Table 3 ERIC strategies used during the implementation of the program and their degree of alignment with barriers

Conduct educational meetings

Educational meetings and training were held with the different stakeholders (line managers, executive, peer messengers, and all other staff).

Goals and 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.

Partially aligned - meetings were held, but not on an ongoing basis and not using content from the messaging system.

Identify and prepare champions

Ethos peer messengers were program champions with evidence of selection by senior staff and training and support provided to them.

Learning Climate^a

Hospitals were viewed as frequently hostile and punitive when issues were raised. Spurious focus on quality improvement.

Aligned – Peer messengers wanted to contribute to quality, safety, and workplace culture, and were professional in delivery of feedback that encouraged self-reflection, not blame.

Develop educational materials

An Ethos procedure document, as well as promotional materials, were developed for staff and went through several versions.

Access to Knowledge & Information^a

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

Aligned – a range of materials were developed from detailed program descriptions to promotional screensavers and went through multiple iterations as required.

Create a learning collaborative

An inter-hospital Ethos working group was established to share challenges and issues of those implementing the program.

Networks & Communication

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

Not aligned – Issues occurred within each hospital, while collaborative work occurred at the Group level.

Develop a formal implementation blueprint

The program information and implementation plan laid out the aims/purposes of Ethos, scope (all staff), and included a high-level timeline for implementation in each hospital.

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.

Partially aligned – Blueprint included only broad goals and strategies. Performance measures and plans for refining the plan were not specified.

Promote network weaving

The program information and implementation plan mentioned the plan to continue “to engage external stakeholders”.

Networks & Communication

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

Not aligned – poor communication, tribalism, occurred within each hospital, while networking was done externally or at a Group level.

Distribute educational materials

Program materials promoting Ethos including posters and screensavers distributed. FAQ and web portal created. Multiple versions created over time.

Access to Knowledge & Information

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

Partially aligned – materials distributed initially, but not effectively over time.

Recruit, designate and train for leadership

Both line managers and senior hospital leaders undertook specialised training to support their involvement and leadership of Ethos, and some had designated roles.

Leadership Engagement

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

Partially aligned – strategy addressed engagement with the program more than leadership accountability issues.

Assess for readiness and identify barriers and facilitators

Assessment of readiness for implementation was planned for each site 4–6 months prior to implementation.

Knowledge & Beliefs about the Intervention

On balance beliefs were distrusting, sceptical or measured in their view of the program and how effective it could be.

Partially aligned – limited detail on how assessment conducted, and lack of evidence to suggest it adequately evaluated knowledge and beliefs of staff prior to implementation.

Identify early adopters

The independent review examined the process of adoption at two sites first to implement Ethos and learned from their experience.

Knowledge & Beliefs about the Intervention

On balance beliefs were distrusting, sceptical or measured in their view of the program and how effective it could be.

Aligned – from analysis of early implementing sites, identified a range of misconceptions about the program and how it worked, recommended improvements.

Use advisory boards and workgroups

Ethos Action Plan Working Group created with both internal Ethos program leads from each hospital and some external academics. In a series of formal meetings, oversaw refinements to the program following Internal Review.

No individual barrier with Level 1 or 2 endorsement for this strategy

N/A

N/A

Involve executive boards

The program had the full support of the Group executive, and at a hospital level, a member of the executive was designated the Ethos sponsor. Engagement sessions were run with hospital executive and senior leaders so they could support the program.

Leadership Engagement

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

Partially aligned – addressed program engagement but not accountability issues with leadership.

Obtain formal commitments

The program information and implementation plan specified the full commitment of the Group’s board and outlined various roles and responsibilities of key leaders and Ethos sponsors. Commitments were also made related to the evaluation of the Ethos program.

Leadership Engagement

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

Partially aligned – numerous key partners were not in a leadership relationship. Commitment from leadership explicit at a Group but not hospital level.

Purposely re-examine the implementation

The independent review and the researcher-led evaluation of the program implementation were conducted. A working group was established, and an action plan put into place following this to ensure recommendation revisions were adopted.

Design Quality & Packaging

Poor perceptions of the messaging tool and process, scepticism about anonymity, dislike of the lack of “natural justice”, confusion about the inclusion of both positive and negative feedback in the one system.

Aligned – evidence of materials and strategies being revised in light of new information and recommendations.