Conditions shaping policy enactment: Insights from evaluators at the bottom of the implementation staircase

The current study advances understanding of policy enactment by conceptualizing the conditions influencing policy implementation in healthcare. A qualitative interview study examines how micro-level evaluators experience enacting macro-level policy, leveraging the implementation staircase model (Reynolds & Saunders, 1987). Three key themes emerged: alignment divide, value and impact, and policy leadership, summarizing nine conditions for policy enactment. Data were collected from semi-structured interviews (n = 8), document reviews (n = 6), and researcher reflections. Findings suggest that the evaluators' position at the lower levels of the implementation staircase amplifies the gap between policy and practice. Results highlight the crucial role of relationships between top and bottom layers of the staircase in influencing policy enactment.