In this viewpoint article, the authors recognize the increased focus in health systems on co-design for innovation and change. This article explores the role of leaders and mangers in developing and enhancing a culture of trust in their organizations to enable co-design, with the potential to drive innovation and change in healthcare.
Using social science analyses, the authors argue that current co-design literature has limited focus on interactions between senior leaders and managers, and healthcare staff and service users in supporting co-designed innovation and change. The authors draw on social and health science studies of trust to highlight how the value-based co-design process needs to be supported and enhanced. We outline what co-design innovation and change involve in a health system, conceptualize trust and reflect on its importance within the health system, and finally note the role of senior leaders and managers in supporting trust and responsiveness for co-designed innovation and change.
Healthcare needs leaders and managers to embrace co-design that drives innovation now and in the future through people – leading to better healthcare for society at large. As authors we argue that it is now the time to shift our focus on the role of senior managers and leaders to embed co-design into health and social care structures, through creating and nurturing a culture of trust.
Building public trust in the health system and interpersonal trust within the health system is an ongoing process that relies upon personal behavior of managers and senior leaders, organizational practices within the system, as well as political processes that underpin these practices. By implementing managerial, leadership and individual practices on all levels, senior managers and leaders provide a mechanism to increase both trust and responsiveness for co-design that supports innovation and change in the health system.
Introduction
Co-design is value-based approach that brings diverse people together to build, refine or change parts of the health and social care system (Ní Shé and Harrison, 2021). This approach moves from consulting to enabling the involvement of all from the start (Ní Shé et al., 2019; Robert et al., 2022). The process ensures and supports all relevant partners to be involved in defining the problem, designing the solution and monitoring and championing the implementation. By gathering all key stakeholders, including those with lived experiences, co-design encourages the formation of equal and reciprocal relationships underpinned by trust and open communication. Co-design should not include a one-off workshop but focus on long-term evolving partnership that drives innovation and enables sustainable change within a specific context (O’Donnell et al., 2019; Ní Shé and Harrison, 2021; Busch and Palmås, 2023). There is a concern that co-design is the latest part of “managerial fads and fashion’ (Abrahamson, 1991). The recent literature has started to reflect on this with literature on a focus on potential corruption and unintended consequences of co-design (Ní Shé and Harrison, 2021; Busch and Palmås, 2023)
As Evans and Terrey (2016, p. 243) outline co-design done badly can “destroy trust systems”; but when done well, it can help “solve policy and delivery problems, stabilise turbulent lives, and improve life chances”.
A co-design approach provides a mechanism to move beyond stumbling blocks because it is based on diverse inclusion of members enabled by trust and context specific solutions (O’Donnell et al., 2019, 2022). Meaningful and inclusive involvement of all relevant partners in the design, management, and implementation of change requires skills, time, flexibility, and resources (Ní Shé et al., 2019; Locock et al., 2022). However, challenges exist. Post the COVID 19-pandemic change fatigue has emerged as staff burnout increased and trust in their organization to respond to the change decreased (Morain and Peter, 2023). The literature also outlines that involvement requires responsiveness, resourcing and support from senior leaders and managers to ensure the change is sustained (Boaz et al., 2016; Harrison et al., 2022b).
This viewpoint article is exploratory developed form our discussions, interpretations and experiences of co-design. We explore the role of leaders and mangers in enhancing trust in their organizations by responding and enabling co-design innovation and change. Current co-design literature remains scant on interactions between senior leaders and mangers, healthcare staff and service users in developing a culture of trust to support co-designed innovation and change. As authors’ we argue that it is now time to shift the academic focus on the role of senior managers and leaders to embed co-design into health and social care structures. The literature stressed that in order to enable participatory governance approaches such as co-design there is a need to focus on the role of senior leaders and managers (Fung, 2015; Ní Shé et al., 2020b; Harrison et al., 2022b). We outline what co-design innovation and change involves in a health system, reflect, and understand what trust is and finally note the role of senior leaders and managers supporting trust and responsiveness for co-designed innovation and change.
Co-design innovation and change in health systems
Central to an adaptive health system is the ability to be responsive to change that is inclusive of the relevant “actors” and addresses their needs within the local context of delivery (Rapport et al., 2022). It is well recognized that undertaking change within health systems is challenging. Much of the recent evidence notes that “change failure” is ever-present (Harrison et al., 2022a, b). It can often be poorly managed and lacks inclusive involvement or support from senior leaders. More recently, as levels of burnout increase across the health and social care system, staff' experience of creating change and enabling change is deemed limited (Creese et al., 2021; Harrison et al., 2022a). This is further exemplified by the significant psychological and physiological impact of burnout resulting in higher staff turnover, absenteeism and presenteeism within healthcare organizations (Kearney et al., 2020) making it difficult to successfully co-design innovate and change within such a challenging context (Fulham-McQuillan et al., 2023; Byrne et al., 2023).
However, such challenges can be managed effectively with the right leadership and management to embrace co-design and drive innovation and change. To effectively achieve this leaders and managers need to demonstrate “authenticity, openness, humility, compassion, and appreciation, where everyone has a voice” (Kearney, 2022, p. 156) and ensure co-design and innovation is supported at all levels. This support can include embracing co-design that drives innovation and positive change, providing necessary resources and time, as well as embedding co-design and innovation into the organizational culture.
Innovation does not happen without people and the most innovative staff are generally not at the senior level of the organization (Kearney, 2021). Frontline staff play a significant role given their daily experience of the system and must be supported to fully utilize their creativity (Kearney, 2022). Leaders and managers that embed co-design and innovation as part of the culture and support staff at all levels need to utilize their core competencies and work together with key stakeholders. In doing so, they think beyond the current boundaries that are driving the development of innovations, to advance scientific knowledge and address patient needs now and in the future.
Co-design is of significant value to health systems in driving innovation and addressing patient needs. This in turn can save lives as well and improve the quality of life and patient care. Co-design and innovation in healthcare is not an option but a necessity to address the significant and potentially unprecedented challenges facing today’s healthcare organizations (Kearney, 2022). For this to be successfully achieved both leaders and managers must engender trust and support staff to embrace co-design, drive innovation and change. This requires breaking the current status quo as we cannot continue to do the same thing and expect different results.
Understanding trust
Trust is argued to be the most fundamental relationship attribute that affects behaviors and outcomes within the health system (Hall et al., 2001). Trust can be conceptualized as an acceptance of the uncertainty and the risk associated with the expectation that the other party will act to the best of their ability and in good faith (Sheehan et al., 2020). It is a psychological state that captures an optimistic disposition of an individual and a level of confidence in the moral orientation of fellow citizens (Li et al., 2018), which denotes both the affective and ethical components of the concept. Trusting involves a decision to willingly give away power and thus make oneself vulnerable to the actions of another party, and it is predicated on the possibility of a negative outcome for “if there is no possibility of betrayal, then we are not talking about trust” (Sucher and Gupta, 2021). Trust and vulnerability are therefore intertwined as the process of trusting creates vulnerability, and yet trust arises from conditions of vulnerability that are unavoidable in medicine (Hall et al., 2001).
There is an agreement in the literature around the key features that constitute trust. Trust is thought to be a future-oriented concept for it is based upon an expectation of how another party will behave in the future (Gilson, 2003). It is also context specific as structural elements such as institutional barriers, norms, and values affect one’s ability to trust (Gilfoyle et al., 2022) as do professional norms and power dynamics inherent in healthcare organizations (Gilbert, 2005). Thirdly, trust is a relational concept as it involves at least two parties and a task, notwithstanding differences between trusting an individual or an institution, which amplifies complexities around the behavior (Sheehan et al., 2020). Furthermore, interpersonal and impersonal trust signifies trust in an individual, and trust based on roles, systems or reputation respectively (Atkinson and Butcher, 2003). Given the multifaceted nature of trust, Robin et al. (2020) propose the concept “complex ecologies of trust” that posit the interplay between trust, distrust, skepticism, and their dialectic combination in the center of inquiry. In organizations, trust creates higher levels of workplace cooperation and positive performance outcomes and enables sustainable partnerships and social networks (Gilfoyle et al., 2022). A meta-review of 112 independent studies confirmed that trust is positively related to team performance (De Jong et al., 2016), and therefore creates the conditions for solving collective action problems (Uslaner, 2002). The effects of trust and created social value closely align with the motivations underpinning co-design approaches (Ní Shé et al., 2020a). However, the asymmetries in the trust-building and trust-destroying processes (Kramer, 1999) and a complex interplay between interpersonal relationships, organizational practices and political processes inherent in building trust in health systems (Gilson, 2003) render this process less straightforward. In this context, the role of senior leaders and managers in creating and nurturing the conditions for trust becomes pivotal.
Senior leaders and managers supporting trust and responsiveness for co-designed change and innovation
Embedding co-design change within a complex organization remains a challenge (Harrison et al., 2022b). The term “to embed” is often used in health and social care aligned to change or long-term implementation of evidence-based initiatives. However, the word “embed” has not been clearly defined in the literature and is a complex concept. Shifting from one off initiatives to long term embeddedness requires reflections on changing structures, supporting staff and resourcing and monitoring co-designed change (Fagotto et al., 2019). Chwalisz links embeddedness with becoming “a permanent part of the policy cycle” (Chwalisz, 2020 p. 121). Bussu and colleagues outline three dimensions of embeddedness as “temporal, spatial and practices” (Bussu et al., 2022). Temporal embeddedness is focused on shifting from an “exception” to permanency within spaces where power and decision-making are operationalized. The third element of practices is aligning the correct resources, policy and mechanisms (Bussu et al., 2022) and these practices can be utilized to enhance trust and support co-design for innovation and change.
Senior leaders and mangers have an interest in creating the conditions of trust to reduce transaction costs (Kramer, 1999; Kramer and Cook, 2004), secure communication and dialogue (Gilson, 2003), and increase motivation, work engagement and the quality-of-service delivery. Organizational, managerial, leadership and individual practices that create and nurture trust, and thus support co-designed innovation and change, need to operate simultaneously on several levels. On a macro level, impersonal trust based on roles, systems or reputation of a healthcare institution can serve as a precursor and guarantor or interpersonal trust (Gilson, 2003; Atkinson and Butcher, 2003). The relationships between senior leaders and mangers, healthcare staff and service users are shaped by the institution in which they are embedded, and public trust in healthcare institutions may serve as a foundation of trust between these agents (Figure 1).
Figure 1: Senior leaders and managers supporting trust and responsiveness for co-designed change and innovation.
On a mezzo level, senior leaders and managers can support co-designed innovation and change by implementing organizational leadership styles and practices that influence trust. From a relationship-based perspective, the most important precursors of trust are transformational leadership, perceived organizational support and interactional justice (Dirks and Ferrin, 2002). By demonstrating individualized care, concern and respect for healthcare staff and service users, as well as support at every organizational level, managers and leaders can engender transformational leadership and nurture trust (Dirks and Ferrin, 2002). This process can further be aided through the implementation of high-trust management practices that encourage patient-centric and cooperative problem-solving approaches (Gilson, 2003).
Finally, on a micro level, leaders can adopt two core sets of strategies to build trusting high-quality relationships with the stakeholders and support effective implementation (Metz et al., 2020, 2022). Technical strategies for developing trust include frequent interactions, responsiveness, demonstration of expertise, and achievement of quick wins, whereas relational strategies include showing vulnerability, being authentic, engaging in co-learning and empathy-driven exchanges, and adopting bi-directional communication. Taken together relational and technical strategies can help build trust with and among the stakeholders by demonstrating knowledge, reliability and competence, and strengthening the quality and reciprocity of relationships respectively. Similarly, relational signaling theory suggests that leaders can foster trust by performing actions that send signals to other stakeholders that they wish to maintain the relationships, and attend to needs to the other (Six et al., 2010). This is achieved through recognizing the legitimacy of others’ needs and providing care and assistance, and preventing disappointment by clarifying expectations and surfacing and settling differences. In addition, behaviors that inspire trust rely upon the notion of a “moral manager”, which includes role modeling ethical behavior through visible action, and communicating about ethics and values to foster a culture of open dialogue (Treviño et al., 2000). The level of consistency between desired and observed ethical behavior of leaders, as perceived by followers, is therefore a predictor of trust (Van den Akker et al., 2009). Finally, senior leaders and managers need to secure funding arrangements and resource allocation to build trust with service users (Gilson, 2003), and engage in a reflective practice to interrogate their attitudes towards vulnerable social groups for trust appears to favor the privileged (Li et al., 2018, Baroudi et al., 2022).
Conclusion
Building public trust in the healthcare system is an ongoing process that relies upon personal behavior of managers and senior leaders, organizational practices within the healthcare system, as well as political processes that underpin these practices (Gilson, 2003). Health systems need leaders and managers to support innovation and change. A co-design approach requires reimagining the governance and processes models to enable shared power (Harrison et al., 2021; Busch and Palmås, 2023). For example, consideration must be given to how to involve seldom included groups who as people may experience barriers in participation in healthcare decision-making or accessing healthcare services (Islam et al., 2021; Ní Shé et al., 2019). A default workshop held in a hospital room presented as co-design is not sufficient as it may cause more harm than good with those involved if no change occurs (Locock et al., 2022).
Existing organizational structures and practices may not provide an opportunity for equal involvement with seldom included and hard-to-reach social groups. Understanding these challenges and proving an enabling culture is critical for leaders and mangers (Busch and Palmås, 2023). We believe that building and nurturing a culture of trust on all levels within but also transcending the health system is a core element for enabling successful co-design for innovation and change. This viewpoint advances on the gaps in the literature to stress the critical role of senior leaders and mangers in creating the conditions of trust and being responsive to what has been co-designed to enable innovation and change. We recognize that further empirical work is required to build the evidence base. Health systems needs leaders and managers to embrace co-design that drives innovation now and in the future through people – leading to better healthcare for society at large.
The authors do not have any potential conflicts of interest or support from a third party to declare for this research.
