Leading implementation in health and social care : the line manager in the spotlight

Abstract: Background: Health and social care organizations are frequently undergoing changes intended to improve quality of care and are expected to implement practices based on the best available evidence. However, about two-thirds of all implementation efforts fail. This has resulted in the well-known evidence-practice gap that means patients and clients may not receive the best possible care. Leadership is critical for implementation success. Implementation science and leadership research suggest that implementation is a structured process that requires certain leadership actions, which should be performed in an active and engaging way to increase the likelihood of implementation success. Line managers’ play a key role in facilitating implementation processes because they are usually responsible for implementing and directly overseeing implementation efforts. Yet what line managers’ do and how they can lead implementation is not well understood. Aim: The overall aim of this thesis is to increase the knowledge of line managers’ leadership during implementation. More specifically, this thesis explores leadership from the line manager perspective (Study I and Study III) and from the employee perspective (Study III), and validates a scale used to measure implementation leadership from line managers’ and employees’ perspective (Study IV). This thesis also investigates how context influences line managers in leading implementation (Study II). Methods: Multiple designs and data collection methods were used in this thesis. Study I and Study II, which were conducted in social care, used a cross-sectional qualitative design in which data were collected using semi-structured interviews. These studies explored how line managers’ describe their actions when leading implementation (Study I) and how context influences them in this process (Study II). Study I uses the “Phases of an Implementation” and Study II the “Consolidated Framework for Implementation Research” frameworks from implementation science to analyse the data. Study III and Study IV were conducted in health care. Study III used a longitudinal design and data were collected using web-based questionnaires administered to line managers and employees at three time points (at pre-, and post-intervention, and at a six-month follow-up). This study investigated agreement between line managers and their employees’ for general leadership behaviours. Study IV was a validation study that used a cross-sectional design. Data were collected from web-based questionnaires distributed to employees. The leadership theory, “Full-Range Leadership Model”, was used in both Study III and Study IV to measure leadership. Findings: Study I found that line managers described their implementation leadership as a rather ad hoc, unstructured process in which they were active in some phases while passive in others. They were most active in informing and preparing their employees for an implementation when a decision had been made on which effort to implement. The line managers’ were most passive in performing an analysis of needs prior to an implementation decision and in following up the process in the later phases of an implementation. Study II found that many factors in the inner and outer context influenced line managers’ implementation leadership. These contextual factors include support from the closest manager and senior management, social interactions (networks and internal communications), opportunities to improve knowledge and skills, and opportunities to apply for project funding. However, not all factors, when available, had an impact on the managers’ implementation leadership. One explanation for this was that an interaction between factors was often needed to have a positive impact (e.g., project funding from actors in the outer context only had an impact if a positive and supportive climate existed in the inner context). Study III found a disagreement between line managers’ self-ratings and their employees’ ratings of the managers’ leadership. The managers rated their leadership either more positive (higher) or less positive (lower) than their employees. A leadership intervention aimed at improving implementation leadership led to greater agreement at unit level. Study IV found that the iLead scale showed good psychometric properties and can be used to measure active and passive implementation leadership. Conclusions: Line managers could benefit from being cognizant of implementation as a structured process that requires strategic thinking. Training interventions that develop managers’ knowledge and skills may be supportive in how to most effectively lead implementation. It should be acknowledged, however, that line managers’ task in leading implementation need to align with all other challenging managerial activities that they perform daily. Furthermore, feedback on line managers’ leadership behaviours that includes their employees’ perspective can help managers become more aware of their leadership behaviours and thus become more effective leaders. The iLead scale is a valid scale that can be used to measure managers’ active and passive implementation leadership from both their own and employees’ perspective. Finally, line managers need support in leading implementation and are influenced by various contextual factors. Yet the contextual factors that provide support are complex, various, and often overlapping. A one-size-fits-all support does not exist. Each line manager’s situation should be considered in its entirety when tailoring individual manager support.