Table 2 Determinants affecting implementation success for a hospital professional accountability program

Barrier

Intervention characteristics

Design Quality & Packaging

Confusion about both ‘positive’ and ‘negative’ feedback in the same messaging tool, the labelling of feedback in this way, concerns about anonymity and a lack of ‘natural justice’.

Inner setting

Networks & Communications

Poor communication vertically and horizontally, despite procedures in place for consultation. Communication characterised by lack of transparency, hierarchy, and tribalism.

Implementation climate - Goals & Feedback

Broad goals but lack of clarity about what the program would achieve, perpetuated by the dearth of feedback at both an individual and organisational level on usage of Ethos.

Implementation climate - Learning Climate

Hospital settings, leadership and climate were viewed as frequently hostile and punitive when issues were raised. Spurious focus on quality improvement.

Readiness for implementation - Leadership Engagement

Staff perceived leaders as not accountable with a poor track record of addressing unprofessional behaviours. Senior leaders were supportive of Ethos but were not core implementers and were not always knowledgeable on the program.

Readiness for implementation - Access to Knowledge & Information

Training not accessible to all, visibility of Ethos declined over time and specific information on the messaging process was inadequate.

Characteristics of individuals

Knowledge & Beliefs about the Intervention

Many were distrusting, sceptical or cautious in their view of Ethos and its potential effectiveness.

Enabler

Inner setting

Structural Characteristics

On balance, sense that the Group was values-based, which positively impacted how staff interacted with one another.

Implementation climate – Tension for Change

Unprofessional behaviour was widely considered a problem, though some expected it would continue to be tolerated by leadership.

Process

Engaging - Champions

Ethos peer messengers volunteered or were invited to take on the role and were intrinsically motivated by the work.

Reflecting & Evaluating

Clear commitment to, and evidence of, evaluation and utilising those insights to revise and update Ethos and its implementation.

Mixed

Inner setting

Culture

Inconsistent views of the culture as respectful and driven by benevolent values, versus hostile, unequal and driven by a financial imperative.

Implementation Climate –Compatibility

Delivery of feedback and respectful interaction pillars of professional conduct; limited integration of the program with other systems, particularly HR.

Implementation Climate – Relative Priority

Differential perspectives related to stakeholder group; middle managers and most staff viewed the program as low priority, whereas peer messengers saw it as important.