The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams

Abstract

Background Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. Methods The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). Results The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process. Conclusion To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare

“…As researchers start to grapple with the intersection of implementation science and health equity [ 46 ], carefully identifying who is suggesting the modifications may be an important aspect of tracking the co-creation of implementation strategies [ 21 – 24 ]. Identifying sources of power in the implementation process [ 47 ], and incorporating the voices of those in the community, will be important for the field as we move toward equitable practice in our science.…”

Mitigating unintended consequences of co‐design in health care

“…Recent reviews of the literature found the involvement of service users/patients still at low and often tokenistic levels 16,26 . Apparent gaps in scientific rigour, tensions and hierarchical power differences between those involved in the process, coupled with a focus on short‐term outcomes, raise questions regarding the use of co‐design 16,34 . Few works provide any evidence or guidance on supporting the involvement of health‐care staff who may have a diverse range of needs to support their full participation 27 .…”

“… 16 , 26 Apparent gaps in scientific rigour, tensions and hierarchical power differences between those involved in the process, coupled with a focus on short‐term outcomes, raise questions regarding the use of co‐design. 16 , 34 Few works provide any evidence or guidance on supporting the involvement of health‐care staff who may have a diverse range of needs to support their full participation. 27 There are strong critiques on the use of narrow approaches that lack the involvement of priority populations, having co‐design approaches set before a project commences, and the process being managed by health‐care staff.…”

Implementation of A Structured Emergency Nursing Framework Results in Significant Cost Benefit

“…Successful implementation needs appropriate funding, planning and strategies that address the complexity and micro-politics embedded within all health care systems. Implementation strategies need to support individual practitioners, managers, and understand the context as well as receive strong organisational support and patronage which is in uential to normalising a new practice among staff 23 . An evidence informed and context speci c implementation strategy is essential to sustained, reliable and high uptake 16,24 .…”