Microsystems culture change: a refined theory for developing person-centred, safe and effective workplaces based on strategies that embed a safety culture

Background: Attending to culture is central to developing workplaces that are safe and effective – those
\nthat prioritise learning to support continuing quality, person-centred relationships and the wellbeing
\nof providers and recipients of care. Culture at the microsystems level, where care is experienced
\nand provided, directly impacts on staff and patients but is generally given much less attention than
\norganisational cultures at the meso level. This paper presents a refinement of a previously published
\nmiddle-range theory of culture change derived from a concept analysis of effective workplace culture.
\nIt draws on findings from a project that set out to embed a safety culture and grow quality improvement
\nand leadership capability through a regional patient safety initiative in frontline teams across four
\nacute NHS hospital trusts in south-east England.
\nAims and objectives: To refine theoretical understanding about how to recognise and develop effective
\nworkplace cultures at the microsystems level based on practical insights from the Safety Culture
\nQuality Improvement Realist Evaluation (SCQIRE) project.
\nMethods: The evaluation approach for the SCQIRE project combined realist evaluation and practice
\ndevelopment methodology. Realist evaluation was selected to answer the question ‘what works for
\nwhom and why when embedding a safety culture, improvement capability and leadership in frontline
\nteams?’ Key to this approach is the local development, testing and refinement of ‘CMO’ relationships
\nbetween: contexts (C); mechanisms, for example triggers and explaining why components work (M);
\nand outcomes (O). Drawing on project data, the enablers, attributes and consequences of an effective
\nworkplace culture have been used to critically examine the factors that contributed to frontline teams’
\nability to create and sustain a safety culture.
\nFindings: A total of 24 CMO relationships resulted in four emerging programme theories that described
\nwhat worked, why and for whom in relation to: 1) frontline teams developing their safety culture; 2)
\nfacilitators working with frontline teams to embed safety culture, quality improvement and leadership;
\n3) organisations supporting frontline teams; and 4) the patient safety collaborative initiative.
\nConclusions: It is concluded that the close relationship between person-centred values, ways of
\nworking and continuing effectiveness mean it is not possible to develop a safety culture without
\nalso being person-centred in relationships. Other theoretical refinements proposed include greater
\nemphasis on the role of appreciative active learning, person-centredness in everyday relationships
\nand an integrated approach to learning, development and improvement embedded at both micro and
\nInternational Practice
\nDevelopment Journal
\nOnline journal of FoNS in association with the IPDC and PcP-ICoP (ISSN 2046-9292)
\nWorking together
\nto develop practice
\nPerson-centred Practice
\nInternational Community
\nof Practice
\n2
\n© The Authors 2019 International Practice Development Journal 9 (2) [4]
\nfons.org/library/journal-ipdj-home
\nmeso levels. The theory strengthens individual enablers of safety culture, with particular attention
\ngiven to quality clinical leadership based on an inclusive, participative, collaborative approach involving
\nall stakeholders, and to facilitation that embraces all the skills required for learning, developing and
\nimproving with person-centred values. Organisational enablers emphasise the need for a corporate
\nbody of facilitators to support frontline teams, as well as the role of senior organisational leaders in
\nenabling a bottom-up approach to supporting quality and innovation.
\nImplications for practice:
\n• Safety and person-centred values are interdependent with ways of working in relationships and
\nongoing team effectiveness. None of these can be considered without the others
\n• Investment in quality clinical leadership is essential for the development of high-performing
\nteams, safety culture, achievement of shared meanings and direction, and valuing of engagement
\nof both staff and patients
\n• Facilitators supporting frontline teams require corporate support and a wide range of skills
\nincluding leadership, the ability to promote engagement in co-creating meaning, and appreciative
\nlearning that draws on the workplace as a powerful resource
\n• Senior organisational leaders need to model organisational values in every situation but also
\nbe skilled at enabling frontline teams to become empowered through supporting a bottom-up
\napproach to innovation and change

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