Assessing 'readiness for change' in organisational culture : a descriptive study using a sequential explanatory mixed method design

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Concerns for increasing interventions in childbirth and associated adverse maternal and neonatal consequences influenced the introduction of a mandated government policy to reduce overall intervention in birth in New South Wales, Australia in 2010. Literature suggests there are contextual factors that influence intervention in childbirth including the care location and its culture. However little evidence is available concerning the assessment of an organisation’s culture to provide insight into changes required to reduce interventions. Therefore, this study aimed to examine the culture of one maternity service to assess its readiness for making changes to reduce birth interventions, specifically vaginal birth after caesarean (VBAC). The research site was a tertiary maternity service in New South Wales, where clinical outcome data had demonstrated a higher rate of interventions than peer hospitals, and the highest rate in the state. This study used three phases in a sequential explanatory, mixed method design; each phase informing the next. Phases 1 and 2 used quantitative methods; in phase 1 surveys administered to all clinicians measured attitudes towards VBAC and described the predominant culture; the phase 2 survey asked clinicians to nominate peers whom they regarded as having the qualities of an effective collaborator. Ten nominees were invited to participate in the phase 3 in-depth interview, with six sequential interview techniques, to elicit conscious and unconscious perceptions of the culture of the organisation. Data from the three phases were triangulated and themes analysed using the Status, Certainty, Autonomy, Relatedness and Fairness (SCARF) model developed by neuroscientists as the theoretical lens. Each phase of this study revealed a maternity service without the characteristics of an organisation that is ready to embrace change. A hierarchical culture was identified with lack of teamwork, cohesion and collaboration. Characteristics of interprofessional collaboration that could improve safety and quality of care were not evident in this organisation. Participants revealed they had developed adaptive behaviour patterns as a mechanism for survival that ultimately threatened professional relationships and further inhibited their ability to collaborate. Negative professional experiences in the past coloured present behaviour, which limited trust, respect and confidence to interact in collaborative relationships. Avoidance behaviour resulted in working on the margins rather than actively participating in collaborative teamwork. Interpretation of the study findings using social cognitive neuroscience provided an understanding of why avoidance behaviour and non-engagement occurs when a person’s social domain needs are not met. Maximising opportunities for social domains to be orientated to an approach (reward) response rather than an avoid (threat) response using the SCARF model appears to be a useful way forward. A clinical example of successful implementation of a practice change using the SCARF model in a different maternity service supported the findings of this study and its recommendations, providing evidence of the applicability of the model where there has previously been evidence of system inertia. Assessment of an organisation’s readiness to change is crucial prior to implementing a change process. Characteristics of organisational culture that may influence reshaping capabilities of organisations should be known and considered to maximise effectiveness of any change process. The SCARF model has potential to assist maternity services to identify strategies that are conducive to changing organisational culture to reduce interventions in childbirth thereby ensuring quality maternity care and health outcomes.
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