# Exploring the Dynamics of Actors, Structural Factors, and Bricolage in the Implementation and Sustainability of eHealth Solutions: Qualitative Multiple-Case Study

## TL;DR

This study explores how healthcare professionals adapt and improvise to overcome challenges in implementing eHealth solutions, using a qualitative case study approach.

## Contribution

The study introduces a dramaturgical and bricolage framework to understand how actors transform barriers into drivers of innovation in eHealth implementation.

## Key findings

- Bricoleurs use contextual and technical knowledge to transform barriers into promoters of eHealth innovation.
- Structural factors like organizational silos and leadership shifts hinder bricolage and implementation success.
- Colocation, supportive management, and tailored training are key drivers of successful bricolage practices.

## Abstract

European health care systems face mounting pressures from an aging population, workforce shortages, and decentralization, challenging the delivery of accessible, high-quality care. eHealth solutions are widely promoted to enhance efficiency and improve the quality of care. Despite a strong policy report, anticipated benefits remain unrealized, as implementation processes often encounter barriers and high failure rates. Research shows that drivers and barriers are dynamic and shaped by actor interactions. Some studies suggest that certain actors, often acting as bricoleurs, play a critical role in overcoming these barriers through adaptive and improvised practices. However, little is known about how these actors enact roles, what features enable bricolage, and how structural conditions influence these practices.

The aim of this study is twofold. First, it investigates the roles and features of actors involved in innovation processes, with a particular emphasis on the application of bricolage to overcome barriers and the influence of structural factors on these processes. Second, it aims to contribute both theoretical and empirical insights to deepen the understanding of barrier dynamics within innovation processes.

We conducted a multiple-case study comprising 10 semistructured interviews, 11 focus groups with health care professionals, managers, trainers, and policymakers, participant observations of training sessions, and document analysis. An iterative process integrated the dramaturgical approach with the concept of bricolage, guiding the reflexive thematic analyses.

Roles were enacted based on available information, context, and assigned functions. Service specialists (eg, superusers) and mediators (eg, unit or project managers) gained backstage insights through shadowing staff, evaluations, and support activities. When mandated and equipped with contextual and technical knowledge, these actors became bricoleurs, addressing unforeseen challenges by creatively mobilizing resources and thereby transforming barriers into promoters. Effective bricolage required proximity to the implementation site, dedicated involvement, and experiential knowledge of health care and technical domains. Key drivers included colocation, supportive management, stable teams, superusers, tailored training, follow-up activities, and informal evaluations. Barriers such as organizational silos, leadership shifts, staffing shortages, high turnover, geographic dispersion, and technology perceived as challenging or surveillance-oriented constrained bricolage and hindered implementation.

Actors may become bricoleurs when their assigned roles, contextual knowledge, and backstage access enable them to improvise in response to unforeseen challenges. Through a dramaturgical lens, bricolage is an adaptive performance that sustains frontstage care delivery. Bricoleurs combine proximity, experiential knowledge, and dual expertise to transform barriers into drivers by adjusting the innovation process and fostering interaction. These practices illustrate the mutual shaping of structure and agency: enabling conditions expand the space for bricolage, while barriers narrow it. Understanding this dynamic is essential for advancing theory on innovation processes and for designing implementation strategies that leverage bricolage as a mechanism for transforming barriers into drivers of innovation.