Article Text

Download PDFPDF

Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK
  1. Jenna P Breckenridge1,
  2. Nicola Gray2,
  3. Madalina Toma2,
  4. Sue Ashmore3,
  5. Ruth Glassborow4,
  6. Cameron Stark5,
  7. Mary J Renfrew1
  1. 1School of Nursing and Health Sciences, University of Dundee, Dundee, UK
  2. 2Scottish Improvement Science Collaborating Centre, School of Nursing and Health Sciences, University of Dundee, Dundee, UK
  3. 3Baby Friendly Initiative, Unicef UK, London, UK
  4. 4Improvement Support and ihub, Healthcare Improvement Scotland, Edinburgh, UK
  5. 5Public Health Medicine, NHS Highland, Inverness, UK
  1. Correspondence to Dr Jenna P Breckenridge; j.breckenridge{at}


Background Various theories provide guidance on implementing, sustaining and evaluating innovations within healthcare. There has been less attention given, however, to personal theories drawn from practice and the expertise of managers and front-line staff is a largely untapped resource. In this paper, we share learning from experienced improvement organisations to provide a conceptual level explanation of the conditions necessary to facilitate and sustain improvement at scale.

Methods Staff (n=42) from three leading change organisations in the UK, spanning health, education and social care, took part in three consultation meetings with the aim of sharing knowledge about sustaining large-scale change. This included one government organisation, one National Health Service Board and one large charity organisation. Using a participatory grounded theory approach, the workshops resulted in a co-created theory.

Results The theory of Motivating Change describes the psychosocial-structural conditions for large-scale, sustained change from the perspectives of front-line staff. The theory posits that change is more likely to be sustained at scale if there is synergy between staff’s perceived need and desire for improvement, and the extrinsic motivators for change. Witnessing effective change is motivating for staff and positive outcomes provide a convincing argument for the need to sustain improvement activity. As such, evidence of change becomes evidence for change. This is only possible when there is a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity. When these conditions are in place, organisations can generate self-proliferating improvement.

Conclusions The theory of Motivating Change has been co-created with staff and offers a useful explanation and guide for others involved in change work that capitalises on front-line expertise.

  • quality improvement
  • human factors
  • leadership
  • quality improvement methodologies

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Twitter To engage with us about this article via twitter: @Jen_Breck @EBImprovement @NicolaGray001 @toma_madalina84 @maryrenfrew

  • Contributors JPB designed the project, led and facilitated the knowledge mobilisation activity, analysed the workshop notes, prepared the complete first draft of the paper and redrafted in response to team input. MJR contributed to design, workshop facilitation, data analysis, commented on drafts and coordinated communication with the partner organisations. MT contributed to workshop facilitation, commented on drafts and contributed to the final writing of the manuscript. NG contributed to workshop facilitation and commented on drafts. SA, CS and RG facilitated partnership working with their organisations, contributed to theory development, commented on drafts and agreed on the final manuscript on behalf of participating members in their organisations.

  • Funding This work is supported by core funding from the Scottish Improvement Science Collaborating Centre, which is jointly funded by the Scottish Funding Council, Health Foundation, Chief Scientist Office, and NHS Education Scotland. The funding bodies had no role in the design or interpretation of this study or in writing the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.