Time for change in implementation research and practice

We argue implementation research pays insufficient attention to time. We were prompted by learning gained from the Harnessing Innovation in Global Health for Quality Care (HIGH-Q) programme to explore implementation through time as an analytical lens. Time directly underpins how individuals, teams, and organisations adopt and sustain new practices, yet existing frameworks primarily reference it indirectly. We propose that considering time as a multi-dimensional construct is relevant to the science of implementation in complex systems and to promoting its thoughtful practice.

HIGH-Q research involved coordinated ethnographic, quantitative and interventional studies of workforce enhancements in hospitals already benefiting from long-term neonatal technology and quality improvement support. Findings made it clear how time scarcity constrains improvement and use of new technologies in low-resource environments. New clinical technologies such as continuous positive airway pressure require time of users directly and indirectly linked to new cognitive and coordination work. Tasks compete for scarce time resulting in prioritisation, while time is needed for skill development, reflection, and team adaptation. Conceptually we suggest the following: (1) time functions as a finite and negotiable resource that must be deliberately allocated to new practices, without creating temporal space, change efforts risk displacing existing essential work; (2) "hidden time" is required for reflection, collaboration, management and internalisation of new routines-activities rarely acknowledged in project planning; (3) time is an expression of value, reflecting what actors prioritise and the moral or organisational meaning attached to the allocation of effort; (4) healthcare work is governed by temporal structures-shifts, schedules, and social norms-that may hinder flexibility and adaptation; (5) maintaining "time in reserve" supports resilience and psychological recovery in stressful environments, yet interventions may erode this capacity; and (6) implementers' own time investments are frequently omitted when characterising interventions, despite being crucial for sustainability.

Viewing implementation through the prism of time exposes hidden constraints and misalignments between expectations, timelines and real-world conditions. Time in its multiple manifestations should be explicitly examined alongside theories of change and implementation frameworks to help understand why interventions in complex systems succeed or fail, especially where personnel and resources are already scarce.