Innovation is proposed to improve the quality, productivity and efficiency of health care [
1,
2]. The importance of health care providers focussing on support systems for innovations in daily practice has been stressed as a response to growing public demands and political pressures [
3,
4]. Research has shown that there is a strong link between innovation and leadership in the public sector [
5‐
10], but relatively few studies have aimed at understanding how professionals themselves prompt change [
11].
Managers can create a supportive culture for bottom-up innovations by different means, such as consulting staff, promoting innovators, and protecting them from control-oriented central agencies [
7]. Furthermore, managers can enhance innovations by handling the need to produce (exploitation) and the need to develop (exploration) [
12,
13] and finding an appropriate balance between the two quite different activities. Although innovation in the public sector is a relatively new field [
14‐
16], the quality improvement paradigm has been a forerunner and parallel management model of public sector innovation [
17,
18]. Studies show that innovations are supported by a strong culture and climate of learning and collaboration [
19], and a receptive capacity for new knowledge [
20]. Most innovations are actually outcomes of combinations; that is, integration of diverse forms of knowledge and interaction when people with different backgrounds meet [
16,
21].
Innovation
In this study, innovation is viewed as a function of learning and knowledge creation, integrated into daily work practices, experiences and professional skills, as is the creation or discovery of new solutions, new approaches, or new ideas [
22]. Innovation is the introduction of new elements into public service, representing a discontinuity with the past [
23]. Innovation is an important form of everyday practice-based learning [
24]. With this approach, innovation processes are conceptualized as learning processes and tend to stress not only external drivers of change but also a more intrinsic understanding of innovation. Innovation or learning may thus take its starting point in a disruption of practice and in the practitioner’s uncertainty of how to solve a problem [
25,
26]. An uncertainty requires new knowledge, and new knowledge may challenge the boundaries of local practice and collegial cooperation (habits) and as such offers a learning opportunity and basis for innovation. Thus, all learning in work is to some extent innovative in that it introduces change [
24], which also makes learning a key concept in research on innovation [
27].
Different organizations provide widely different contexts for innovations. Research has found that a learning-promoting climate and culture to mobilize human resources, and a pro-innovation attitude in the organization, are important drivers of change [
2,
3,
7,
10,
28]. Rosen [
3] suggests that time and resources dedicated to fostering a learning environment are likely to be well invested, as is a greater focus on tangible customers’ needs. However, little is known about how innovation capacity in primary health care in general can be stimulated; even less is known about how specific interventions should be designed to support managers’ work with practice-based innovations.
The key resource in many public services, such as primary care, is undoubtedly the staff’s expertise and capacity for problem solving [
29,
30]. The demand for professionals to continually engage in learning and the renewal of professional capacity has been reinforced, and opportunities for reflexive awareness of the impact of informal work processes are considered necessary for promoting and supporting developments in practice [
3,
31,
32]. Thus, change must be accompanied by support structures and managerial actions, encouraging new behaviour and facilitating meaning making [
2,
11,
33].
Three previous studies of well-functioning primary health care centres in Sweden (in the same region in which this study takes place) showed that professionals were provided with time and space for quality improvement work and that they worked to coordinate their efforts through non-hierarchical relationships and collaborative teamwork [
19,
34,
35]. The studies established that professional autonomy was highly valued, sustained and maintained through delegation of responsibility, trust, support and feedback; and that healthy work environments, such as accessible and fair leaders, skilled communication, collaboration/teamwork, employee involvement, and good relations with stakeholders, contributed to the development of a well-functioning health care centre. Conditions that provided a fertile ground for innovations were a culture and climate of managing learning, combined with the ability to monitor performance, adapt to external requirements, and collaborate with others [
19].
Ambidexterity theory and leadership for innovation
The theoretical framework for the intervention in focus is organizational ambidexterity theory. Organizational ambidexterity encompasses the search for the appropriate balance between exploiting existing competencies (the need to produce) and exploring new opportunities (the need to innovate) [
13,
36]. Exploitation and exploration are different activities and require quite different abilities within an organization. Whereas exploitation is about using existing knowledge, skills and processes to safeguard customer satisfaction, maintain business as usual and efficiency, exploration concerns creating new knowledge, skills and processes. Thus, when it comes to exploration, organizations must use a creative and dynamic approach to enable innovations and be willing to adjust and change services, products, processes and markets. Exploration concerns transformation, that is, making changes within the organization with the aim of doing something different. It involves risk taking and experimentation.
Within organizations, there is a tension between the need to produce (exploitation) and the need to innovate (exploration). This tension may be met by flexibility and a combination of different leadership behaviours to switch between these two activities, a so-called ambidextrous leadership [
37]. Dexterous originates from the Latin word dexter, meaning “on the right side”, and the prefix ambi- means “both”. Thus, ambidextrous describes someone who is equally skilful at using both hands.
Studies show that in organizations where managers have the ability to work with both activities, innovations take place to a greater extent among employees. In the organizations where there is a high degree of both exploitation and exploration, a high degree of innovation also occurs; but less innovation occurs when only exploration is high [
38,
39]. Recently, researchers have argued that leaders also need to engage in the tension by providing enabling leadership that bridges the tension between exploitation and exploration activities by creating an adaptive space where new ideas can be scaled within the formal system [
40,
41].
The implication of this work is that, on an organizational level, there is a need to select and reward leaders who express both kinds of behaviours [
39]. Leaders should be made aware of the importance of both opening and closing behaviours to stimulate knowledge development and knowledge use among employees to simulate innovation [
38,
39]. There is a need to raise awareness of the complexity of the innovation process and design education activities that present and practice different elements of ambidextrous leadership. These include exploration behaviours, such as allowing errors and experimentation, and exploitation behaviours, such as monitoring and controlling, allowing routines, and keeping plans. Similarly, employees should learn about experimentation and exploitation [
39]. There is a risk of not putting emphasis on exploitation when innovation work is initiated or that that aspect is neglected [
38,
39].