a priority in one setting may be met with indifference in another.
The context and the characteristics of teams in terms of assumptions, values and beliefs are organic, developed and sustained by the people within the organisation. One observed consequence of these characteristics is clinical variation in outcomes in maternity care where the variations cannot be explained by the characteristics or demographics of the women alone (Lee et al. 2013; Women’s Healthcare Australasia 2014). The relationships between care providers, collaborative approaches to care and aspects of team dynamics can influence clinical outcomes (Hastie and Fahy 2011; Downe et al. 2009; Raab et al. 2013). Understanding the significance of context in a change process is crucial to maximise effectiveness. Lack of recognition or understanding of the influence of context has been described as the root cause of mediocre success of programmes regardless of the integrity of, or evidence for, the change (Glasgow et al. 2013; Krein et al. 2010; Taylor et al. 2011).
Contextual factors that influence readiness for change can be described broadly as the collective capability and motivation of the individuals within the organisation for change (Lau et al. 2016; Krein et al. 2010). Organisational attributes such as strong and supportive leadership, participant trust of each other and the organisation with opportunity for engagement, value for the specific change as well as there being an adaptable environment for change will have a positive influence on change implementation (Ovretveit 2011; Taylor et al. 2011; Lavoie‐Tremblay et al. 2015; Guerrero and Kim 2013). A triangle of performance has already been described whereby culture, leadership and systems can influence the agility and resilience of the people within the organisation and can directly affect the rate and quality of change strategies. Where strong and positive leadership is evident that promotes a culture of shared status and safety amongst clinicians (Nembhard and Edmondson 2006), there is more likely to be a willingness and effective ability to influence and sustain change.
Implementation of change initiatives is described as mediated and shaped by the organisational culture (Latta 2009) and therefore the focus of assessing effective change should be on why or how the change occurred rather than what the change was, which could provide insights for evaluation and replication (Krein et al. 2010). A targeted assessment of contextual readiness could facilitate the uptake of evidenced‐based practice change.
My introduction to PD was accidental and occurred because of a significant omission in a change management process. That was the lack of assessment of contextual readiness to change. It became apparent in the early phase of my PhD study (Adams 2017) that the organisation was not ready for the proposed change, and the remainder of the study was occupied with revealing and measuring the reshaping capabilities to increase readiness for the change.
The maternity teams in the study identified that although there were collegial relationships, the effectiveness of the approach to care was more rhetoric than reality. I captured stories from the clinicians who generously and honestly shared their perceptions of their workplace. There was an overwhelming desire to have a different workplace, to have greater teamwork and collaboration, which was tempered with a strong sense of not knowing how to make a change. This uncertainty led to a sense of inertia, with the easier solution being to maintain the status quo. These stories marked my turning point in recognising the vital component of contextual readiness regardless of the project or the approach to change. Assessment of readiness takes time, motivation, the appropriate tool/method and energy. However, without this investment, engagement and authentic participation can be threatened.
The study continued with a different approach, one that harnessed the energy of the clinicians and their unrecognised or unstated desire to implement change. All clinicians were invited to nominate an obstetric and midwifery peer who they believed had the attributes to be an effective project collaborator. A collaborative approach to recruitment had positive consequences greater than I imagined, which further facilitated engagement and participation. The nominated participants were different from those who may have been nominated normally by the organisation or who normally would have volunteered. The nominated participants felt more visible than ever previously experienced, which increased their willingness to engage and the value of the participation process, which resulted in a more productive and effective contribution (Adams et al. 2016).
Engagement
A facilitator of PD can benefit from having many tools available to support the process. One of these tools, the SCARF© model (Rock 2009), describes how the activation of a person’s approach (reward) response can increase engagement, collaboration, cooperation and productivity in a change process. The neuroscience behind this model is not as new as the acronym. SCARF© provides a language to explain and describe the neuroscience of the physical responses to actual or potential barriers to change. The social domains to be considered are status, certainty, autonomy, relatedness and fairness (Rock 2009). By isolating the social domain that is being, or could be, threatened can facilitate the development of strategies by the facilitator to reduce stress responses and create conditions conducive to greater collaboration, cooperation and productivity.
Recognising the social domains assists in understanding that a change process is likely to threaten these domains. Therefore, it is important to increase opportunities to maximise reward responses in the easiest manner possible. For example, a PD project that encouraged a degree of autonomy in design, with a team who developed shared goals to increase relatedness and fairness, would be more likely to engage the team and decrease threat responses.
Strategies that maximise the opportunity for the social domains of participants to be orientated to an approach (reward) response rather than an avoid (threat) response can lead to a culture that embraces change. Investment in the development of facilitators skilled in techniques to predict and recognise potential and actual threats to social domains, and the ability to regulate reactive behaviour, will be crucial. Using social cognitive neuroscience to influence change has not been a conventional methodology in health services, but this may provide an opportunity for organisational shift from system inertia.
Facilitation – Crystal’s unrecognised talent
We can see from Cathy’s account that facilitation is a key component of PD implementation in any setting. The evidence for a practice improvement or service redesign, the opportunity for the change and the organisational readiness are significant enablers of the process. Their success, however, will be influenced by sound facilitation skills of the transformational leaders engaged in supporting participants through the process. These leaders will have a focus on building relationships that identify and utilise the skills of the many and encourage curiosity and creativity in the process (see Chapters 12 and 13 for more on this). The facilitators themselves can benefit from being active learners and examining their own practice, beliefs and values to move to developing others in the same process. My experience demonstrates the journey from clinical midwife to committed, experienced and authentic PD facilitator (see Chapters 10 and 11 for more on facilitation development).
After many years working as a clinical midwife, I was drawn into the world of improvement through an invitation to implement the Productive Ward programme: ‘Releasing Time to Care’. This programme encouraged teams to look at waste within existing ward processes and make changes to improve safety, effectiveness and person‐centredness. This was the first time that I experienced the power of the patient voice; of using qualitative as well as quantitative measures of improvement. It was also the first time that I felt that a true board to ward approach to change was embraced and evaluated.
My transformation came from being tasked with delivering this programme, but without the training, tools or methodologies to draw from. I knew what needed to be delivered and was left to define the why and how with the teams and individuals in the programme. Working with colleagues we embarked on this privileged journey of embedding sustainable