“Power-with” structures in complex healthcare systems: Gladys Yinusa Interviews Hilary Bradbury
“Action researching means we’re reflecting together. We’re bringing stakeholders into inquiry for change to their own experience. In the healthcare world it is not just because we respect patients that we include them. Although that is true. It is also because we end up with better information when there are more eyes, more hearts and minds involved. This allows action researching to become a self-correcting mechanism. By including those we normally leave out we’re undertaking a shift in power away from the hierarchical triangle toward the circle form.” – Hilary Bradbury in conversation with Gladys Yinusa.
Overview of interview by Gladys Yinusa
The 2021 Action Research Plus AR+ e(CO)Retreat Gathering created an open space for collective reflection and learning among action researchers. The larger purpose of ART is to respond to our eco-social crisis. One particularly fascinating aspect was the understanding of the uncertainties and the complexities facing most organisations today. In that context we addressed the notion of institutional power structures and the role of action-oriented research in the process of transformation.
In talking with Hilary I specifically wanted to delve further into the distinction between ‘power-with’ and the ‘power-over.’ These structures exist within the complex healthcare system I study. Professor Hilary Bradbury is a scholar-practitioner whose work focuses on the human and organisational dimensions of creating healthy communities. She is the principal at Foundation AR+, which is a global community of participative action researchers. She shared her views and examples from her experiences.
In the interview I asked Hilary to consider what the ‘power-with’ stance means for those of us in next generation of action researchers. What does this look like in the healthcare field. We also highlight key insights for new action researchers to encourage us to reflect on our practice and stay connected with the community of action researchers. Our conversation:
Yinusa: Welcome, Prof. Bradbury. Thank you so much for taking the time.
Bradbury: Thank you too. I know you’re busy writing your dissertation.
Yinusa: So true but I wanted to follow up, having attended the AR+ e(CO) Retreat Gathering where you gave a fascinating presentation. Some of the key takeaway for me was your talk about the different power structures that exist. You spoke of the ‘Power over’ pyramid/triangle structure within an organisation and how we can move towards the ‘Power with’ circle structure. You basically centred how we do action research transformations around that core image. Triangle to Circle.
I wondered if you’d elaborate on the notion of what the ‘Power with’ structure entails. And how can complex healthcare systems, for instance, use this concept?
Bradbury: I am delighted to talk about that. I like that you are interested precisely in this issue because I think it is central. It is not the only thing, but I would say it’s one of the three most central things for us in our practice of action research for transformations (ART).
So, let’s situate ourselves a little bit with context. I understand that you are in the healthcare world. So, you are dealing with the organisational aspects of health care. So in that there are many power structures that all intermingle. By the way I was a full professor at what is called an Academic Medical Centre in the University of Oregon System. I often worked therefore with physicians and with nurses to support their leadership and organizational development. And outside the classroom I also led a successful mindfulness program with patients on the palliative care wards. So in my own experience, and I will check this with you in the moment, some of the primary power issues in healthcare are how physicians relate to nurses. Everybody says we are a team. But that shift from the triangle to circle is a little tricky because of how people are socialized and the gender dynamics in healthcare. But physicians and nurses are managing it reasonably well as they repattern things with more inter-professional respect.
Then a bit harder to repattern, and another very important power-over triangle, is physician and patient. Or indeed physician and healthcare personnel in general, so nurse, physician, therapist. The patient is trained is to be passive in the space of white coat expertise. So that’s another one of those power triangles. And why not have a third one a we’re at it. We can think that behind the scenes there is a tremendous power over us. Because this one is invisible, and it sounds so abstract. And that’s the question of whose knowledge and whose purpose for knowledge counts? And what kind of knowledge has power.
As action researchers behind the scenes, we need to be interested in this. Is real knowledge only when it’s got statistics, or it’s from the experts, or it allows you to tell people what to do. Maybe this is the hierarchy of all hierarchies. It’s the one that causes the physicians to think, you know I have got the answer, so I can tell the nurses. I mean literally, a physician writes orders. Obviously we want experts, we need experts, but in such a way that knowledge itself can be treated as something that is useful for those involved. For that it’s brought more into this circular form. So let me check with you. Is that the kind of conversation we want to have?
Yinusa: Yes, that’s absolutely the right conversation. We are in the right field.
Bradbury: O good. Let me check with you again. Do you see these triangles of power over systems in the healthcare system that you are studying?
Yinusa: Yes, definitely it does exist and really came out strongly in my interactions within the system as well [United Kingdom]. I think, even beyond the layer of just physicians and other healthcare professionals, even down to those who are working really closely with patients. I recently had an encounter working with mealtime volunteers. So just even the dynamic of their relationship, the contact, and interactions they have with the patients is such a useful feedback that could be going back to the ward staff, for example. But it often gets lost along the way. That is the same knowledge-sharing that you are talking about. So that we are having to be really intentional about questioning how this knowledge sharing is moving through and around the cycle circle, as opposed to only one way inside a pyramid structure.
Bradbury: Yes, nice. You’re mentioning mealtime volunteers reminds me of one of the outcomes from a study that I did with meditation volunteers on the palliative care wards. We noticed that there was no formal mechanism for communications between volunteers, some of whom were themselves physicians and nurses. These volunteers would sit with patients, especially the more lonely patients. But they would find out enormously important information about nutrition, for example, you know, and other kinds of things too. So, one of the more useful things that we did, which came as a surprise in our action research study was that we created a mechanism for letting the staff know. Whoever was rounding next would hear from volunteers. You know, here is how I think the patient is doing. Obviously within the bounds of confidentiality. Some years later we heard, that mechanism was enormously useful and had spread elsewhere. So, it is just a very simple example, isn’t it, of how the knowledge that does not seem very ‘experty’ or very statistically driven in some ways is in fact very useful. But no one thought to capture it.
So that is the first triangle, right. So, using this self-correcting mechanism of reflecting together, bringing stakeholders involved, this gives us the reasoning for why we want to shift from the triangle to the circle. It is not just because we want to be nice; it is not just because we respect patients. Although that is true, it is also because we end up with better information when there is just more eyes if you will, there is more hearts involved.
Are we still on track? Perhaps I will give you a good example that I know.
Yinusa: Yes, it’s on track. I would like to hear of the example.
Bradbury: Okay, well, so one of my favourite pieces of work in this setting, is the work of Svante Lifvergren, who is a Swedish physician, an MD. And like you he became a PhD inside the hospital system. Like you just fell in love with action research.
I think he was also a hospital administrator concerned with what they call improvement science in Sweden. They often call action research improvement science, by the way, and they are very interested in co-producing things with their patients. I like that language. One of the questions he took up is how to have the individual patient experience and their pathway through the system become more basically healthful, more pleasant, more easy, Both efficient and effective. What a revolution.
The work started in conversation with one of his patients. Svante is a lung doctor, and his patient Lars said to him, you know, I have to come here under the most awful circumstances to your emergency room. I can hardly breathe, and you know my lungs are collapsing. Couldn’t you please come to me? Svante thought about it and said you know, that is such a good idea. Actually it is a radical idea; as you know, to make a major shift in how patients are treated. This triangle between Lars and Svante, is turning into a circle. So, Svante says, you know what Lars, that is a brilliant question. How are we going to do it?
So Svante began to understand that another circle needs to be created. The next one among the physician and all the other people in the clinic who served Lars. The nurses, lung therapists, everybody right. To cut a long story short, like good old action researchers, Svante called a meeting. And said this is what our patients want us to do, basically to radically transform this system, around their needs. What do you think we can do? And everybody’s like, that’s such a complex question. But just asking was like the proverbial butterfly flapping that caused a hurricane.
They begin reasonably quickly to do some experiments , e.g., sending a small team of nurses, which turns out to be far less costly than bringing Lars into the medical clinic, into the ER. I mean, it is literally 10% of the price. It is also the same cost ratio in the United States. So you’re saving that 90%. Then Svante’s meetings start to widen the circles, and show the data. Early findings in this action research, include data collection that shows patients, get better, are happier and they are saving money. What is not to like. There was pretty compelling evidence and so support grew.
So out of a small set of experiments, people began to hear about it, you know let’s do it in our clinic. Then connecting these dots it grew. I call this ‘social proliferation.’ It’s a way to scale by proliferating these small local efforts and having them take root with others.
Yinusa: That’s a good example.
Bradbury. Just by the way, this project started because Svante came to visit us over here on the west coast and heard about other work that we were doing. Not in the health care system but in the corporate system. I had been leading some work at the port of Los Angeles. But again, it was the same idea. How do we bring pollution out of the system, how do we bring health into our shared system? By bringing the executives of the cargo shipment system together. Then talking about it and then beginning to find the leverage points for improvement.
The port and the hospital are both complex. But if you invite in the people, if you create a relational space with the people, if you begin to think together about improvements, you can begin to take action. So, for me, these are nice examples of the three spaces of ART Coming together, moving from triangle to circle. Does that seem relevant to your system?
Yinusa: It does definitely. I think, for me, the emphasis on the relational space is really helpful. Creating that environment, as you said, though they do similar things but because of the siloed nature of working. There is often no creation of that space for health care professionals to come together to tackle related issues. I think that is where the disconnect is oftentimes. It was surprising for me, one of my takeaway was that healthcare professionals never really have the relational space where they sit together. You know to really have that conversations to tackle issues say on nutritional care. But my action research created the space for them, and you know, there was a shared understanding of each other’s roles as well as the challenges they faced, which unbeknown to some other professionals, were not supporting others to carry on their role effectively.
So, I think this is also why I wanted to engage with you as well to talk about you know, how can healthcare systems really leverage using action research for transformation?
Bradbury: Well, this is a question really about the next generation, like your generation and beyond. I think having good examples is super important. Healthcare is more like engineering now. They are very interested in good outcomes and what it takes to get good outcomes. There is a willingness to see the huge value of action research. We share the same spirit. Part of the work is facilitating a next stage of intelligence in the system, helping to diagnose silo problem and overcome them.
So, first of all, you make the case. Having a successful example is compelling. Second, grow your own capacity. I was delighted you took the time to come of the Gathering. This is in part how we stay engaged with our own development. And you met like 50 other people from 20 countries. It’s impossible not to learn something, right. I think part of the work that all of us have to do is simply connect up. You know there’s power in our organising and in our relational space. Like yourself many are doing great work, but you might feel a little lonely as action research is still a bit unusual.
You mentioned earlier that your compatriots, your peers doing action research have dropped out. That’s not unusual. It’s not unusual in any PhD program, but I think doing an action research PhD is particularly hard. Because you need more spectrum as a human being, you need to be an engaging human being. You need to be intelligent, and you need to know your statistics. You need to know how to run a meeting, attract the right stakeholders. You’re a change maker. There is a lot. So, for this we need to grow our own capacity.
Yinusa: Do you have advice on that.
Bradbury: For now make sure you have the support of enough faculty. I don’t expect all faculty, quite honestly, to feel comfortable with action research. But I want an awful lot more faculty to support the kind of work that you are doing. It’s growing in popularity and I hear students don’t have support. In the meantime, AR+ can create social networks among students and faculty elsewhere but, the real magic happens when you have it closer to home.
Yinusa: Thank you. Any last words?
Bradbury: I know that you’re also interested in an administrative career. Consider also how to remain a little bit of a scholar too. Take time for reflection. So that would be my biggest advice. To take time always for reflection on your own practice. Though it may feel time-consuming it’s important to stay somehow involved with other scholar-practitioners of action research. Just to take a couple of hours a month. I see it in our coLABs people just take a couple of hours a month, and over the course of many months, it refreshes them, refreshes their work, and helps those who want to also write about their work. But maintaining that space for reflection as a practitioner is very difficult. It sounds so easy, but it is very difficult. And I think you really have to be intentional about it.
Yinusa: Great advice, great responses. It is good that we get to glean from your wealth of wisdom. I often call action research a form of service, and I know you have been in this field for decades now. So, thank you for sharing. Takeaway for me, is to create the space for reflection as a practitioner and engage with the action research community. A really great takeaway for me and for those that will get to read the write-up that follows this interview afterwards. Again, I appreciate you for the advice, the responses and for your time.
Bradbury: Thank you. I look forward to seeing your dissertation
Yinusa: Me too. Thank you.
Reference to the Swedish case mentioned:
Lifvergren, S. & Zandee, D. 2017. Healthcare transformation: Action research linking local practices to national scale. Bradbury, H. 2017 Ed. Cooking with action research: Stories and resources for self and community transformation. (Available for download at AR+)