Understanding the relational culture of healthcare workplaces: a framework to guide improvement interventions, derived from a realist evaluation of neonatal care in Kenya

The implementation, design, and process of healthcare interventions and quality improvement initiatives often neglect the social and relational components of work, recognised as essential to their effectiveness, in part because these features are under-theorised. This paper offers a new framework and theoretical lens (the GELLE Framework: Grouping, Empowering, Leading, Learning, Equipping) to help conceptualise complex relational workplace culture derived from realist evaluation. In-depth studies were undertaken in two low-resource urban hospital sites in Kenya, focusing on staff providing care to neonates. Data were collected using non-participant observations, in-depth interviews, and social network analysis. A realist analysis identified demi-regularities in the data, built context-mechanism-outcome configurations, and abstracted explanatory theory. Sense-checking of programme theory was undertaken with practitioner stakeholders. The relational culture of healthcare workplaces can be understood in terms of five integrated theoretical domains of the developed GELLE Framework: (1) who individuals consider to be their peers and trusted colleagues (Grouping), (2) the aspects of formality and structure which influence the ability of specific individuals to act (Empowering), (3) how leadership influences relational culture (Leading), (4) how learners can be supported to become competent professionals (Learning), and (5) how physical order influences relational processes (Equipping). Through structured explanation of the relational complexity and non-linearity of healthcare workplace culture, the GELLE Framework offers a practical theoretical lens for practitioners, researchers and programmatic teams to better understand the detailed contributions of relational culture to norms and change processes and therefore the implications for better design and implementation of improvement interventions. Efforts to improve the quality of healthcare are always implemented within the reality of the social and relational workplace. The GELLE Framework we developed offers a lens for better understanding of the relational culture of health facilities, identifying aspects of context amenable to intervention that should inform the design and implementation of improvement initiatives.