. 2022 Feb 15;22:207. doi: 10.1186/s12913-022-07589-z

Table 3.

Expressions of power in high, moderate and low MRU implementing units

Factor	Full implementing unit	Moderate implementing unit	Low implementing unit
Variable implementation
Interviews conducted	14 (plus a group meeting)	13	7
Collective buy-in	- “…one would not hesitate to say that this was one of the best initiatives” (CEO) - “…We cannot do without it. Because it is so important. If it comes to this issue of maternal death, stillbirth rate, the MRU has helped us a lot. Yes. So we really appreciate this MRU programme and we are taking it with two hands.” (maternity OM) -”… this program, I love it…” (paediatric OM) - “…hundred percent I can recommend it.” (dietitian)	-”…I think the MRU is keeping us on our toes.” (NSM) - “I like the MRU, I enjoy it and I think it is yielding results.” (PHC LAM 1) "… when I weigh the pros and cons, we better go with it…it's one helluva job, but believe me, it is worth it." (PHC LAM 2) - “He has planted something… social worker they are responding, dietitian they are responding, nursing side they are responding and clinical manager responding.” (information officer)	- “… there are months where we have skipped [MRU meetings]… and participation is.. somehow it’s not that great” (clinical manager) - “Honestly speaking there isn't a lot of buy-in. There is a confusion between the MRU and [other mortality meetings] … so it was like a duplication of activities… it's taking us away from the focal point of patient care.” (maternity OM) " I don’t know, but I don't think it will be sustainable"(paediatric OM)
Formal authority (power over)	Stable senior and middle managers, active drivers of the MRU “… so I think we owe a lot to our CEO in a sense that he buying in to the idea and he is supporting us.” (clinical manager) “we do have a distributive leadership” (CEO)	High turnover of CEO (3^rd) and clinical manager, supportive but not active drivers “I heard our CEO—he is still new—I heard him saying I need to attend this MRU because when we say it, it's like "wow it's a nice thing"” (information officer) clinical manager attended when “not busy” (NSM) NSM mostly chaired MRU meetings, with active support from paediatric, maternity and PHC nursing managers	Turnover of CEO, and clinical and middle PHC managers during the period of implementation. Key senior players in ‘acting’ positions, including CEO, and clinical and ward managers. Reportedly disengaged Lack of induction of new staff who “…don’t quite understand the value of MRU or what their role is for that matter.” (clinician) Chairing of MRU meetings was “just a matter of whoever is available” (dietitian)
Self-efficacy (power to)	“it was one of the poor performing hospitals in the entire district. But like now, it’s one of the best.” (paediatric OM) “Those who form part of this I think they are empowered, because now you can see everybody is improving, even in their daily jobs they are active. They know what to do. And they know what to follow, what procedures to do, what policies to implement.” (information officer)	“always it's teaching, it's learning, it's empowering.” (PHC LAM2) “The [existing mortality audit meetings] to me is more like information gathering …as compared to the MRU where you would want to go to the bottom of what happened.” (PHC LAM 1) “I think it is really helping because …now in paeds for pneumonia no death, I don’t know for how long, diarrhoea, no death, there no death from malnutrition I think, ja one, you see it can be one at times it is zero, zero” (information officer)	"if we have one death, we sit down with the doctor, we must find out what is the cause, because we have that [mortality review] programme. Starting from home what happened… [from the] clinic, check road to health booklet, casualty, up to the ward. So we do an improvement plan so we don't repeat" (paediatric OM) District clinical specialists attended the mortality review meetings and were “really helping" (paediatric OM) “our hospital has always encouraged companionship during delivery” (maternity OM)
Agency (power within)	Ability to engage powerful players: “I had constant meetings with the staff at X Clinic, because there were about six mid-wives who resigned, and … the management of the clinic then said no, we are downgrading the hours to 12 h. We then said no, let's engage the district. The district said unfortunately there was a moratorium and I said no, let's write the motivation directly to the office of the MEC [provincial minister of health], and she approved that we can appoint the people” (CEO) Perceived equality: “Don't come and think that you [the CHWs] are subordinate to anybody. You are part of the team, whatever suggestion you have, because you are the people that have a direct contact with the patients, and all the communities” (WBOTs team leader)	Ability to engage powerful players: “Obviously when we are in a situation like this one, pick up the phone whether it is weekend, it’s during the night; call the DCST [district clinical specialist team] if you can.” (NSM) “…I realized this would end up being a maternal death, so I contacted my nurse manager and the nurse manager said “no even contact the CEO”, so I called the CEO, so eventually they accepted the patient and then she was well.” (maternity OM) “…now what I do, after checking [the data], and then I will sit down with them, all of them and then I name and shame [laughs]… now everyone…. the unit managers … they must own their data.” (information officer)	Free to innovate: "I am free to innovate, start projects… many people who have practice the years I have are bored with their practice because they do one and the same thing over and over. So me, I am not bored with my job, because I can always start something new and work on something" (dietitian) Narrative of resistance: “in my view sustaining MRU while we are doing [other mortality audits] is not very beneficial” (maternity OM)
Relationships, team work, collective action (power with)	Inter-professional: “So I think that, that teamwork that is there, that is making everyone come in to want to contribute to the betterment of this community as far as health care is concerned” (clinical manager) Hospital and PHC: “I think it’s the integration between PHC and the hospital. We’ve got an open relationship with each other. You know, if they’ve got a problem at the clinic they will tell you, listen, we’ve got a problem, this is what happened and then it will be fixed” (PHC OM) Collective mindsets: “to be able to have a similar understanding of the primary goal of the whole picture of PHC and the hospital. Because, without it, without the two linked together you wouldn’t be able to achieve what we are able to achieve as far as MRU is concerned.” (clinical manager) Shared resources: “I mobilised my maintenance team and said, for the coming two weeks, you just take the car and go to the clinics, make your own assessment of the facilities. You know, those things that you can do immediately. And those that need replacement like ceilings, then you can just write the motivation – I'll take it to district so the district can assist with the resources” (CEO) “at hospital, not a long while back they were, in need of… surgical… consumables, then at the clinics we will send them to the hospital. Next time we are short of things they will help us…” (PHC OM)	Hospital and PHC: “Immediately they admit a woman they realize that something was not properly done, they pick up the phone quickly and then talk to their partners their colleagues in the clinics so it helps us to be able to care completely for our patients. … it helps us to build strong relationships.” (NSM) "[the hospital] and feeder clinics were not having a relationship, but now, after we engaged with the MRU, we have a relationship which we want to strengthen." (PHC LAM1) Collective mindset: “For some time back we were presenting as PHC as two local areas and the hospital was presenting theirs, however currently we are consolidating our data to be just as one presentation.” (PHC LAM2)	Inter-professional: “We have a group of young health professionals in the hospital, they call themselves the "fresh team", the young ones, it's doctors and allied support staff… they have those open days but they go into communities and address teenagers and try to role model…” (maternity OM) Hospital and PHC: "The dietitians in the hospital and the feeder clinics we have a whattsapp group" (dietitian) PHC “send their subordinates, managers never used to come.” (clinician) “…we discuss confidential issues we wouldn't want WBOTs [ward based outreach teams] to be part of MRU.” (maternity OM) "Last month, we had very decreased admissions in the ward, and they were saying eh-eh our BUR [bed utilisation rate] is going down, as if we are not working… BUR is going down because PHC is doing their work… but if we are closing the tap, the hospital is suffering because we don't admit" (paediatric OM)

Factor

Full implementing unit

Moderate implementing unit

Low implementing unit

Variable implementation

Interviews conducted

14 (plus a group meeting)

Collective buy-in

- “…one would not hesitate to say that this was one of the best initiatives” (CEO)

- “…We cannot do without it. Because it is so important. If it comes to this issue of maternal death, stillbirth rate, the MRU has helped us a lot. Yes. So we really appreciate this MRU programme and we are taking it with two hands.” (maternity OM)

-”… this program, I love it…” (paediatric OM)

- “…hundred percent I can recommend it.” (dietitian)

-”…I think the MRU is keeping us on our toes.” (NSM)

- “I like the MRU, I enjoy it and I think it is yielding results.” (PHC LAM 1)

"… when I weigh the pros and cons, we better go with it…it's one helluva job, but believe me, it is worth it." (PHC LAM 2)

- “He has planted something… social worker they are responding, dietitian they are responding, nursing side they are responding and clinical manager responding.” (information officer)

- “… there are months where we have skipped [MRU meetings]… and participation is.. somehow it’s not that great” (clinical manager)

- “Honestly speaking there isn't a lot of buy-in. There is a confusion between the MRU and [other mortality meetings] … so it was like a duplication of activities… it's taking us away from the focal point of patient care.” (maternity OM)

" I don’t know, but I don't think it will be sustainable"(paediatric OM)

Formal authority (power over)

Stable senior and middle managers, active drivers of the MRU

“… so I think we owe a lot to our CEO in a sense that he buying in to the idea and he is supporting us.” (clinical manager)

“we do have a distributive leadership” (CEO)

High turnover of CEO (3^rd) and clinical manager, supportive but not active drivers

“I heard our CEO—he is still new—I heard him saying I need to attend this MRU because when we say it, it's like "wow it's a nice thing"” (information officer)

clinical manager attended when “not busy” (NSM)

NSM mostly chaired MRU meetings, with active support from paediatric, maternity and PHC nursing managers

Turnover of CEO, and clinical and middle PHC managers during the period of implementation. Key senior players in ‘acting’ positions, including CEO, and clinical and ward managers. Reportedly disengaged

Lack of induction of new staff who “…don’t quite understand the value of MRU or what their role is for that matter.” (clinician)

Chairing of MRU meetings was “just a matter of whoever is available” (dietitian)

Self-efficacy

(power to)

“it was one of the poor performing hospitals in the entire district. But like now, it’s one of the best.” (paediatric OM)

“Those who form part of this I think they are empowered, because now you can see everybody is improving, even in their daily jobs they are active. They know what to do. And they know what to follow, what procedures to do, what policies to implement.” (information officer)

“always it's teaching, it's learning, it's empowering.” (PHC LAM2)

“The [existing mortality audit meetings] to me is more like information gathering …as compared to the MRU where you would want to go to the bottom of what happened.” (PHC LAM 1)

“I think it is really helping because …now in paeds for pneumonia no death, I don’t know for how long, diarrhoea, no death, there no death from malnutrition I think, ja one, you see it can be one at times it is zero, zero” (information officer)

"if we have one death, we sit down with the doctor, we must find out what is the cause, because we have that [mortality review] programme. Starting from home what happened… [from the] clinic, check road to health booklet, casualty, up to the ward. So we do an improvement plan so we don't repeat" (paediatric OM)

District clinical specialists attended the mortality review meetings and were “really helping" (paediatric OM)

“our hospital has always encouraged companionship during delivery” (maternity OM)

Agency (power within)

Ability to engage powerful players:

“I had constant meetings with the staff at X Clinic, because there were about six mid-wives who resigned, and … the management of the clinic then said no, we are downgrading the hours to 12 h. We then said no, let's engage the district. The district said unfortunately there was a moratorium and I said no, let's write the motivation directly to the office of the MEC [provincial minister of health], and she approved that we can appoint the people” (CEO)

Perceived equality:

“Don't come and think that you [the CHWs] are subordinate to anybody. You are part of the team, whatever suggestion you have, because you are the people that have a direct contact with the patients, and all the communities” (WBOTs team leader)

Ability to engage powerful players:

“Obviously when we are in a situation like this one, pick up the phone whether it is weekend, it’s during the night; call the DCST [district clinical specialist team] if you can.” (NSM)

“…I realized this would end up being a maternal death, so I contacted my nurse manager and the nurse manager said “no even contact the CEO”, so I called the CEO, so eventually they accepted the patient and then she was well.” (maternity OM)

“…now what I do, after checking [the data], and then I will sit down with them, all of them and then I name and shame [laughs]… now everyone…. the unit managers … they must own their data.” (information officer)

Free to innovate:

"I am free to innovate, start projects… many people who have practice the years I have are bored with their practice because they do one and the same thing over and over. So me, I am not bored with my job, because I can always start something new and work on something" (dietitian)

Narrative of resistance:

“in my view sustaining MRU while we are doing [other mortality audits] is not very beneficial” (maternity OM)

Relationships, team work, collective action (power with)

Inter-professional:

“So I think that, that teamwork that is there, that is making everyone come in to want to contribute to the betterment of this community as far as health care is concerned” (clinical manager)

Hospital and PHC:

“I think it’s the integration between PHC and the hospital. We’ve got an open relationship with each other. You know, if they’ve got a problem at the clinic they will tell you, listen, we’ve got a problem, this is what happened and then it will be fixed” (PHC OM)

Collective mindsets:

“to be able to have a similar understanding of the primary goal of the whole picture of PHC and the hospital. Because, without it, without the two linked together you wouldn’t be able to achieve what we are able to achieve as far as MRU is concerned.” (clinical manager)

Shared resources:

“I mobilised my maintenance team and said, for the coming two weeks, you just take the car and go to the clinics, make your own assessment of the facilities. You know, those things that you can do immediately. And those that need replacement like ceilings, then you can just write the motivation – I'll take it to district so the district can assist with the resources” (CEO)

“at hospital, not a long while back they were, in need of… surgical… consumables, then at the clinics we will send them to the hospital. Next time we are short of things they will help us…” (PHC OM)

Hospital and PHC:

“Immediately they admit a woman they realize that something was not properly done, they pick up the phone quickly and then talk to their partners their colleagues in the clinics so it helps us to be able to care completely for our patients. … it helps us to build strong relationships.” (NSM)

"[the hospital] and feeder clinics were not having a relationship, but now, after we engaged with the MRU, we have a relationship which we want to strengthen." (PHC LAM1)

Collective mindset:

“For some time back we were presenting as PHC as two local areas and the hospital was presenting theirs, however currently we are consolidating our data to be just as one presentation.” (PHC LAM2)

Inter-professional:

“We have a group of young health professionals in the hospital, they call themselves the "fresh team", the young ones, it's doctors and allied support staff… they have those open days but they go into communities and address teenagers and try to role model…” (maternity OM)

Hospital and PHC:

"The dietitians in the hospital and the feeder clinics we have a whattsapp group" (dietitian)

PHC “send their subordinates, managers never used to come.” (clinician)

“…we discuss confidential issues we wouldn't want WBOTs [ward based outreach teams] to be part of MRU.” (maternity OM)

"Last month, we had very decreased admissions in the ward, and they were saying eh-eh our BUR [bed utilisation rate] is going down, as if we are not working… BUR is going down because PHC is doing their work… but if we are closing the tap, the hospital is suffering because we don't admit" (paediatric OM)

OM operational manager, LAM local area manager, CEO chief executive officer, NSM nursing service manager, PHC primary health care, WBOT ward based outreach team