From policy framework to practice real work : exploring knowledge mobilisation within a complex adaptive system
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Rationale: Successful implementation of evidence-based innovations has been identified as offering the best outcomes for service users, communities, and organisations. A widening understanding of structures, processes and resources essential to the successful adoption of innovative practices has informed the development of implementation frameworks that seek to bring research users and providers closer together. Despite these efforts, best available research knowledge is still difficult to translate into innovations in practice at scale, requiring the investment and co-ordination of resources across interconnected social structures that can be resistant to change. However, some changes do take hold and lead to new practices becoming integrated into organisational routines. Mobilising individual and collective knowledge have been identified as a key factor in delivering organisational changes. Research in this area has highlighted the role of complex, context dependent and power-laden organizational structures in relation to the spread and use of knowledge while the role of the individual as the agent of change within these organisational structures has received less attention. This study adds empirically to the conceptual and theoretical literature by focusing on the individual as the agent of change and the role of knowledge as a catalyst for the implementation of changes in practice. Drawing on literature on the creation, sharing and use of knowledge and employing the principles of complexity theory to construe the context as a series of complex adaptive systems, the study seeks to gain an understanding of how a Government policy framework transforms into individuals creating, sharing and actioning knowledge to secure changes in practice. Study Context: This study considered how the ambitions of a Scottish Government Policy, Ready to Act (R2A) were implemented within the organisational setting of an NHS Scotland health board. The participants in the study were a group of Allied Health Professionals (AHPs) which included physiotherapists, occupational therapists, speech & language therapists, podiatrists and dieticians along with their leaders and representatives from the Scottish Government who had been instrumental in setting the overall direction of service redesign. The R2A policy aimed to break down professional silos to create a more integrated service delivery that focused on early intervention and prevention approaches. The overarching research aim was addressed in this context through the following research questions: What are the underlying mechanisms that enabled individuals to create, share and action knowledge to reconfigure services towards early intervention-prevention service delivery within this context? What underlying mechanisms facilitate and maintain the momentum and direction of change across diverse and dynamic agents within the system? Study Design: The qualitative longitudinal study adopted a realist approach to consider what works for whom and in what context in relation to implementing practice change in line with policy ambitions. Participants’ understandings of the change process and their attributions for successful changes were explored over a 17-month period. Context-mechanism-outcome (CMO) theory configurations were constructed and refined through three tranches of focus groups (4) , interviews (23), observations (50 hours) and documentary analysis (16 documents) to provide a robust explanation of how knowledge drawn from a learning activity was mobilised across a complex adaptive system of health and social care. Theoretical Framings Employing concepts from complexity theory and knowledge mobilisation literature, the health and social care context is construed as a complex adaptive system (CAS), where interconnected entities adapt and self-organise in response to stimulus or feedback from their environment. Considering outcomes as an emergent quality of the system rather than a product of command and control, enabled the unpredictable and uncontrollable aspects of the context to be viewed as potential assets to the knowledge mobilisation process. Main Findings: The study considered two workstreams of AHPs who were collaboratively designing changes in practice which aligned with the ambitions of the R2A policy. The groups had different starting points in relation to their workstream tasks. These different starting points, and the resources and histories of the participants had continuing impacts on how the individuals within each workstream group responded to knowledge presented within the learning activity and to the policy ambition of a move to a proactive approach to service provision. Employing a complexity theory lens provided a useful analytical frame for surfacing and explaining differences in the nature and pace of change across contexts. Key constructs from complexity theory (self-organisation, feedback loops, emergence and interconnectivity) provided a useful way of explaining differences across the system and brought attention to elements of the change process which were unforeseen, forgotten or hidden in plain view. The study also identified distributed leadership and the cultivation of an allocentric disposition, where individuals were willing to engage with the knowledge from other groups and individuals, as necessary antecedents of knowledge mobilization. The importance of feedback loops in maintaining the trajectory and momentum of change across the system and over time was another important finding. Feedback loops were observed manifesting as epistemic artefacts which were created, refined and often replaced by individuals and groups as the system adapted and evolved. The longitudinal nature of the study revealed incremental changes which were important, but which were largely unacknowledged by the measures of change adopted by local management and the Scottish Government. Theoretical Contribution: The study revealed how the attributes of complex systems were harnessed to mobilise knowledge and deliver desired outcomes. Drawing together the literature on epistemic artefacts and the attributes of complex adaptive systems, this study provides a greater understanding of the role of artefacts within feedback loops in the sharing and application of knowledge. The nature of feedback loops has not been explored fully in previous studies. This study sheds light on how linguistic, social, and physical artefacts are created and employed within the process of knowledge mobilisation to support sustainable changes in practice. Empirical Contribution: This research provides a rich, detailed account of knowledge mobilisation in AHPs, an under-researched group of key actors within health care. It provides much needed longitudinal empirical evidence to a field which has received predominantly theoretical attention and provides an inter-group observation of knowledge mobilisation within a complex adaptive system. Practical Contribution: Employing realist methodology provided an ontologically deep exploration of the factors impacting on individuals and collectives as they sought to create, share, and implement their knowledge to deliver changes in practice. The realist methodology also provided a reflexive space for participants to review and unpack their experiences and set these within the context of how events emerged across the wider system over time. The refined CMO theories resonated with the experience of stakeholders from a wider national context who identified with the complexity-informed explanations of outcome variation across the system. The refined CMO configurations provide practical guidance on how key factors of complex adaptive system were harnessed to support the development and spread of innovation. Implications of the study The findings from the study suggest that where knowledge is a catalyst for changes in practice, the scale-up and spread of change across a complex adaptive system is facilitated through micro-processes of feedback. These feedback loops are highly sensitive to context. Understanding how feedback loops evolve and influence the trajectory of change within specific contexts offers an opportunity to harness the feedback loop to create virtuous cycles of change, moving the CAS in the desired trajectory of change. Understanding how vicious cycles of undesirable change or status quo are being sustained through feedback loops offers formative opportunities to dampen the influence of these feedback loops. The findings also suggest distributed and hierarchical approaches to leadership are both required within complex organisations. Although command and control structure are necessary to ensure the organisation is stable enough to function effectively, a distributed model of leadership is necessary to foster engagement and innovation. These different forms of leadership were not in competition but could be construed as operating as further feedback loops which influenced the direction of change. Creating change across this complex system relied on the mobilisation of knowledge between engaged agents. This occurred within this study through respectful and empowering relationships which were based on a model of distributed leadership and an allocentric disposition. These factors took time to become established. Individuals and groups working to mobilise knowledge were supported when anticipated timeframes for projects and activities were extended to facilitate change processes, particularly in context where individuals and groups had no history of working together. This study sought to provide a coherent explanation of the events experienced by practitioners and leaders as they addressed the shared ambitions of a government policy. The findings suggest that feedback loops which emerge from a deep understanding of how relationships are formed, managed and sustained across a system, provide key knowledge that can be mobilised to promotes the scale up and spread of innovation across a complex system.
Thesis, PhD Doctor of Philosophy
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