Rich, NickAlhafufi, Murtadha2026-08-062026https://hdl.handle.net/20.500.14154/79803Healthcare organisations within the United Kingdom operate within complex and changing service environments that are characterised by complexity and excessive demand. These conditions require the cooperation of multidisciplinary healthcare teams to continuously adapt and improve the performance of services and associated working practices. As a result, managing change within healthcare teams has become an increasingly important subject. The existing academic literature shows significant evidence of failure, and it provides only a limited understanding of how change is implemented, services are improved, and change sustained at the team level. As a result, debates as to which approaches work or could apply in this complex service setting rage amongst professionals and academics alike. To date, no reliable, setting-specific and universally-accepted change management model exists that could be used to guide change efforts and performance improvement in these contexts. The shortfall in models that offer utility to NHS professionals has been partially filled by the ‘importation’ of industrial manufacturing and commercial models that have been presented as successful in settings that are untypical of healthcare. The application of these models may also underpin the general perception that typically, for the NHS, change fails. This study therefore seeks to develop a deeper understanding of effective change practices within the NHS context and to develop a model that reflects how effective change can be managed in practice by identifying, from expert insights, key themes (enablers and inhibitors) and their interactions or mutual influences that are associated with successful outcomes. The context of this study is the NHS in Wales (the responsibility of the devolved powers of the Welsh Government to deliver care services to the population of Wales). NHS Wales was selected because it is a microcosm of the UK system, it has all the contextual challenges of a publicly-funded NHS and all of the secondary care services that would exist in any other UK nation. The researcher selected secondary care because it is the most expensive, complex, broad ranging and most difficult setting to enact change within. The setting is also dominated by large providers known as Health boards who control these services of the hospital systems for a region within Wales. The selection of Wales was beneficial in terms of access to experts and drawing professionals into this study from all areas of the country. The NHS in Wales is also subject to ambitious policies for national and local service improvement in all major patient pathways which added the need to study how teams in Wales enact change and achieve favourable outcomes. The context was considered highly attractive to answer the academic gap in knowledge and to extend current knowledge through three key research questions: RQ 1: What are the key themes (enablers or barriers) that impact on change implementation in public healthcare? RQ 2: How are the enabling and inhibiting themes for change management processes linked to each other? RQ 3: Which themes have a central shaping influence on the change process, and which have a more limited influence. To address this research gap, an interpretivist qualitative approach was adopted for theory-building from the NHS contexts and specific nuances that make healthcare a different form of service than most others. The methods employed by the researcher included phases and reflective phases of field research which commenced with semi-structured interviews with purposively-selected NHS change experts to answer research question one. The perceptions of Welsh NHS change experts were designed to identify common themes associated with change, its structure, and outcomes. A different group of expert NHS change informants was recruited and engaged in the second phase of research which employed Fuzzy Interpretive Structural Modelling (FISM) complemented by Fuzzy MICMAC analysis (research questions two and three) to determine thematic influences and connections between the themes from phase one. Reflexive thematic analyses identified eight key themes influencing change implementation, while FISM and Fuzzy MICMAC analysis examined the relationships, hierarchy, and influence of these themes within the wider system. The perceived thematic drivers for sustained positive change outcomes included leadership, communication, support and facilitation, stakeholder engagement, continuous improvement and learning, perceived change outcomes, history of change, and organisational culture. The findings also highlight the importance of an intervention known as Plan-Do-Study-Act or PDSA cycle. The PDSA cycle originates from the application of Total Quality Management to organisations in manufacturing and general services as a form of continuous improvement that supports ongoing learning, reflection, and adaptation of a service based on experimentation and feedback of results to teams. Within the service setting, and in particular healthcare, this intervention is poorly practiced and not well adopted as customary practice. This study shows the critical and pivotal nature of this form of learning and improvement for NHS service teams as a meaningful alternative to more dominant, yet ineffective, change models such as Lewin’s ‘unfreeze-change-refreeze’ cycle and Kotter’s 8 steps approach. Overall, the study demonstrates that change implementation within NHS Wales is not a simple linear process, as promoted by Lewin and Kotter, but is most effective as an ongoing and socially embedded learning journey shaped by team interaction and supported by compassionate transformational leadership styles. This study contributes to and extends current understanding of change within public healthcare by challenging traditional change models and demonstrating the importance of a contextually-relevant PDSA method for team learning to support and sustain the capacity of staff to improve services continuously within NHS Wales healthcare settings. The study also makes contributions by extending the theoretical approaches of socio-technical systems theory, Total Quality Management (TQM), and organisational learning theory in the context of modern NHS service organisations and team engagement with change. These theoretical lenses tend to focus on general change in healthcare services but have not been used to frame team-level change. A uniting discovery of this study is the eight themes and psychological safety in the workplace that allows higher performance of socio-technical teams, based on collective learning (TQM and learning organisation) which is unlocked by the cultivation and reinforcement of methods and working practices that allow staff to engage with experiments where favourable outcomes lead to more change and unfavourable outcomes lead the team to rethink why the expected outcomes from a change had not been achieved. These processes lead to better knowledge management, a pooling of team knowledge about a service and how to improve it based on positive or negative feedback and PDSA cycles of continuous small but sustainable change that lead to new learning and new potential targets for service improvement.338enHealthcare changeChange managementNHS WalesService improvementThesis