When front-line health practitioners are asked to embrace the new paradigm of collaborative innovation, they often end up in contention with the realities of a long-existing bureaucratic landscape.
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«For practitioners, innovation can often feel like an uphill battle against the KPIs of the past that are, in fact, still making up the realities of their present», Keith Peavy says.
«Policy-driven calls to be innovative, collaborate and take a citizen and patient-centric approach for the co-creation of services of care can easily be experienced as just another wave of demands that leave our front-line workers gasping for air. Which is sad, because I’ve seen how well attributes of these approaches can work if given the opportunity».
As an American Ph.D candidate in Innovation and Entrepreneurship at BI and C3, Keith Peavy’s research began in Norway in the midst of an ambitious paradigm shift. In what has been referred to as The Relational Shift, public sector innovation policy came to emphasize collaboration and co-creation, with a directed focus on cultivating relationships and having citizens/patients co-design and become active participants in their own treatment.
«The language of this shift is very interesting. It entails how we’re supposed to move away from New Public Management’s stringent measuring and the classic Weberian depiction of the iron cage of rationality, control and surveillance. In the language of a relational shift, we see a move over to the inclusion of more substantive qualities such as trust, empathy, sharing and even love», Peavy says.
«I was curious as to who it is that is going to teach us how to do this. Because practitioners were saying ‘of course we want this kind of innovation. We even need it. But how?! Are our leaders going to support this? Will our performance indicators reflect this? How will love will be measured?”
What innovation looks like
Peavy’s research aims to understand how practitioners on the frontline of health care receive these new demands for collaborative innovation.
He contributed to a BI program for midlevel executives titled «Relational Leadership» that highlighted aspects of this paradigm shift. It was here he was introduced to the director of Stangehjelpa. A mental health clinic, Stangehjelpa had been built from the ground-up from 2009 until it had a staff of 35 and had become a choice of preference for people of all ages suffering from addiction and psychological trauma.
«Her mission was to challenge a medical model where an overwhelming emphasis is placed upon a systematized approach of assessment, diagnosis and treatment of the patient – which according to her had been ‘enshrined by law’”, Peavy says.
Instead, the director wanted the practitioners to be willing to relationally engage the patients as persons, actively avoiding terms like “patient” or “user”.
“The clinic’s collective goal was to be able to ask patients ‘What is important for you?’ and using the answers for a co-created treatment plan, successfully moving the patient into becoming an active owner of their own well-being.”
The clinic gained national attention, becoming central in the discourse concerning co-creation and low-threshold mental health services that many politicians had adopted. Through their collaborative work, they created their own jargon.
«Even the front-line practitioners felt so connected to the project that they willingly let their performance and patient satisfaction be measured, something that is otherwise often vehemently opposed.
The new language meets the old logic
At Stangehjelpa, Peavy had identified frontline practitioners who were endeavoring with the challenges posed by the new paradigm of collaborative innovation. Now, he got to see how such approaches can often lead to clashes with the status quo concerning norms and regulations.
Efficient and successful as it was, the clinic soon came under intense scrutiny and it was even suggested they were breaking the law due to their processes and positions on the regime of diagnosing. In a meeting with regulatory officials, Peavy sought to understand why this was happening as Stangehjelpa’s approach to mental health practice had recently and very publicly been heralded by Norway’s Health Minister Bent Høie as “representing a new world, something new that should be spread throughout the entire country”.
«I was shown a slide that depicted a circle of regulations that in this official’s words ‘mirror one another’ and dictate how practitioners are supposed to practice and engage the patient. I couldn’t help but wonder how one is supposed to innovate and breach this ironclad circle of regulation», Peavy says.
The result of this inherent tension between directives for collaborative innovation and the old paradigm of permeability and control is that practitioners develop strategies to insulate ongoing work, professional identities, and even personal selves.
The new paradigm presents potential threats to what Peavy refers to as the practitioner’s ontological security, a concept developed by Anthony Giddens (1991). He observed this when he followed the new paradigm’s introduction into municipal care services in Oslo. Here, instructions included the co-creation of services through partnering with citizens and practitioners as being a source of love for the children they encounter.
When the practitioners engaged with the new policies, Peavy would observe and interact with them in informal ‘water cooler‘ settings where they would exchange expressive, but subtle embodied gestures, such as scoffing, when discussing the more relational qualities of co-creation and love:
“They would ask questions such as ‘We are being told to love, but is this something that will be measured?’, ‘What does it mean to involve the citizen?’, ‘Are we not already doing this?’ and ‘Who are they wanting me to be?’ along with phrases like ‘Same shit, new wrapping’, ‘This is soo Norway’ and ‘We’ve totally seen this before’”, Peavy says.
He saw that many health practitioners that had started out with a clear purpose to help their fellow citizens had come to feel restrained from realizing this purpose due to the massive amounts of administrative work and documentation that must be done in order to reconcile to systemic requirements.
“The scoff is not simply a dismissal of the relational ideal. It represents real disappointment and even a hint of sadness based on shared experience. I think that it would be safe to say that it signals an anticipation for more disappointment”, Peavy says.
“They told me it’s not that we shouldn’t work in these ways, but that it is more about how to reconcile these aspirations to daily constraints of their work”.
The Era of Change-washing
One insulating mechanism is what Peavy calls shoehorning.
«In reporting to leaders or politicians how they are now incorporating collaborative innovation in their work, practitioners often develop these pristine presentations where all the boxes and arrows are in their right place with the aim to shoehorn these novel concepts and make them fit”, Peavy observes.
These are collectively crafted techniques devised to insulate or protect ongoing work that they have already committed time and resources to and even to protect themselves from new waves of changes and what can be experienced as threats to the validity of their competencies.
«These are strategies of insulating which Anthony Giddens, in his commentary on ontological security, refers to as being something of a protective cocoon. These often tacit or taken-for-granted actions are to keep ontological insecurities at bay», Peavy says.
These attitudes and acts of protection could be in response to what has been termed Change-Washing. A term coined by Snow and Greenspoon (2020), change-washing refers to the experience public practitioners encounter when a continuous stream of reforms tout the bringing about of change, but their outcomes reveal little or no substantive shifts in the systems, services and culture. Over time th experience of change-washing becomes demoralizing for those engaged. It is only natural that they seek to insulate themselves from it.
The way forward for Collaborative Innovation
Peavy believes that the new focus on collaborative innovation is good for society. But as it is at odds with the instrumental aspects of an existing paradigm, it takes careful crafting to make it stick.
One example of how to do it is coming down the line in Oslo: Oslohjelpa has been inspired by fundamental aspects of Stangehjelpa and has worked smartly to gather the necessary political and operational support. The initiating politicians summoned the director of Stangehjelpa to serve in a mentor capacity to the project and the city districts. During one session, she spoke to a group of approximately 75 city-district leaders and politicians, drawing up a rough sketch of the governance hierarchy and asking bluntly if they had tangible knowledge of what it is like on at the front lines: ‘If we are not serving these people, then what is the point of us?’ she asked.
«The message is that if we’re calling for increased collaboration and co-creation, we need to be mindful about what we’re asking for from practitioners”, Peavy says.
“From an innovation standpoint, the perspectives of front-line workers in the trenches ought to be sought out as valuable insights to our processes of co-creation. We need to give them a space in which to openly share why they may feel that this is just ‘Same shit new wrapping’”.
An instance of this occurred during the launching of Oslohjelpa. The project leaders from the city districts had been given a broad mandate by the political leadership, and called a meeting for practitioners only and encouraging them to speak freely about their confusions and frustrations with no need for glossy presentations.
“Just seeing what they could achieve once they felt secure about their positions and by drawing on each other’s expertise and experience, was proof to them how well engaging like this can work».
First written for Senter for helseledelse.
Text: Daniel Butenschøn/C3.
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