Balancing power in co-production: introducing a reflection model

The shift towards active user participation in co-producing health and welfare services has brought to light challenges related to power imbalances. While co-production aims to create effective change and value through partnerships, the inherently asymmetric relationship between caregivers and users presents obstacles. This asymmetry, often manifesting as power imbalances and resistance to change, hinders the establishment of equal and reciprocal relationships necessary for successful co-production. This paper addresses this challenge by focusing on the role of improvement coaches, who are key figures in facilitating or hindering user influence. The study explores how a reflection model, drawing on Franzén's power triangle, can be used to visualize and address these power relationships during co-produced improvement work, particularly in complex care situations where power dynamics are often subtle and easily overlooked. The aim is to provide a practical tool for improving co-production by promoting systematic reflection on power imbalances.

Existing literature emphasizes the importance of user involvement in improving health and social care services, highlighting the benefits of co-production. However, studies also point to the persistent power imbalances between professionals and users, and the challenges of achieving genuine partnership in practice. Previous research highlights the roles of asymmetric power relations, caregivers' attitudes, and fears of power loss in hindering co-production. The need for addressing underlying power imbalances to create equitable and reciprocal relationships is frequently underscored. However, there is a gap in understanding how to actualize these principles in everyday practice. The theoretical foundation of this study is based on relational power perspectives, focusing on the exercise of power in relationships, and the concept of power as a multifaceted, constantly shifting phenomenon. Franzén's power triangle, categorizing power in terms of resources, discourses, and contexts, provides a valuable framework for analyzing power dynamics in the context of co-production. The literature on reflective practice, and its potential to stimulate learning and development, informs the development of the reflection model proposed in this study.

This study employed a two-fold design. First, qualitative interviews were conducted with twelve improvement coaches (Esther coaches) within the Esther Network in southeast Sweden. These coaches had experience in co-producing improvement work with users having complex care needs. The interviews were semi-structured, focusing on user influence, coaching improvement work, and the user's influence within improvement projects. A strategic sample of interviewees was used, ensuring representation from various municipalities and professional backgrounds. Interviews were transcribed verbatim and analyzed using inductive conventional content analysis, followed by a deductive directed content analysis using the lens of Franzén's power triangle. This empirical data served as the foundation for developing the reflection model. The second part involved the three authors, who collaboratively conceptualized and refined the reflection model based on the interview findings and the theoretical framework of Franzén's power triangle. Two of the authors were involved in the Esther Network; the third was an improvement science associate professor. Ethical considerations were addressed through informed consent and adherence to Swedish legal requirements.

The analysis of interviews with improvement coaches revealed two main categories of power-related factors: enablers and barriers to co-production. Four subcategories were identified under these categories: access to resources (user’s resources, alternative resources, unit’s resources, organization's resources), lack of access to resources, discursive barriers (among users and professionals), and discursive resistance (strategies to balance power and overcome barriers). The findings highlighted the crucial role of resources at various levels—individual users, care units, and the organization. Insufficient resources (understaffing, lack of time and continuity) were significant barriers to co-production. Attitudes and perceptions of both caregivers and users were also identified as crucial factors. Caregivers' paternalistic attitudes and users' self-subordination posed considerable challenges. Improvement coaches reported employing various strategies (discursive resistance) such as actively involving users, valuing their contributions, and challenging ingrained perceptions. However, they also noted that overcoming these barriers could be difficult due to the contextual factors. These findings informed the development of a reflection model that considers the interactions between resources, discourses, and contexts in the co-production process.

The findings emphasize the dynamic and relative nature of power in co-production, aligning with Franzén's relational power perspective. The reflection model, the power triangle of co-production, is proposed as a tool to address this dynamic, focusing on the interaction between resources, discourses and contexts. The model's three-step cycle (reaction, interaction, action) encourages systematic reflection and action. This addresses the need for continuous awareness, reflective practice, and dialogue to facilitate more balanced relationships and institute change. The model offers a balance between structure and flexibility, providing a framework for reflection while allowing for contextual adaptation. It encourages a critical approach, recognizing that resistance to change may not always be overt. The study's focus on improvement coaches' perceptions is both a strength and limitation, acknowledging their crucial role while recognizing that other perspectives (e.g., organizational leaders, users) would provide further insights. The model's potential for broader applicability is supported by the Esther Network's international reach, suggesting its relevance across diverse healthcare contexts.

This study contributes a novel reflection model, the power triangle of co-production, designed to balance power dynamics in co-produced improvement work within health and social care. The model's flexibility and focus on interactive reflection make it adaptable to various settings. Future research should test this model within improvement coach training, incorporating user perspectives to further refine its effectiveness. Further exploration of the model's application from organizational and economic perspectives would also be beneficial.

The study's reliance on improvement coaches' perceptions represents a limitation, as other stakeholders' perspectives (users, organizational leaders) could offer different insights. The model's development did not explicitly involve users, a point for future improvement. The context-specific nature of the Esther Network could limit the generalizability of findings, although the model's adaptable framework is intended to mitigate this. Despite these limitations, the model provides a valuable starting point for addressing power imbalances in co-production.