Healthcare professionals as change agents: Factors influencing bottom-up, personal initiatives on appropriate care, a qualitative study in the Netherlands

Introduction: Healthcare organisations face multiple challenges, often conceptualised as appropriate care. It requires change on different levels: healthcare systems (macro), healthcare organisations (meso), and healthcare professionals (micro). This study focuses on bottom-up changes initiated by healthcare professionals. The aim is to investigate hindering and stimulating factors healthcare professionals experience. Materials and methods: The study used a qualitative design with purposive sampling of eight Dutch healthcare professionals who initiated changes. We conducted online interviews and used Atlas TI with a combination of open, axial, and selective coding for data analysis. Results: The results indicate that professionals are often mission-driven when they initiate change, support from clients and peers may help them overcome barriers. Conversely, peers who feel threatened in their autonomy hinder initiatives of professionals, especially when their changes have financial consequences for their organization. Conclusion: Aligning and integrating macro- and micro-level initiatives is crucial to advancing the movement towards appropriate care and stimulating bottom-up initiatives of healthcare professionals. More research remained needed, in particular studies on the hindering or stimulating role of employers and healthcare professionals' representatives, and the adoption of the concept of appropriate care by patients