The trouble with culture : an interpretive case study of organisational culture, learning and quality improvement in the National Health Service

Abstract

This interpretive case study investigates the relationship between organisational \nculture, organisational learning and cultural change in the National Health Service \n(NHS). Starting from a social constructivist standpoint, it conceives of \norganisational culture as a dynamic entity, socially and discursively constructed \nthrough engagement with surroundings, in contrast to the managerial discourse \nevident in NHS policy and research literature. The conceptual framework \ninforming the research is based on cultural historical activity theory and a three \nperspectives theory of organisational culture. This allows exploration of individual \nand collective learning within the context of organisational social and cultural \npractice, exploring the organisation at the macro level but also through the lived \nexperiences of individuals. \nAn interprofessional department in an NHS provider organisation was studied for \nfour months as it went through a programme of service improvement. Data was \ncollected and analysed iteratively through a combination of observation, interview, \ndocumentary reading and field notes. Analysis using an activity theoretical \napproach generated a „thick description‟ of the organisation. Organisational \nstories were analysed to explore meaning making. \nFindings suggest that organisational culture can be considered a shared epistemic \nobject within fluid networks of activity. Individual and collective learning is linked \nthrough practice, mediated by external political motivations and internally \ngenerated contradictions. Understandings of professional power play a major part \nand can lead to unexpected directions of travel. \nConceptually, the study shows activity theory to be a useful framework for \nanalysing learning and cultural change in NHS organisations. It adds to the \ndebate on the self and the role of power and contradiction in activity theory \nthrough the application of a three perspectives approach to culture. It can help \nguide practitioners and policy makers in the NHS by encouraging them to rethink \ntheir understandings of culture and how cultural change is achieved through \nmediated practice.

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