Understanding the mechanisms involved in implementation of a workplace compassionate care intervention: a novel agency-structure approach

Introduction An inextricable link between context and implementation of innovations in organisations is well established. Context is understood as a dynamic landscape encompassing evolving interactive processes characterised by interactions between human actors and actors and context. Context is multi-level and operates at the micro, meso and macro. This paper introduces a novel theoretically informed agency-structure approach which was used to analyse the implementation of a workplace learning intervention targeted at enhancing relational nursing care: the Creating Learning Environments for Compassionate Care (CLECC) intervention. This approach enabled identification, characterisation and explanation of sources of contextual variation in the implementation of this intervention, offering a vehicle to understand complex mechanisms involved in introducing changes to nursing practice. Methods A longitudinal case study design was used to study CLECC's implementation in an English mental health setting. Data collection comprised semi-structured interviews ( n = 12) with staff involved in the implementation of CLECC, and analysis of key documents. Structuration Theory and Normalisation Process Theory jointly informed analysis. Results A dynamic agency-structure approach enabled identification of three empirically evidenced interrelated contexts shaping the implementation of CLECC: i. COVID-19, ii. mental health and iii. nursing. Implementation was enacted at micro, meso and macro levels through these contexts, involving a complex interplay between individuals, organisations and political processes and structures. Discussion Our novel theoretical approach provided a valuable lens for examining the complex and dynamic implementation processes, illuminating the interplay between individual agency and structural influences across multiple levels and mechanisms through which interventions are embedded or not in organisations. The value of this combined approach can be extended, with the potential for wider relevance to implementation science as a whole, enabling a unique framework through which to map the complex relations and processes shaping implementation. Through its novel theoretical approach, this paper makes an important contribution to the implementation science literature, with insights into and explanations of the mediating role of contextual variations in implementation.