‘Knotworking’ and ‘not working’: a realist evaluation of a culture change intervention with a frontline clinical team in an acute hospital

Culture change and teamwork are often cited in healthcare policy and research as central to improvements in patient care. A critical review of the literature suggests that theory is insufficiently used to inform culture change or team development interventions. Culture change interventions are rarely evaluated in implementation research with few rich qualitative accounts of clinical team development in context.
This case study drew on the principles of realist evaluation to identify what worked, or did not work, for whom, in what circumstances in relation to an eighteen-month culture change intervention that had been carried out with a frontline clinical team identified as being in difficulty. It addressed the following research questions using multiple methods in a pragmatic and reflexive way:
1. How does a clinical team identified as being in difficulty experience a change process directed at changing team culture?
2. How do collaborative change processes engender culture change in the context of teams in difficulty?
Conventional problem-solving approaches to team development were found to reinforce existing patterns of deficit relating leading to a critique of organization development practice. The project found that different contextualized experiences had different effects on the learning behaviour of the team and on the leadership-followership relationship. A critical appreciative approach and narrative methods were found to create psychological safety for a collaborative inquiry to take place. Building on previous theoretical research, the study proposes a reconceptualization of experiences of teamwork as emergent states of “knotworking” and “not working”.
The project offers a framework for realist evaluation with clinical teams in difficulty. It recommends that intervention and evaluation are collapsed into a single approach of collaborative inquiry, and has provided easy to use resources for clinical teams to evaluate and improve their team culture in a climate of psychological safety. A practice model of creating a critically appreciative space is proposed and described. Narratives of patient care emerged as a source of generativity for team development, which led to reflections about how patient experience and involvement might support future team development interventions and directions for research.

Doctorate in Professional Studies in Health.