Investigating mechanisms of change in implementation processes : theoretical and methodological perspectives

Background: The implementation of research findings into practice is complex and challenging. Recurrent reports point to the failure of implementation and a costly gap between current knowledge and the services provided to end users. To overcome these challenges and to improve our understanding of implementation, it has been suggested that researchers make use of theory and study the change mechanisms that describe how and why implementation strategies influence outcomes in a specific context. Yet, such studies remain scarce.

Aim: The overall aim of this thesis is to investigate change mechanisms in implementation. This is done through a theoretically based analysis of how behavior change interventions (study I and II) and leadership style (study III) influence employees’ initial (study I and III) and sustained (study II and III) use of a teamwork work process (study I and II) and an occupational health intervention (study III).

Methods: Teamwork implementation was studied with a comparable case study design (study I), and teamwork sustainability was further studied with a design based on realistic evaluation (study II). Data were collected with interviews, observations and document analysis. Both studies used the theoretical framework DCOM® to analyze behavior change interventions and observations of teamwork behaviors as the outcome. The influence of line managers’ leadership style on implementation was investigated in a longitudinal intervention study (study III). Data were collected from questionnaire surveys at baseline and follow-up at 12 months. Employees’ use of the web-based intervention was collected from electronic data logs and used as the outcome.

Findings: An implementation strategy based on communication, daily feedback, ongoing problem-solving and adjustments to the teamwork intervention was found to be successful for the implementation of teamwork. The fallback in the implementation strategy had a negative influence on sustainability. The analysis describes how and why the implementation strategy influenced implementation outcomes in a complex organizational context. Line managers’ supportive change activities, which are directly related to the intervention implemented, had a significant influence on employees’ initial and sustained use of the web-based occupational health intervention. The line managers’ transformational leadership did not have a direct influence on use but an indirect influence mediated by their supportive change activities.

Conclusions: The DCOM® framework and realistic evaluation provided useful theoretical and methodological frameworks for the investigation and understanding of how the implementation strategy and contextual factors interact and cause behavior change. The findings imply that an implementation strategy should be based on a theoretical understanding of change mechanisms and an analysis of context to successfully influence behavior change. Furthermore, the findings points to the dynamics of context and suggests that context needs to be continuously updated and in turn used to guide updates to the implementation strategy. Finally, the thesis underlines the importance of line managers’ dedicated focus on supportive change activities and challenges previous research suggesting that transformational leadership is the leadership style of choice for successful implementation.

List of scientific papers

I. Frykman, M., Hasson, H., Muntlin Athlin, A. & Von Thiele Schwarz, U. 2014. Functions of behavior change interventions when implementing multiprofessional teamwork at an emergency department: a comparative case study. BMC Health Services Research. 14.
https://doi.org/10.1186/1472-6963-14-218

II. Frykman, M., Von Thiele Schwarz, U., Muntlin Athlin, Å., Hasson, H. & Mazzocato, P. 2017. The work is never ending: uncovering teamwork sustainability using realistic evaluation. Journal of Health Organization and Management. 31.
https://doi.org/10.1108/JHOM-01-2016-0020

III. Frykman, M., Lundmark, R., Hasson, H., Villaume, K. & Von Thiele Schwarz, U. 2017. Line managers’ influence on an intervention process: perspectives on transformational leadership and managers’ supportive change activities. [Manuscript]