When culture change programs fail to take hold

Organisation-wide culture change programs are deployed in healthcare to shift workforce behaviour, embed safe patient care, and improve outcomes for both patients and staff. Yet sustaining the gains such programs achieve remains inconsistently realised. A new scoping review published in JBI Evidence Implementation examined why, and found that the answer may lie in a phase of change that research has largely neglected.

The scoping review, Factors influencing embedding of organization-wide culture change programs in health care, focused on embedding. This is the phase between initial implementation and long-term sustainability. During this phase, change initiatives become integrated into everyday work routines and organisational systems such as governance, policy, and monitoring. It is distinct from implementation, where staff, training, and funding are mobilised to launch a program, and it is also distinct from sustaining, which refers to the continuation of a program and its associated outcomes after both implementation and embedding efforts are completed (usually two to six years after the implementation phase has concluded).

Examining a decade of published evidence, the reviewers identified only 17 relevant studies, all from high-income countries. The narrow research base is limited in organisational setting, focused predominantly on nursing, medical staff, and project leads, and produced infrequently. No study examined the embedding of an organisation-wide culture change program simultaneously across multiple acute hospitals and community health services.

Despite the scarcity of research, ten factors emerged that determine whether embedding succeeds or fails. Grouped into three interconnected categories: people, processes, and the change program. The ten influencing factors span education and training; leadership; accountability; organisational culture; stakeholder engagement; process and structures; measurement, monitoring, and feedback of outcomes; adaptability of the program; alignment to external factors; and adequate resourcing. Two factors appeared across every study: education and training; and measurement, monitoring, and feedback. 

A definitional problem runs through the entire literature. No study applied a consistent definition of embedding. Without conceptual clarity, cross-study comparisons are unreliable, and the development of practical frameworks remains constrained.

Four priorities for future research emerge from the review: defining embedding as a discrete concept; determining the minimum configuration of factors required for success; understanding how factors operate differently at organisational versus facility level; and examining their influence across professional roles — including clinical, technical, and administrative and corporate health care workers, whose roles the existing literature has not yet adequately examined.

The review provides a systematic map of current evidence. What it cannot yet offer, and what the authors identify as a tangible gap, is a model that formally incorporates the embedding phase into health care change management frameworks.

Factors influencing embedding of organization-wide culture change programs in health care: a scoping review is available in Issue 2 2026 of JBI Evidence Implementation