of those individuals already actively doing improvement work on the ground. Motivating Change Framework provides a practical and usable resource to facilitate the implementation and evaluation of future large-scale, sustained change.


The project was led by the SISCC team based in the School of Health Sciences at the University of Dundee and was co-created with colleagues from Healthcare Improvement Scotland, NHS Highland and UNICEF UK.


Breckenridge JP, Gray N, Toma M, et al Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK. BMJ Open Quality 2019;8:e000553. doi: 10.1136/bmjoq-2018-000553

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Healthcare Improvement Scotland

NHS Highland