Table 3.

Substantive theory for engaging and empowering – challenges and corresponding actions required for successful evidence translation and improvement

Engage and empower
Common challenges	Simple rules: strategies for overcoming challenges
If people are not motivated, change will not take place, and without their engagement, insights will be lost  - People will resist changes that do not fit with their perceptions of what change is required and it is necessary to understand their emotional responses  - Healthcare professionals and patients hold local knowledge about how care practices and processes work  - No one person can ‘see’ the whole system, but each person can provide valuable insights	Actively engage those responsible for and affected by change - Understand what really matters to people and connect with emotional drivers for change - Engage people in identifying and understanding problems so they ‘own’ the rationale for change, to harness their knowledge and input to design and test solutions and gather feedback on what does or does not work
Expect conflict and tension  - Sharing knowledge and making sense of different, conflicting, perspectives is challenging; different professional groups have different norms and languages  - Power differentials exist and it takes time to build trust and relationships to support meaningful dialogue  - Patient’s experiential knowledge is not always valued	Facilitate dialogue - Create a safe environment for people to share their views and increase common understanding of the system - Promoting listening and constructive dialogue and building trust, relationships and partnership - Facilitate discussion and engage people in active reflection and discussion at all stages of design, conduct and evaluation, and respect emotionally charged responses
Underlying expectations are to get it right, first time, quickly  - Focus on centralised leadership, command and control  - Expectation of ‘positive results’ and importance placed on ‘being right’, with a lack of constructive challenge  - Limited opportunities to share opinions or concerns, and lack of permission or support to try their own ideas  - Judgemental cultures can represses learning	Build a culture of willingness to learn and freedom to act - Provide healthcare professionals and patients with the freedom and support to investigate and take action - Support the development of a learning culture which is willing and able to conduct improvement work - Encourage learning from failure as well as success and openness about real performance and problems
Improving complex systems takes time, effort and reflection  - Care professionals rarely have time to consider how different parts of the system work together beyond their professional group, unit or department  - Change takes time, and requires different skill sets to those in which professionals are traditionally trained  - Competently enacting new practices requires training and practice  - Organisations lack improvement infrastructure	Provide headroom, resources, training and support - Provide professionals with time out from daily practice spaces to collaborate with each other and patients - Provide training and support for new interventions or changes to practice to build competence and confidence - Build skills and competencies for improvement in individuals and at an organisational level, including specialist skills and data infrastructure