Background

The success of change in healthcare is highly dependent on the complex network of human interactions, which collectively can broadly be considered as “Organisational Culture”. Culture is known to be highly context specific, and hospitals are structured such that individual specialised units present different contextual environments. This thesis aims to investigate how the unique cultural context of a critical care environment influences the success of change initiatives.

Methods
This research was carried out as two separate studies. Firstly, a scoping review was carried out to review existing literature discussing the impact of cultural and behavioural factors on implementation in a critical care context. All identified sources from Ovid MEDLINE, EMBASE and ASSIA databases which discussed the influence of culture on implementation in adult critical care settings were included, and inductive thematic analysis of the literature identified and modelled key themes.

Secondly, a retrospective qualitative case-study was carried out to investigate the impact of organisational culture on a major implementation project which introduced citrate anticoagulation in renal replacement within critical care units in 3 Welsh District general hospitals in 2015. The themes
identified within scoping review data were used to structure an interview template. This template was used to carry out semi-structured interviews with 9 participants representing different staffing groups directly involved in this project. Interviews were carried out at a fixed point 5 years after
implementation, and further thematic analysis was performed on the transcripts from these interviews.

Results

21 literature sources were included in the scoping review, and analysis identified the key themes of Education/Knowledge, Multidisciplinary Communication, Leadership, Effective Documentation and Buy-In. These themes were synthesised into a model exploring how each of these factors can be considered as resources which contribute to a “Culture permissive to Change”. Further models were generated from the thematic analysis of the case study to expand on this, demonstrating that change occurs in multiple phases which are not necessarily sequential or welldelineated, and that each of these phases present different resource demands. Critical care units are initially dependent on external resources and administrative backing before becoming more self-sustaining.

Additional models provide additional insight into how culture interacts with a process-focused, resource-driven understanding of change, illustrating the progression from deficit to re-accumulation of local experience, and exploring how leadership figures derive their credibility from multiple sources. The development of “Culture of Openness and Approachability” was extremely important in promoting unit level staff ownership and facilitating input into the feedback processes, and the significance of cultural distinctions between staff groups is also addressed, as the impact of senior
medical leadership is seen to be particularly pronounced in the critical care setting. The interpretation of broader shared values and deeper assumptions surrounding safety varied between staff groups, which has implications when addressing barriers to buy-in, particularly that of anxiety within the nursing sub-culture.

Discussion

Despite the limitations of sample size and time delay between implementation and data collection, this study generated several useful models which may be generalisable to other critical care contexts. Recognising these how contextual factors influence the quality of communication within critical care, and understanding how this culture navigates though different phases of change represents an opportunity for improved planning and adaptation in future critical care implementation projects.