Culture and cognition in health systems change

PURPOSE: Large-scale change involves modifying not only the structures and functions of multiple organizations, but also the mindsets and behaviours of diverse stakeholders. This paper focuses on the latter: the informal, less visible, and often neglected psychological and social factors implicated in change efforts. The purpose of this paper is to differentiate between the concepts of organizational culture and mental models, to argue for the value of applying a shared mental models (SMM) framework to large-scale change, and to suggest directions for future research. DESIGN/METHODOLOGY/APPROACH: The authors provide an overview of SMM theory and use it to explore the dynamic relationship between culture and cognition. The contributions and limitations of the theory to change efforts are also discussed. FINDINGS: Culture and cognition are complementary perspectives, providing insight into two different levels of the change process. SMM theory draws attention to important questions that add value to existing perspectives on large-scale change. The authors outline these questions for future research and argue that research and practice in this domain may be best served by focusing less on the potentially narrow goal of "achieving consensus" and more on identifying, understanding, and managing cognitive convergences and divergences as part of broader research and change management programmes. ORIGINALITY/VALUE: Drawing from both cultural and cognitive paradigms can provide researchers with a more complete picture of the processes by which coordinated action are achieved in complex change initiatives in the healthcare domain.