Enlightened Change Agents or Nuisance Power? A Qualitative Interview Study Exploring How Hospital Board Members Deal...

Transformative learning in health professions education aims to develop health professionals as "enlightened change agents", who critically question routines and contribute to health system improvement. In hospital governance contexts, dissent from professionals acting as enlightened change agents may be framed as nuisance.

To explore how executive hospital board members interpret and respond to dissent from health professionals acting as enlightened change agents, and how they involve these professionals in governance and decision-making.

We conducted a qualitative phenomenological interview study with six experienced hospital board members from academic and non-academic hospitals. Semi-structured interviews were thematically analyzed using an iterative inductive-deductive approach until data saturation was reached.

Board members portrayed themselves as translators of societal and technological trends into organizational policy who seek broad support while retaining final authority. They operated under ongoing financial and continuity pressures, which constrained room for innovative ideas that fell outside immediate priorities. Board members described dissent as welcome when it was perceived as constructive and actionable within current priorities. When dissent was perceived to delay decision-making or challenge strategic agendas, it was more likely to be reframed as "nuisance power". Three response pathways to dissent were identified: acceptance, tolerance and intervention. Interventions included appealing to majority rule, ignoring dissenters, using hierarchical authority, facilitating exit, or even involving external regulators.

In this hospital governance context, change agency by professionals may be reframed as "nuisance power" when it is perceived to impede board priorities, highlighting how governance conditions shape whether dissent is engaged or marginalized.

Hospital boards may reduce informal marginalization by explicitly organizing how dissent is heard and fed back within governance processes. Educational programs should better prepare future change agents to work strategically within governance processes through framing, alliance-building, and negotiation.