Increasing middle managers’ commitment to innovation implementation: An agenda for research

Middle managers who supervise frontline workers and who themselves are supervised by an organization’s senior managers are in a unique position to promote the implementation of innovation in health care organizations. ¹ There has been a substantial increase over the past 20 years in the number of studies that have looked at middle managers’ roles in innovation implementation, ² highlighting their substantial influence on and potential to drive innovation. This is particularly important given the fast pace of innovation in healthcare in response to changes in disease patterns, aging populations, new treatment discoveries, technological advancements, political reforms, and new policy initiatives.^3–7 Understanding the determinants of middle managers’ commitment to innovation implementation is thus critical, but the extant literature offers little understanding of these determinants so far. ²

Urquhart et al.’s study, ⁸ published in this issue, makes an important contribution to this field. They report that middle managers’ commitment to innovation implementation was determined, in large part, by their perceptions of the potential benefit of the innovation for patients and by the ease with which an innovation could be implemented. These findings are consistent with those described by Birken et al., ² who found middle managers’ knowledge and beliefs about the intervention to be among the most commonly identified determinants. But Urquhart et al.’s study goes beyond this. They shine much-needed light on what strategies might be used to increase middle managers’ commitment to innovation implementation. Birken et al.’s systematic review found that a plurality of studies that assessed the determinants of middle managers’ role identified senior managers’ engagement as central. ² The work by Urquhart et al. suggests that the political will and resources necessary to implement innovations that senior managers confer increase the ease of innovation implementation, thus increasing middle managers’ commitment. Specifically, as Urquhart et al. note, their findings point to the need to educate middle managers about the potential benefit of implementing a particular innovation and involving them in the planning around the innovation.

Urquhart et al.’s study takes an important step toward a more nuanced understanding of middle managers’ roles in innovation implementation and how to support it. However, as the authors point out, additional work is needed to harness the potential for middle managers to promote innovation implementation. There are four critical areas for future research on the topic. First, we need a clearer understanding of moderators of the influence of determinants of middle managers’ commitment to innovation implementation. For example, to what extent might the influence of middle managers’ perceptions of an innovation as beneficial to patients be diminished by the number of innovations that they are expected to implement? That is, do middle managers have a finite capacity to implement innovations that they believe will benefit patients? This deserves investigation.

Second, objective measures of middle managers’ commitment and its determinants are needed. To date, nearly all measures have been subjective. For example, Birken et al. found that 40% of studies included in their systematic review measured the determinants of middle managers’ role based on self-report; of these, 26% were based on reports from both middle managers and others, but 52% were based on middle managers’ reports alone. ² And while perception reflects the reality within which middle managers operate, their professed commitment to innovation implementation may not clearly translate into a behavioural commitment. Indeed, evidence consistently suggests that intentions do not always translate into behaviours. ⁹ Research is needed to assess the extent to which self-reports are consistent with objective measures of a commitment to innovation implementation.

Third, the strategies that Urquhart et al.’s findings point to must be tested empirically. Indeed, whether our increasing understanding of the determinants of middle managers’ commitment to innovation implementation harnesses the potential that we hope for is an empirical question. Future studies should assess the effect of strategies on middle managers’ commitment. In particular, they should examine the influence of both discrete strategies and combinations of strategies: to the extent that determinants of middle managers’ commitment interact with each other, carefully selected combinations of strategies are likely needed for maximum impact. For this reason, studies of the influence of strategies on middle managers’ commitment should be driven by theory. Some of this work is already underway. For example, Martin et al. ¹⁰ leveraged the theory of middle managers’ role to promote clinical supervisors’ engagement in implementing a cognitive behavioural therapy intervention.

Fourth, and related to the third critical area for future research, future studies are needed to assess middle managers’ commitment as a mediator of the relationship between the determinants, such as those identified by Urquhart et al., and innovation implementation. That is, do strategies that target determinants of middle managers’ commitment indeed increase middle managers’ commitment and, in turn and perhaps more importantly, promote innovation implementation? To be sure, the role of middle managers’ commitment is important in and of itself – in terms of middle managers’ own wellbeing and job performance. However, middle managers’ commitment also represents one piece in what we hope is a causal chain that leads to improved health care processes and patient outcomes. Efforts should be made to demonstrate causal relationships among these constructs that theory (and a growing body of evidence) suggests.

In conclusion, Urquhart et al. make an important contribution to heretofore poorly understood determinants of middle managers’ commitment to innovation implementation, and they point toward promising areas for future research that have the potential to promote the very outcomes that motivate research in this critical field.