Evolution of Participant Attitudes during a Practice Change Process

Background: Quality improvement efforts in primary care medical practices can be hampered by a lack of motivation and participation among practice members. Participant attitudes have been linked to of motivation, and may offer insights for building motivation and participation. However, little is known about the evolution of participant attitudes during a quality improvement process. Methods: Ethnographic fieldnotes and survey data from a series of meetings involving practices participating in EPOCHS, a clinical trial to improve primary care practice capacity to change and rates of preventive service delivery, were analyzed to generate a case comparison study of the evolution of participant attitudes. Initial sampling included practices with high or low facilitator and self ratings of motivation to change. Ethnographic fieldnotes generated by researchers and a research facilitator observing and/or guiding practice meetings were analyzed by a multidisciplinary team using a template style of coding to identify participant attitudes. Survey data from practice meetings were analyzed to identify self-reported participant attitudes. The analysis template coded; participant motivation to change, individual and group attitudes about participation and communication, feelings about safety and the possibility of change, and the degree to which participants felt the process was energizing, fun and involved learning. An immersion crystallization method of analysis was used to identify new sources of participant motivation. Results: Preliminary results indicate positive attitudes toward sharing and reflection activities during the change process. Practices with high participation in the change process, a clear shared practice vision and open communication were more likely to believe change was possible. Practices where change was a common and communal activity were most likely to keep high levels of motivation throughout the change process. Practices distracted by internal conflicts often had low motivation and did not feel change was possible. Practices where staff did not feel valued or heard showed little motivation to change. Motivated individuals were not always high in participation, but they almost always saw the practice as highly participatory. Those who considered communication clear and open often saw change as possible and were likely to retain high motivation. Conclusions: Motivation to change can be better understood and managed by identifying and paying attention to the attitudes of participants involved in a change initiative. A detailed description of participant attitudes throughout a change process in prima