The work is never ending: uncovering teamwork sustainability using realistic evaluation

Abstract

Purpose The purpose of this paper is to uncover the mechanisms influencing the sustainability of behavior changes following the implementation of teamwork. Design/methodology/approach Realistic evaluation was combined with a framework (DCOM®) based on applied behavior analysis to study the sustainability of behavior changes two and a half years after the initial implementation of teamwork at an emergency department. The DCOM® framework was used to categorize the mechanisms of behavior change interventions (BCIs) into the four categories of direction, competence, opportunity, and motivation. Non-participant observation and interview data were used. Findings The teamwork behaviors were not sustained. A substantial fallback in managerial activities in combination with a complex context contributed to reduced direction, opportunity, and motivation. Reduced direction made staff members unclear about how and why they should work in teams. Deterioration of opportunity was evident from the lack of problem-solving resources resulting in accumulated barriers to teamwork. Motivation in terms of management support and feedback was reduced. Practical implications The implementation of complex organizational changes in complex healthcare contexts requires continuous adaption and managerial activities well beyond the initial implementation period. Originality/value By integrating the DCOM® framework with realistic evaluation, this study responds to the call for theoretically based research on behavioral mechanisms that can explain how BCIs interact with context and how this interaction influences sustainability.

Evaluation frameworks in health services: An integrative review of use, attributes and elements

“…Twenty papers referred to nine different existing frameworks and five to the development of frameworks for evaluation of specific initiatives. Studies came from a wide range of locations: seven from the UK (Adegoke, Hofman, Kongnyuy, & van den Broek, ; Byng, Norman, Redfern, & Jones, ; Dickerson, Green, & Blass, ; Froggatt & Hockley, ; Furness et al., ; MacArthur, ; Themessl‐Huber, Lazenbatt, & Taylor, ), six from USA (Bahr et al., ; Eisenbise, ; Hill et al., ; Hundley, ; Serowoky, George, & Yarandi, ; Sockolow, ), three from Australia (Gardner, Gardner, & O'Connell, ; Hungerford, Prosser, & Davey, ; Wand, White, & Patching, ), two from Canada (Bainbridge, Brazil, Ploeg, Krueger, & Taniguchi, ; Yonge, Myrick, & Ferguson, ), two from Switzerland (Bryant‐Lukosius et al., ; Chmiel, Shaha, & Schneider, ) and one each from Africa (Bergstrom et al., ), Norway (Varsi, Ekstedt, Gammon, & Ruland, ), Spain (Oroviogoicoechea & Watson, ), Sweden (Frykman, von Thiele Schwarz, Muntlin Athlin, Hasson, & Mazzocato, ) and Thailand (Jaipakdee, Jiamjarasrangsi, Lohsoonthorn, & Lertmaharit, ). A broad range of nursing and midwifery interventions and programs represented community settings and hospitals in rural and metropolitan locations.…”

“…A weakness of the CFIR was its broad, big picture view that limited successful implementation as details were hidden (Varsi et al., ). The Realistic Evaluation (Pawson et al., ) framework helped explain why the intervention was, or was not, sustained by identifying interaction with the context (Frykman et al., ; Oroviogoicoechea & Watson, ). Developed frameworks were useful for focussing an evaluation on the underlying factors influencing change (Serowoky et al., ), and facilitating exchange of knowledge between stakeholders in rigorous, yet flexible ways that informed service development (Themessl‐Huber et al., ).…”

“…Additionally, the Realistic Evaluation framework gave no consideration to the value of feedback loops which was deemed important (Byng et al, 2008). Although some users identified Realistic Evaluation as a theory-driven framework that met their needs (Oroviogoicoechea & Watson, 2009;Wand et al, 2011), others found that supplementing the framework with theory was required to understand mechanisms for change (Frykman et al, 2017;MacArthur, 2014).…”

“…Supplementing models with a theoretical model to explain TA B L E 2 Matrix of concepts supported by each framework causal mechanisms may assist interpretation of findings (Eisenbise, 2015). Realistic Evaluation (Pawson et al, 1997) was also reported to be useful to develop outcome measures (Wand et al, 2011), to understand how behaviour and context influences outcomes (Frykman et al, 2017) and to identify why initiatives had not been successful in improving outcomes (Oroviogoicoechea & Watson, 2009). The MRC framework (Moore et al, 2015) was found to be useful in clarifying causal mechanisms and identifying the factors associated with variations in outcomes (Furness et al, 2018).…”

“…While frameworks are always underpinned by theoretical principles, a discussion of theory was absent in a number of papers in this review (Adegoke et al, 2011;Bahr et al, 2017;Chmiel et al, 2017;Furness et al, 2018;Gardner et al, 2014;Jaipakdee et al, 2015;Serowoky et al, 2015;Themessl-Huber et al, 2008). A number of authors argued that without theory, findings cannot be adequately interpreted and the plausibility or generalisability of findings may be limited (Frykman et al, 2017;Hill et al, 2017). Other authors addressed this potential limitation by incorporating a theoretical framework or model in the evaluation (Frykman et al, 2017;Yonge et al, 2011).…”