Completing the sustainability puzzle; The impact of middle managers’ sensemaking on the organisational change process towards a more sustainable hospital

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Completing the sustainability puzzle

The impact of middle managers’ sensemaking on the

organisational change process towards a more sustainable hospital

Master specialisation: Organisational Design & Development Study program: Business Administration

Radboud University

Organisation: Radboudumc

Supervisor: Prof. dr. K. Lauche Second evaluator: Dr. A. Smits

Date: June, 2017

Name: Riëlle Martens

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Completing the sustainability puzzle

The impact of middle managers’ sensemaking on the

organisational change process towards a more sustainable hospital

Master thesis

Riëlle Corine Anna Martens 2016 – 2017

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Acknowledgements

This Master thesis is the end result of my research project at the Radboudumc, and most important, my final project of two pleasant and informative years at the Radboud University. I never regretted the decision to continue my study in Business Administration, after I graduated two years ago for my bachelor in Human Resource Management at the Fontys University of Applied Sciences. Now, six years later, I look back at a wonderful study period in both Eindhoven and Nijmegen, and I am ready to face my future.

The front picture of this thesis illustrates multiple hands. Multiple hands that are necessary to complete the sustainability puzzle. It presents the hands of non-clinical managers who hold shared beliefs and values to design a shared culture of sustainability within the Radboudumc. However, these hands also illustrate the hands of organisational members in the strategic top and the operating core who hold shared beliefs and values to change the Radboudumc, and to eventually design a more sustainable healthcare sector. In the end, all hands of hospitals are required to suppress the social and environmental impacts of the healthcare sector that affect peoples’ health.

As I reached the final stage of my study, I would like to thank multiple people for their unconditional support. First and foremost, I would like to thank Prof. dr. Kristina Lauche for her tremendous supervision, and her many insightful ideas and conversations during my period of thesis writing. Without her my Master thesis would have not been at this level. Besides, I would like to thank Dr. Armand Smits for his critical note, insights and recommendations for possible improvements. Also, I want to thank the Radboudumc and all non-clinical managers that were willing to participate in my study. Without them I would have never been able to conduct this study. A special word of thank to Wouter van Wijhe for the successful collaboration and for providing me with the necessary information to conduct this research.

Finally, I would like to thank my parents, my uncle and aunt, and all my friends that supported me during this period of thesis writing. My parents always believed in me and encouraged me to make the decisions that made me happy; not only during this period of thesis writing, but in my whole study period. Also, I want to thank my uncle and aunt for their insightful feedback on my thesis and their critical note. And finally, I want to thank all my friends, they were always there for me; during the periods of fun, but also during the harder periods. Thank you all!

Then it only remains me to say, enjoy reading my thesis, and let us complete the sustainability puzzle of the healthcare sector!

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Abstract

Nowadays, it is hardly possible for the healthcare sector to offer the best possible care for patients, due to the sector’s negative social and environmental impacts. To offer the best possible care, hospitals are required to change towards sustainability. A key role in designing a shared culture of sustainability can be assigned to middle managers. Middle managers are able to formulate the change and implement it to design a more sustainable hospital. Therefore, it is extremely relevant for hospitals to understand and deal with the sensemaking activities of middle managers concerning sustainability. My study addresses the impact of middle managers’ sensemaking on the organisational change process towards a more sustainable hospital.

The study of this thesis is conducted within the Radboudumc, investigating the sensemaking and sensegiving activities of ten non-clinical managers (i.e. middle managers). A qualitative, inductive, social constructivist perspective is used to gain insight into the constructed realities of these non-clinical managers. The data is gathered through document analysis and semi-structured in-depth interviews.

The results showed that non-clinical managers were increasingly aware of a change process towards sustainability, within society and within the organisation. Still, sustainability was not enough incorporated into the underlying beliefs and values of non-clinical managers. This was caused, inter alia, by non-clinical managers’ main focus towards the primary process, which is partly directed towards the people dimension of sustainability. Besides, the Radboudumc needs to do more to spread the word about sustainability; to increase the visibility of sustainability, and to integrate it into the underlying beliefs and values of non-clinical managers. As a result, sustainability was only partly managed and disseminated by the non-clinical managers.

This research extends existing literature as it studies the micro foundations of sustainability; focusing on the role of middle managers during the change process towards a more sustainable hospital. In addition, it supports the change process towards sustainability of the Radboudumc and of other hospitals operating in the Netherlands, or comparable countries, that are integrating or willing to integrate sustainability into the organisation.

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Managementsamenvatting (Voor het Radboudumc)

In de afgelopen jaren is in toenemende mate een externe en interne druk ontstaan op de gezondheidszorg om duurzamer te opereren. Het Radboudumc wil zorg leveren die toekomstbestendig is zowel in ecologisch, economisch als in sociaal opzicht. Om duurzaamheid succesvol te integreren heeft het middenkader van ziekenhuizen een belangrijke rol, aangezien zij de belangen van de strategische top en de belangen van zorg professionals vertalen en aan elkaar koppelen. Hierdoor ontstaat een grotere kans op een door verschillende medewerkers ondersteunde verandering naar duurzaamheid. Echter, hierbij is het van belang dat duurzaamheid eerst geïntegreerd wordt in de betekenisgeving van het middenkader. Het doel van dit onderzoek is om inzicht te verkrijgen in hoe het middenkader de verandering naar een duurzamer ziekenhuis interpreteert en ervaart, en hoe dit vervolgens invloed uit kan oefenen op het veranderproces.

Dit onderzoek is op een kwalitatieve, inductieve wijze uitgevoerd binnen het Radboudumc. Data is verzameld door middel van document analyse en semigestructureerde interviews met tien bedrijfsleiders (i.e. non-clinical managers). Hierbij lag de focus op inzicht verkrijgen in bestaande ervaringen, overtuigingen, waardes en percepties ten aanzien van het begrip duurzaamheid, de verandering, de bottom-up initiatieven en de top-down initiatieven.

Uit de resultaten kwam naar voren dat de verandering naar duurzaamheid steeds zichtbaarder wordt, in de maatschappij en in de organisatie. Echter, het daadwerkelijke bewustwordingsproces gaat erg langzaam, doordat de focus van bedrijfsleiders vaak nog te veel gericht was op het primaire proces. Het belang van een verandering naar duurzaamheid werd wel onderkend, maar het lukte onvoldoende om een vertaling te maken naar de afdeling. Dit bleek meerdere oorzaken te hebben. Onder andere waren bedrijfsleiders ervan overtuigd al duurzaam te handelen, aangezien een gedeelte van de sociale aspecten geïntegreerd was in het primaire proces. Daarnaast ontbrak de zichtbaarheid van duurzaamheid in het Radboudumc. Hierdoor werd duurzaamheid nog beperkt uitgedragen door de bedrijfsleiders.

De beschreven aanbevelingen zijn voornamelijk gericht op het vergroten van de bewustwording onder bedrijfsleiders. Het is van belang inzicht te verkrijgen in hoe de bedrijfsleiders tegen duurzaamheid aankijken. Hierdoor is een betere samenwerking mogelijk, om zo de zichtbaarheid en integratie van duurzaamheid efficiënt te vergroten. Een duurzaamheidsrapport geschreven voor de laag van bedrijfsleiders kan hierbij helpen. Evenals, het laten verantwoorden van afdelingen over hun duurzaamheidsintenties en –aanpak.

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Introduction

Our world population is growing, consumption is increasing, and in turn the earth is being polluted and damaged. Not only our environment is suffering, resulting in a higher probability of severe weather, but this climate change also has a significant social impact, such as increased migration and risk of conflicts (Burrows & Kinney, 2016). Various social and environmental impacts ensure that many consider climate change to be today’s most pressing global issue (Holmner, Rocklöv, Ng, & Nilsson, 2012). Due to the global interest and urgency of this problem, sustainability has become a central topic for many organisations (Bansal & DeJardine, 2014; Haugh & Talwar, 2010). The healthcare sector is expected to lead by example, but still contributes significantly to the pollution of our earth (Buffoli et al., 2013; Holmner et al., 2012; World Health Organisation, 2011). Therefore, a change towards sustainability in the healthcare sector is desired and needed.

The study in this thesis aims to advance our understanding of how hospitals change towards a more sustainable hospital. In this thesis sustainability is defined as “a concept whereby companies integrate social and environmental concerns in their business operations and in their interaction with stakeholders on a voluntary basis” (Commission of the European Communities, 2001, p. 6). Meanings to this change middle managers construct is central in the success of the transformation. This research adopts a sensemaking perspective on middle managers’ meaning construction to sustainability, suggesting that these meanings are constructed in social interaction, leading to a shared culture of sustainability and a more sustainable hospital.

Nowadays, organisations increasingly aim to integrate sustainability practices into their business, focusing on multiple value creation (Bansal & DesJardine, 2014). According to research of the Boston Consultancy Group (BCG) about 70 percent of the organisations placed sustainability permanently on their management agenda (BCG, 2012). Various external pressures to adopt sustainability practices into the organisation, caused by the interests of multiple individuals, become visible within our society. Executives see it as necessity for economic survival, consumers expect sustainable products (Peloza, White, & Shang, 2013), and a stricter legislation related to the social and environmental aspects of doing business is introduced (Blazevic, Lauche, Janssen, & Van Riel, 2015). These grounds oblige organisations to integrate sustainability practices into the organisation in a certain way.

The healthcare sector encounters the same external pressure or maybe even a bigger one, due to the large value that people attach to healthcare (Christensen, Grossman, & Hwang

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2009). Additionally, this sector is worth the attention due to its size, growth and direct impact on health. In 2015 the spending on healthcare in the Netherlands accounted for 10.8 percent of the Gross Domestic Product (GDP), compared with the innovation and technology sector that accounted for only 2 percent of the GDP in 2015 (OECD, 2016). It is the primary process of hospitals to offer the best possible care for patients, directed towards their personal needs (Buffoli et al., 2013). In established hospitals, offering the best possible care is hardly possible, due to the negative social and environmental impacts of hospitals that affect peoples’ health. To satisfy the needs of multiple stakeholders, an increase of integrating sustainability practices into hospitals arises. Nowadays, 54 percent of the hospitals around the world incorporated sustainability practices into their business activities and 80 percent of the hospitals expect to do this in the upcoming two years (Initiative for Global Environmental Leadership [IGEL], 2015) Nonetheless, great leaps are still needed to achieve a more sustainable healthcare sector (Zadeh, Xuan, & Shepley, 2016).

1.1 Research framework

Several studies suggest that the integration of sustainability practices into hospitals is accomplished by the dissemination of information, the change of policies and practices, and the implementation of new sustainable business strategies (see Haugh & Talwar, 2010). On top of that, hospitals make greater efforts to incorporate sustainability in case of a well-supported change process of the organisation’s symbolic world, which is about changing the culture of an organisation with its own meanings (Howard-Grenville, Golden-Biddle, Irwin, & Mao, 2011; Haugh & Talwar, 2010). Organisations often struggle with the question how to achieve this cultural change, to allow sustainability infusion into their existing business (Bertels Papania, & Papania, 2010; Blazevic et al., 2015; Palmer, Russell, & McIntosh, 2012). If sustainability is not integrated into individuals’ set of beliefs and values, the organisation will never become truly sustainable (Galpin, Wittington, & Bell, 2015; Russell, as cited in Palmer et al., 2012). Hospitals need to understand and deal with the meanings that individuals construct towards sustainability in order to integrate sustainability into their underlying set of beliefs and values.

A key role in changing the hospital’s culture can be assigned to middle managers (Galpin et al., 2015). Middle managers formulate the change and implement it to design a more sustainable hospital. To ensure that the formulation and implementation succeeds, middle managers are required to influence how organisational members understand, interpret and make sense of the organisational change (Rouleau & Balogun, 2011).

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10 In today’s society, organisational members often experience the change process towards sustainability as difficult, due to various reasons. One of the reasons is that sustainability is still perceived as a threat. Also, the results of sustainability infusion can not be measured immediately, but are something to be measured on the long term (Blazevic et al., 2015). As a result, sustainability infusion often lacks a sense of urgency (Haugh & Talwar, 2010). Besides, the organisational change process towards sustainability often starts as a local initiative that needs to be ‘sold’ internally and create momentum for change (Howard-Grenville, 2007). Furthermore, some managers still believe in a trade-off between profitability and sustainability (McWilliams & Siegel, 2000). Finally, the strategic goal to adopt or increase sustainability practices need to be translated towards members lower in the organisation, which is often hard because change recipients are influenced by the way they make sense of a strategy (Balogun, 2006). As a result, strategic goals can be different intended at the strategic top than the actual outcomes of implementation at the operating core of the organisation. This ensures that sustainability outcomes can differ widely within the organisation (Blazevic et al., 2015).

Since middle managers fulfil a key role in changing the hospital’s culture, they are able to reduce some of the difficulties experienced by organisational members. Nonetheless, middle managers can experience the same difficulties. When sustainability is integrated into middle managers’ set of beliefs and values, they can act as linking pin between strategic initiatives and local initiatives (Balogun, 2006). In both bottom-up and top-down change, middle managers receive and transfer information. In this process, they adjust the information in such a way that it is meaningful for the recipient of the information. Therefore, middle managers have an important stake in satisfying the internal pressures of sustainability infusion of the strategic top and the operating core, and thus in the formulation and implementation of the organisational change process towards more sustainability. This makes it extremely relevant for hospitals to understand and deal with the sensemaking activities of middle managers concerning this topic. According to Rouleau and Balogun (2011), sensemaking is “a social process of meaning construction and reconstruction through which middle managers understand, interpret and create sense for themselves and others of their changing organisational context and surroundings” (p. 955). The outcomes resulting from middle managers’ sensemaking process influence other organisational members and create a shared culture of sustainability. This process of influencing others’ sensemaking activities, toward the underlying beliefs and values of middle managers, is defined as sensegiving (Gioia & Chittipeddi, 1991).

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How do middle managers make sense of and in turn give sense to the organisational change process towards a more sustainable hospital?

The study in this thesis theoretically contributes to existing literature concerning the adoption of sustainability practices in the healthcare sector; focusing on the role of middle managers in the change process towards a more sustainable hospital. Most existing research is focused on the macro levels of sustainability; explaining the role of organisations in the integration of sustainability practices. However, little in known about the micro foundations of sustainability practices within organisations; investigating the role of individuals in sustainability development (Siegel, 2009). Especially the process in which middle managers’ sensemaking efforts influence other organisational members, to adopt middle managers’ point of view in the change process, stays underresearched (Rouleau & Balogun, 2011).

To successfully integrate sustainability into a hospital, middle managers are required to incorporate sustainability into their underlying set of beliefs and values. This means creating a culture of sustainability. However, little is known on how the culture of an organisation changes toward more sustainability (Bertels et al., 2010; Blazevic et al., 2015; Palmer et al., 2012). To investigate the sensemaking activities of middle managers during this change process, I focus on their previous experiences, beliefs, values and perceptions. Especially during times of change, it is extremely useful to understand the socially constructed realities of middle managers towards this process. By getting insight into the sensemaking process of middle managers, it might be possible to steer stronger towards the intended aim of sustainability infusion, provided by individuals at the strategic top and the operating core. This study differs from other studies in the way that it links both top-down and bottom-up changes in the process of sustainability infusion. It is essential to conduct this study in the healthcare sector, due to the ongoing pressure to design more sustainable hospitals (Zadeh et al., 2016).

I investigate the research question by answering two sub questions. Both questions are answered by first getting insight into the different theoretical dimensions of this thesis: sustainability, organisational change, middle managers and middle managers’ sensemaking. This prior theoretical knowledge is required to understand how the organisational change process towards more sustainability might take place. Furthermore, it provides theoretical knowledge on the role of middle managers and their sensemaking efforts during change. Document analysis and semi-structured interviews are used to gain an in-depth understanding of the actual change process, and of the sensemaking and sensegiving activities of middle managers during change. Hence, the sub questions are as follows:

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12 • How does the sensemaking process of middle managers take place during the change

process towards a more sustainable hospital?

• In what way can middle managers’ sensemaking influence (i.e. sensegiving) the change process towards a more sustainable hospital?

Besides a theoretical contribution, answering the research question has a practical contribution for the Radboudumc, which served as a single entity case for this study. The outcomes of this study elaborated on the interpretations and experiences of various non-clinical managers (i.e. middle managers) operating in the Radboudumc, concerning the current change process towards sustainability. Based on these outcomes, current internal practices are able to be maintained or adapted; to steer stronger towards the intended aim of sustainability infusion at the Radboudumc.

Other hospitals operating in the Netherlands, or comparable countries, are also able to benefit from the outcomes of this study. Recommendations are provided on how to successfully integrate sustainability practices into hospitals, by elaborating on middle managers’ sensemaking and sensegiving activities on the organisational change towards a more sustainable hospital. Hence, these outcomes provide the strategic top and the operating core insight in what to expect from and how to deal with middle managers’ sensemaking process during sustainability infusion, which contributes to effectively integrating sustainability practices into a hospital.

1.2 Outline of the thesis

In Chapter 2, the theoretical framework is presented, consisting of the existing scientific literature on the different dimensions of this study. An elaboration on the research case and the research methods of this study are presented in Chapter 3. The empirical analysis of this research is investigated in a qualitative manner. Document analysis is used to gather contextual data. Semi-structured interviews are conducted to gather information about middle managers’ sensemaking and sensegiving activities on the organisational change process. Chapter 4 presents the findings of this study. In the last chapter a definitive conclusion is formulated. The thesis completes with recommendations for the Radboudumc, limitations of the research, suggestions for future research and a reflection on the research process.

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Chapter 2: Theoretical framework

This chapter elaborates on the theoretical dimensions of this research and connects these dimensions in a conceptual model. The chapter starts with a discussion on the concept of sustainability. Subsequently, the concept of organisational change towards sustainability is discussed; followed by a substantiation on the role of middle managers in this change process. Finally, an elaboration is provided on the sensemaking activities of middle managers.

2.1 Sustainability

The concept of sustainability, as organisations know it today, was first introduced in the Brundtland Report of 1987 and defined as “…development which meets the needs of the present without compromising the ability of future generations to meet their own needs” (World Commission on Environment and Development, as cited in White, 2009, p. 213). From that moment on, sustainability is increasingly incorporated by a variety of organisations (Bansal & DesJardine, 2014) and started to shift in meaning (Kuhlman & Farrington, 2010). This shift is the result of modifications by multiple individuals to serve a variety of interests (Johnston, Everard, Santillo, & Robèrt, 2007) and a misdirection of the different elements of the concept (White, 2009). As a result, in the subsequent years, hundreds of definitions on sustainability arose.

Today, a quarter-century after the introduction of the Brundtland Report there is still no universal definition in place. Probably scholars will never agree on a universal definition, causing them to define sustainability as an oxymoron, which means fundamentally contradictory and irreconcilable (Kates, Parris, & Leiserowitz, 2005). The wide-spread scientific discussion on how to define sustainability translates itself into society and business, resulting in various interpretations of organisations and of individuals (White, 2009). Consequently, it is nearly impossible to come up with a universally agreed definition. For organisations to define sustainability, interpretations of various organisational members enable the development of an organisational definition. Due to the various interpretations and the concepts malleability, every organisation is able to choose the definition of sustainability that fits best to the company’s intentions, aims and strategy (Van Marrewijk, 2003).

However, organisations and individuals are in need to define the concept of sustainability in a shared way to engage with each other, to prevent from creating ambiguity, and running into operational difficulties (White, 2009). To satisfy this need, a number of published studies analysed the enormous amount of definitions, derived from the Brundtland

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14 Commission’s definition of sustainability, to come up with five guiding elements: the voluntary dimension, the social dimension (people), the environmental dimension (planet), the economic dimension (profit) and the stakeholder dimension (Dahlsrud, 2008; Kates et al., 2005; Smith, 2011). The definition that is utilized in this thesis, as mentioned in the introduction, consists of the five elements and is according to Dahlsrud (2008) the most frequently counted definition of sustainability in literature. In the upcoming sections I will elaborate on these five elements.

2.1.1 The voluntary dimension of sustainability

The voluntary dimension entails incorporating sustainability into business activities ‘above regulatory requirements’ (Dahlsrud, 2008). This takes place when organisations move on a voluntary basis beyond prescriptions of the law or specific rules (Achterbergh & Vriens, 2010). How to move beyond these requirements is often defined in interaction with various stakeholders (Dahlsrud, 2008). According to Achterbergh and Vriens (2010), organisations and their stakeholders must enable citizens to live a fulfilled life. The main idea is to decide on a voluntary basis, in interaction with various stakeholders, how to design the business activities in such a way that it contributes to the fulfilled life of citizens; without the driving forces of prescribed laws and rules. For instance, deciding voluntary in consultation with your stakeholders to lower the emissions, because these are currently too high.

2.1.2 The triple bottom line: the social, environmental and economic dimension

The triple bottom line refers to the three dimensions of sustainability: social responsibility (people), environmental responsibility (planet) and economic responsibility (profit) (Elkington, 2002). Social responsibility is defined as the alignment between society and business. Organisations are not only concerned with being economic profitable, but are required to integrate social concerns into their business activities, such as creating fair working conditions for their employees. Environmental responsibility is defined as the concerns of organisations towards the natural environment, the planet. The business activities of organisations must contribute to various environmental concerns, such as a cleaner environment by the reduction of carbon emissions. Finally, economic responsibility refers to corporate financial success. Organisations are unable to survive on the long term if expenditure exceeds income (Dahlsrud, 2008; Haugh & Talwar, 2010).

In order to contribute to multiple value creation, it is relevant that these three responsibilities are presented as interconnected concepts (Hopwood & O’Brien, 2002).

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Nowadays, many organisations still believe in a trade-off between profitability and sustainability (McWilliams & Siegel, 2000). This trade-off is caused by multiple individuals serving a variety of interests, which counteracts the ease of sustainability infusion. Hence, the triple bottom line is in literature often illustrated as equal sized rings, which gives the impression that a greater priority can be made towards one of the responsibilities. This results in a trade-off between the three responsibilities (Hopwood & O’Brien, 2002). To solve this tension between profitability and sustainability, Hopwood and O’Brien (2002) introduced a model to nest the economy into society and the environment, resulting in an interconnected model of the three dimensions (Figure 2.1).

The authors explain, our economy is dependent on our society and the environment (Wackernagel & Rees, as cited in Hopwood & O’Brien, 2002, p. 191), ending in the centre of the model. It is not meant as a social hub, but as a subdivision of society and the environment. In turn, society depends on the environment, which in contrast can continue without society. The economy depends on society and the environment; where society can exist without the economy. To enhance the visibility of this nested model, it is necessary to oppose against the current idea of three equal sized responsibilities by changing how individuals see and experience the world (Hopwood & O’Brien, 2002).

2.1.3 The stakeholder dimension of sustainability

The voluntary dimension emphasized the importance of defining sustainability in a shared way. Organisations often experience difficulties in defining shared meanings, as different beliefs and values of the concerned stakeholders exist (Kates et al., 2005). As a result, Figure 2.1: Nested sustainable development model. Adapted from “Environment, economy and society: Fitting

them together into sustainable development,” by B. Hopwood, & G. O’Brien, 2002, Sustainable development,

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16 reconciling on sustainability beliefs and values is a complex job. It happens that individuals find sustainability infusion to difficult or conflicting to their own beliefs and values, and therefore either have critique on the process or reject the process entirely.

Three different perspectives exist in defining what sustainability can mean for an individual: the shareholder perspective, the stakeholder perspective and the societal perspective (Nasrullah & Rahim, 2014). The shareholder approach, as founded by Friedman (1962, as cited in Van Marrewijk, 2003), is concerned with increasing or maximising the profits of the organisation, in which shareholders play a key role. Here, sustainability is defined as being economically profitable; instead of contributing to social and environmental responsibilities. The stakeholder approach, as pioneered by Freeman (1984, as cited in Van Marrewijk, 2003), explains that organisations do not solely bear responsibilities for their shareholders, but need to take a multi-stakeholder perspective into account when doing business. Hereby, profitability and sustainability are equally important. Finally, the societal approach, which is most related to the nested model designed by Hopwood and O’Brien (2002). This broader view of the stakeholder approach explains that organisations are responsible to society as a whole, composed of organisations and their stakeholders (Nasrullah & Rahim, 2014). In turn, society depends on the environment it is nested in.

2.2 The organisational change process towards sustainability

Weick and Quinn (1999) argue that organisational change would not be necessary if people had done their jobs right. Reality is, organisations are constantly in motion and do not consist of fixed and stable parts (Ford & Ford, 1994). However, still 70 percent of the change initiatives fail (Balogun, 2006). As mentioned by Ford and Ford (1994) is change “… the way people talk about the event in which something appears to become, or turn into, something else, where the ‘something else’ is seen as a result or outcome” (Ford & Ford, 1994, p. 759). This makes the change process towards sustainability more than the integration of sustainability practices by the dissemination of information, the change of policies and practices, and the implementation of new sustainable business strategies (Haugh & Talwar, 2010). Organisations make greater efforts to integrate sustainability practices in case of a well-supported change process of the organisation’s symbolic world, which is about changing the culture of an organisation with its own meanings (Howard-Grenville et al., 2011; Haugh & Talwar, 2010). However, organisations moving towards more sustainability often struggle with the question how to achieve cultural change to allow sustainability infusion into their existing business

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(Bertels et al., 2010; Blazevic et al., 2015; Palmer et al., 2012). If sustainability is not integrated into the set of beliefs and values of the organisational members, the organisation will never become truly sustainable (Russell, as cited in Palmer et al., 2012; Galpin et al., 2015). To overcome this problem of sustainability infusion, individuals are required to drive the process of cultural change by creating, sustaining, challenging and sometimes changing the meanings in organisations (Beer & Nohria, 2000; Howard-Grenville, et al., 2011). To actually achieve a shared culture of sustainability, individuals must develop, with respect to the change goal, a motivation to change (Schein, 2002), which will result in individuals’ readiness to change and eventually in a successful change process towards a more sustainable hospital.

Initiatives for change do not only take the form of planned, top-down interventions, but also of bottom-up emergent change (Beer & Nohria, 2000; Blazevic et al., 2015; Dutton, Ashford, O’Neill, & Lawrence, 2001). Even with this understanding, there is insufficient knowledge on how organisations culturally transform towards more sustainability (Bertels et al., 2010; Blazevic et al., 2015; Palmer et al., 2012). Organisations are able to transform in three different ways: natural evolutionary, planned and managed, and unplanned revolutionary (Schein, 2002). However, I argue that organisations do not transform in an unplanned revolutionary way towards a culture of sustainability, since this would mean that individuals’ underlying beliefs and values towards the deep structure of the organisation changes in a sudden rapid and brief period of time (Gersick, 1991), which is unlikely to occur. The other two forms are elaborated on in the upcoming subsections.

2.2.1 A culture of sustainability

Organisations that intend to incorporate sustainability are recommended to design a shared culture of sustainability, which means that organisational members hold shared beliefs and values about the adoption of sustainability practices (Bertels et al., 2010). Shared beliefs and values arise by the meaning construction of individuals concerning the change process towards sustainability (Balogun, 2006). The underlying beliefs and values of individuals determine whether it is possible to design a shared culture of sustainability. A motivation for sustainability change is often driven by external factors, such as the willingness to counteract climate change, but also by internal factors, as individuals deem something as the ‘right thing to do’. This creates readiness to culturally transform towards more sustainability. In the end, a shared culture of sustainability is created by beliefs and values facing the same direction. Companies that are able to design a shared culture of sustainability, support a healthy

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18 environment and improve the lives of others while continuing to operate successfully over the long term (Bertels et al., 2010).

Therefore, perseverance, patience and a motivation of individuals are in all modes of change required to make the long journey of change succeed (Beer & Nohria, 2000). Readiness is created by the proactive attempts of change agents, such as middle managers, to influence the underlying beliefs and values of organisational members. In turn, the readiness of organisational members will shape the readiness of these change agents and other organisational members (Armenakis, Harris, & Mossholder, 1993). Ambiguity and uncertainty can arise when something new to the state of art is introduced, such as new sustainability practices. Ambiguity arises when there is a lack of understanding about the new innovation. Uncertainty arises through the fear of negative consequences for the individual, but also the organisation (Birkinshaw, Hamel, & Mol, 2008). Organisational members can, due to this ambiguity and uncertainty, resist change. Various issues and events in organisations elicit the development of ambiguity and uncertainty experienced by organisational members, such as the difficulties mentioned in the introduction, but also other aspects of organisational change (Armenakis et al., 1993; Balogun, 2006; Bernerth, Walker, & Harris, 2011; Blazevic et al., 2015; Elving, 2005; Howard-Grenville, 2007; Kotter, 2007; McWilliams & Siegel, 2000; Slawinski & Bansal, 2012). When individuals experience ambiguity and uncertainty, they seek to clarify what is going on and make sense of what has occurred (Maitlis & Christianson, 2014).

2.2.2 Emergent, bottom-up change

Natural evolutionary change is characterized by its continuous learning process that occurs through the organisation as all its different parts adopt to the various external factors (Schein, 2002). Individuals working in the organisation learn all the time and make modifications to adjust to their own situation. Some of these changes, regarded by individuals as strategically relevant for the future of the organisation (Dutton et al., 2001), benefit the organisation and enhances the organisation’s performance, which creates in a more emergent manner momentum for new practices (Blazevic et al., 2015). Individuals use external factors as a selling rationale to other organisational members, as also occurs during sustainability infusion. Sustainability infusion often starts as local initiatives that need to be ‘sold’ internally and create momentum for change (Howard-Grenville, 2007). Concerned individuals make attempts to place sustainability on the management agenda, with the aim to eventually mainstream sustainability in the organisation (Blazevic et al., 2015; Dutton et al., 2001). A bottom-up perspective frames concerned individuals as potential change initiators who guide

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issues outside or below top management of the organisation (Dutton et al., 2001). Various issue selling techniques, such as involvement moves, are used by individuals to place sustainability on the management agenda (Dutton & Ashford, 1993). Involvement moves are characterized by sellers’ attempts to involve others in the issue selling efforts, for example middle managers. Several studies suggest (see Dutton et al., 2001) that involving others during the upward issue selling process can positively affect the scope and the impact of change initiators’ attempts, since the issues become more visible within the organisation (Dutton & Ashford, 1993). This can contribute to individuals’ attempts to create momentum for new practices, and make sustainability spread in a more emergent, evolutionary manner (Blazevic et al., 2015).

2.2.3 Planned, top-down change

Planned and managed change is recognized as a transformation process that follows a carefully phased approach; focused on developing particular organisational capabilities in a specific sequence (Beer & Nohria, 2000). This change process underlies the teleological theory, which explains that the development of an organisation proceeds towards a goal or end state. It is a continuous process of goal formulation, implementation, evaluation and modifications of goals based on what was learned by the senior managers in the organisation (Van de Ven & Poole, 1995). Senior managers are seen as the primary source of organisational change, with their deliberate initiation and implementation of changes in response to developments in external factors (Orlikowski, 1996). However, a strategic goal to integrate or increase, sustainability practices into the organisation also needs to be translated towards members lower in the organisation. The strategic initiation and implementation can be seen as an old slot machine, where a penny placed at the top can lead to different paths. Senior managers are unable to foretell the impacts of strategic interventions they initiate from the top as individuals lower in the organisation make sense of the change (Balogun, 2006). The success of a phased approach eventually lies in the capacity of people to make behavioural adjustments (Beer & Nohria, 2000), which happens by making sense of the organisational change.

2.3 The role of middle managers in organisational change

“Middle managers are the sailors in the crow’s nest – sometimes they can see the icebergs and we need to rely on them to warn us and help redirect the ship through troubled waters” (Pappas, Flaherty, & Wooldridge, 2004, p. 14). The most important feature to define middle managers is that these managers supervise supervisors and are supervised by others. As

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20 a result, they have more access to resources than lower echelons, but less access to resources than upper echelons (Dutton & Ashford, 1993). They maintain a central position in the organisation, between the strategic top and the operating core (Dutton & Ashford, 1993; Harding, Lee, & Ford, 2014; Mintzberg, 1980).

Especially during the organisational change process towards a more sustainable hospital, middle managers have a key role in guiding the ship (Embertson, 2006). They possess knowledge about the organisation’s strategy, but also about the social structure of the organisation (Pappas et al., 2004), which helps to achieve a shared culture of sustainability. However, research suggests that middle managers are able to create unintended outcomes based on their underlying beliefs and values (Balogun, 2006), due to for instance a lack of motivation to inspire change. An increasing amount of recent research shows the importance of middle managers during organisational change (see Rouleau & Balogun, 2011). When middle managers are involved in the change process, they are able to improve the organisational performance, in addition to the strategic control of top management (Pappas et al., 2004). Besides, middle managers play a key role in linking both strategic initiatives and local initiatives (Balogun, 2006). They are in this process of linking initiatives more than passive initiators; they critically connect the strategic top and the operating core to develop a shared culture of sustainability. Therefore, middle managers are seen as intermediaries between one layer in the organisation and another one (Riege & Zulpo, 2007).

Since the localization of formal and informal power in hospitals differ from organisations that have this power located in the strategic top, the operating core of hospitals, as doctors and nurses, has an important stake in the development of sustainable care. Support of the operating core is therefore a prerequisite to integrate sustainability practices into the hospital. To keep this support, it is important for middle managers to be professionals themselves (Mintzberg, 1980). In case of bottom-up issue selling, the involvement of middle managers can positively affect the scope and impact of change initiators’ attempts, since the issues become more visible during the upward process. Besides, middle managers are able to ‘sell’ important sustainable practices to top management by themselves (Dutton et al., 2001). In case of top-down change, middle managers translate and communicate strategic initiatives of top management to employees lower in the organisation. To make the change process succeed, employees need to make sense of the strategic initiatives (Balogun, 2006). By middle managers’ role in developing this shared culture of sustainability, the hospital is better able to satisfy the demand for care, and its own organisational goals (Bertels et al., 2010; Embertson, 2006).

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Communication is necessary in every organisational change process (Embertson, 2006). In both top-down and bottom-up change middle managers receive and transfer information. They adjust the information in such a way that it is meaningful for the recipient of the information. Herewith, they develop an environment that encourages individuals to share information. When change communication is poorly managed, resistance to change is more likely to occur (Elving, 2005). Middle managers are able to prevent resistance to change, or at least reduce it, by framing top-down and bottom-up change initiatives in a clear and transparent way before communicating it to the change recipient. Due to the importance of middle managers in a change process, hospitals are recommended to invest in the professional development of their middle managers to maximize their value (Embertson, 2006).

2.4 Sensemaking during organisational change

“Sensemaking is the process through which people work to understand issues or events that are novel, ambiguous, confusing, or in some other way violate expectations” (Maitlis & Christianson, 2014, p. 57). It is a concept underpinned by the philosophical movement of social constructivism (Weick, 1995). Social constructivism assumes that there is no objective world out there, but that it is socially constructed (Maitlis & Christianson, 2014; Symon & Cassell, 2012). Sensemaking is a process of meaning making, thus individuals who face new experiences, try to construct a meaning of this new, different and unknown situation, based on their prior knowledge and experiences (Weick, 1995).

This meaning construction can take place in different ways, within the individual or between individuals. When meanings are constructed within the individual, sensemaking is seen as a cognitive process, in which frameworks, schemata or mental models are developed. Certain stimuli of issues or events are placed into schemata that make sense of the stimuli. In this case, the collective meaning making occurs as individuals adopt a particular view and shape others by influence tactics. When sensemaking takes place between individuals, meanings are negotiated, contested and mutually co-constructed (Maitlis & Christianson, 2014). This means that sensemaking unfolds “in a social context of other actors” (Weick, as cited in Maitlis & Christianson, 2014, p. 66). Individuals interpret their environment in and through interaction with others, aiming to comprehend the world they collectively act in. In this case, collective meaning making occurs through a more mutually co-constituted process, as members engage with each other to build a collective understanding (Maitlis & Christianson, 2014). In both ways of sensemaking, communication plays an important role to construct subjective realities. The

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22 constructed meanings of individuals about the social world direct future behaviour and their way of acting (Weick, 1995). Especially middle managers’ sensemaking is critical to the roles they perform, as intermediary between the strategic top and the operating core, during times of change.

2.4.1 Sensemaking during organisational change

A threat of the organisational identity, such as an organisational change process, is a powerful trigger for individuals’ sensemaking (Maitlis & Christianson, 2014). Organisational identity is defined as the central, distinctive and enduring part of an organisation that distinguishes it from other organisations (Whetten, 2006). It broadly refers to what people collectively feel, perceive and think about the organisation. It emerges from ongoing interactions and communication between various organisational members. Organisational identity is grounded in meanings and symbols, and thus embedded within the culture of the organisation, with its cultural beliefs and values. The organisational image, which is the external produced meaning about organisations, has an influence on the internal processes of identity construction (Hatch & Schultz, 1997). As a result, external pressures are able to influence organisational members to change their meaning about the organisation and the adoption of sustainability practices.

Under conditions of change, organisations need to seriously reconsider their existing identity and image, since both significantly influence organisational decisions and strategic change. Organisational change revises the well known patterns of action of organisational members (Gioia & Thomas, 1996; Maitlis & Sonenshein, 2010), and makes them less automatic and more conscious in their behaviour and way of acting. As a result, a context-depended, non-linear and unpredictable process as change can lead to both intended and unintended outcomes (Balogun, 2006; Balogun & Johnson, 2005). Intended outcomes are consistent with the direction of the intended change desired by the designers. Therefore, they need to be encouraged and strengthened. Unintended outcomes on the other hand can be counteracting or reinforcing. Counteracting outcomes are not supportive of the desired change. For instance, individuals are able to experience ambiguity and uncertainty (Maitlis & Sonenshein, 2010), which can lead to resistance to change. It is hard to prevent counteracting outcomes to emerge; they need to be minimised, and when they arise, detected and dealt with (Balogun, 2006). However, unintended outcomes can also be reinforcing when it enhances organisational performance, such as certain critique that reinforces sustainability infusion.

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Both top-down and bottom-up influences and interactions trigger the sensemaking process of organisational members, such as middle managers (Maitlis & Christianson, 2014). The outcomes are depended on the co-construction between meanings of various individuals that lead to routines, rituals, systems, norms, assumptions and beliefs (Balogun & Johnson, 2005). Also known as the culture of the organisation (Tsoukas & Chia, 2002). This intersubjective shaping of shared meanings, with both vertical and lateral liaisons, makes it hard to foretell the impact of change interventions initiated from the top or the bottom of the organisation. For organisational change to succeed, it is required to get a grip on and understanding of these individual and shared meanings. Herewith, organisations are able to direct individuals to create, sustain, challenge and sometimes change their meanings in a certain way, to ensure they are ready to change.

2.4.2 Middle managers’ sensemaking and sensegiving during organisational change A growing body of literature emphasizes the strategic role and sensemaking contributions of middle managers in terms of organisational change, communication and diffusion of innovations. Middle managers experience, facilitate and support organisational change in their own way, which refers to what middle managers feel, perceive and think of the organisation (Rouleau & Balogun, 2011).

Based on the position middle managers have in the organisation, as intermediary between the strategic top and the operating core, their sensemaking activities are crucial (Maitlis & Christianson, 2014; Rouleau & Balogun, 2011). They continuously respond to both demands of sensemaking and sensegiving (Maitlis & Christianson, 2014). Sensemaking is to understand and adopt the strategy of the change designers. Sensegiving is to translate these strategies to the change recipients, which can be seen as influencing. This process cyclically takes place, as change recipients respond to the sensegiving activities of middle managers (Gioia & Chittipeddi, 1991). Organisational sensemaking is accomplished through the ability of middle managers to shape and share a message, by referring to their underlying beliefs and values that they invoke to design a meaningful message (Rouleau & Balogun, 2011). Herewith, middle managers are able to influence both vertical and lateral liaisons in the organisation. When middle managers sensemaking and/or sensegiving fails, so too may the organisational change (Maitlis & Christianson, 2014).

To act in a certain way, and therefore to affect the organisational change process, middle managers first have to make sense of the organisational change by themselves. Middle managers’ sensemaking is defined as “a social process of meaning construction and

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24 reconstruction through which middle managers understand, interpret, and create sense for themselves and others of their changing organisational context and surroundings” (Rouleau & Balogun, 2011, p. 955). Based on their sensemaking process, intended and unintended outcomes will emerge. In case of intended outcomes, middle managers actively translate and edit plans to create change. They act as ambassadors of the organisational change. Ambassadors need to be out in the organisation, to talk to people, share stories, listen and set an example through their behaviours and actions (Balogun, 2006). Gehman, Treviño, and Garud (2013) argue that it is important to cultivate the core values of these ambassadors and to embed them within the culture of the organisation, in order to design a shared culture of sustainability. The role middle managers possess in the organisation makes their collective meaning construction, that takes place within the middle manager or in co-construction (Maitlis & Christianson, 2014), extra relevant in the process of shaping the collective meaning construction towards sustainability of other organisational members. However, positive feelings may cause middle managers to judge situations overly enthusiastic and misinterpret certain dangers. This is most likely to occur when the emotions of middle managers are very intense towards the organisational change (Maitlis & Sonenshein, 2010). In turn, unintended counteracting outcomes can derail the whole change process towards sustainability, since middle managers possess a central position within the organisation. To avoid unintended counteracting outcomes from emerging, it is important that the designers of change avoid inconsistencies in actions, words and behaviours (Balogun, 2006). For middle managers to be able to receive and transfer information, clear communication from the change designers is required. By sensegiving activities, middle managers transfer the information to the rest of the organisation. Therefore, co-construction between middle managers, the strategic top and the operating core are required to make organisational change towards a more sustainable hospital work.

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2.5 Conceptual model

Figure 2.2: Conceptual model

This literature review has examined the sensemaking and sensegiving activities of middle managers in the context of an organisational change process towards a more sustainable hospital. The integration of sustainability practices into a hospital, leading to organisational change, has an impact on the subjectively created reality towards the hospital’s established culture of various organisational members. To successfully integrate this change process towards sustainability, it is required to design a shared culture of sustainability, in which organisational members are ready to change and share their beliefs and values concerning sustainability. The concept of sustainability is interpretable and the meaning of it varies per person. Insight into how various organisational members understand, interpret and make sense of sustainability is required to steer towards a shared culture of sustainability.

Middle managers have a key role as intermediary between the strategic top and the operating core, but are also involved in lateral processes with other middle managers. Organisations are networks of intersubjective shared meanings that are experienced, sustained, shaped and shared through the development and use of specific communication patterns and social interaction (Weick, 1995). Middle managers continuously respond to both demands of sensemaking and sensegiving (Maitlis & Christianson, 2014). This process cyclically takes place, as change recipients respond to the sensegiving of middle managers (Gioia & Chittipeddi, 1991).

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26 However, how middle managers make sense of and give sense to (i.e. influence) the change differs per individual. This process is based on the subjective created realities of an individual, which directs future behaviour and their way of acting (Weick, 1995). By getting insight into the sensemaking process of middle managers it might be possible to steer stronger towards the intended aim of sustainability infusion, provided by individuals at the strategic top and the operating core, as change towards sustainability occurs both top-down and bottom-up. Concluding, middle managers formulate the change and implement it to design a more sustainable hospital. When middle managers’ sensemaking and/or sensegiving fails, so too may the organisational change (Maitlis & Christianson, 2014).

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Chapter 3: Research methodology

This chapter elaborates on the methodological choices made, which supports the execution of this research. The chapter contains the research strategy, the data gathering, the data analysis and the research ethics.

3.1 Research strategy

This research aims to investigate the sensemaking process of middle managers and how this process in turn gives sense to the change process towards a more sustainable hospital. Since sensemaking results in socially constructed realities and not in objective truths, this research aims at gaining credible insights into the constructed realities of middle managers, created by their previous experiences, beliefs, values and perceptions.

To gain insight into the sensemaking process of middle managers, I applied an interpretivist form of qualitative research. Qualitative research was appropriate since it aims at gaining an in-depth understanding of the socially constructed realities of individuals (Symon & Cassell, 2012). A quantitative approach was unsuitable because it does not allow for subjective variations and rich detail (Van de Ven, 2007). Sensemaking is underpinned by the philosophical movement of interpretivism/ social constructivism. Interpretivism uses human realities as the starting point of developing knowledge. It entails accessing and understanding the constructed meanings that middle managers subjectively ascribe to the organisational change process, in order to describe and explain their behaviour through investigating how they experience, sustain, shape and share these socially constructed meanings (Symon & Cassell, 2012). This means that the realities of middle managers are leading. Citing previous experiences, images and relationships helps to get a clear understanding of the constructed realities of middle managers. To gain this in-depth understanding, capturing textual data by the use of interviews was an appropriate research strategy. Observations were excluded, since time was restricted.

Since there is a lack of scientific knowledge on the role of middle managers in sustainability development, I worked inductively to investigate the sensemaking and sensegiving activities of middle managers on the change process towards a more sustainable hospital. Comparison and analysis of the gained information of middle managers resulted in a pattern that expands scientific literature and supported practice. In this study, a single entity case study is adopted as a research strategy.

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28 3.1.1 Case study

A case study is a research strategy in which a contemporary phenomenon, as an organisation, is investigated in-depth and within its real-world context, especially when the boundaries between the phenomenon and the context are not very evident (Buchanan, 2012; Yin, 2014). Case studies create the possibility to understand an organisation and its organisational life in a profound way without separating it from its context. Therefore, when doing case study research, the research question is often formulated as a ‘how’ or ‘why’ question (Yin, 2014), which is also evident in this thesis. Providing a case description allows the reader to judge whether their study, and other similar cases, might be informed by my results (Symon & Cassell, 2012).

In this study, I chose to investigate the organisational life of the Radboudumc, an academic hospital in Nijmegen, the Netherlands. Access was provided by my supervisor Prof. dr. K. Lauche, who had contact with the sustainability policy advisor of the Radboudumc. To understand the case, I gained in-depth information on the history and development of the change process towards sustainability. A lot of information was able to be gained, since this advisor examines and advices on a daily basis the sustainability developments in the Radboudumc. These conversations were used as preparation, to gain access to documents and non-clinical managers of various departments, and to gain information to design the semi-structured interviews with these managers.

To study the change process towards sustainability, document analysis and semi-structured interviews were used as research methods. Documents were provided by the Radboudumc, and were used to understand the context of the change process and as preparation for the interviews. Semi-structured interviews were used to study sensemaking, as the focus needs to be on talk, discourse and conversation, as that is how a great deal of social contact is mediated (Weick, 1995). The interviews were executed in the natural setting of the research participants to minimize the influence of external factors on the research. Data collection took place for nearly 2 months, in the months April and May 2017.

3.1.2 Case description

The Radboudumc places a great emphasis on delivering sustainable health. In 2011 the Radboudumc took its first steps towards a more sustainable future. The goal of the Radboudumc is to strive for a maximum positive impact on health and a minimum negative impact on the environment. They aim to reach this by integrating innovative, sustainable and affordable healthcare into the strategy of the Radboudumc. “Sustainable healthcare can be defined as

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healthcare that is personal, accessible and affordable, for us and our children, whereby taking the social and environmental aspects into account when doing business” (Radboudumc, 2016, p.3). To achieve this goal, it is necessary and required that sustainability becomes a way of thinking for all the employees operating in the Radboudumc. Until recently, the Radboudumc made solely use of a bottom-up approach in sustainable development. With this approach the Radboudumc did not reach their ultimate goal of ‘a sustainable way of thinking’. The problems that arise within complex, high-impact projects seem to be the main cause for not reaching their goal. It is required that complex projects will be company wide managed, since these projects are often difficult to control for departments. Therefore, the Radboudumc decided to initiate central coordination by the strategic top to solve these problems. The relation between top-down and bottom-up initiatives resulted in the aim to research the role of non-clinical managers (i.e. middle managers) in this organisational change process. Until now, there is a lack of knowledge on how non-clinical managers experience this change process, which makes it hard to accomplish a shared culture of sustainability, and thus to achieve ‘a sustainable way of thinking’. Gaining an in-depth understanding of non-clinical managers’ sensemaking process provides the Radboudumc ideas on how to meet their expectations to formulate and implement the organisational change process.

The Radboudumc consists of 63 independently operating service and patient care departments (Appendix A). These departments are regulated by two types of middle managers: a head of department (‘afdelingshoofd’) and a non-clinical manager (‘bedrijfsleider’). Hereof, 50 departments are patient care departments, operating within their own departmental policy and with their own financial resources. In this study, interviews with several non-clinical managers of patient care departments were conducted. Non-clinical managers are responsible for all non-clinical tasks of the department, such as human resources, finance, procurement and sustainability. In collaboration with the head of department, who is responsible for the clinical activities of the department, non-clinical managers are able to develop and direct the policy of the specific department. This gives both the non-clinical manager as the head of department a lot of power and autonomy within the department and the organisation. Still, non-clinical managers are expected to translate the strategy, developed by the board of directors (‘raad van bestuur’), towards tactics and operations of the department, and they are somehow held accountable for what they do. Patient care departments were approached, since the Radboudumc assumes that these departments are less confronted with sustainability practices, making it more interesting to investigate the sensemaking process of these non-clinical managers.

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30 3.2 Data gathering

3.2.1 Document analysis

Document analysis was used to gain insight into the existing data concerning the change process towards sustainability in the Radboudumc. The benefits of documents are that they provide details of policies, procedures and prospective plans, such as change goals (Lee, 2012). Documents that did not provide insight into the change process were excluded from this analysis. The documents were used to compare the existing data of the change process with the sensemaking activities of non-clinical managers, provided via semi-structured interviews. Documents used for this study were provided by the Radboudumc and were produced for the purpose of sustainability development in the Radboudumc, and not for the purpose of this research. The Magazine Duurzaamheid! #1 is the first edition of an annually returning magazine published in the Radboudumc. In this research, the following documents have been analysed:

Name of the document Purpose Year of publication Duurzaamheid in de genen Information of organisation

and change process

2013

Duurzaamheidsplan 2017-2020

Information of organisation and change process

2016

Magazine Duurzaamheid! #1

Information of organisation and change process

2016

Table 3.1: List of documents

3.2.2 Semi-structured interviews

Interviews are recognized as a primary source of gathering information and getting to know people (Alvesson & Ashcraft, 2012). Since the realities of non-clinical managers were leading in this research, interviews were an appropriate research method to gain this information. In this research, in-depth semi-structured interviews were face-to-face conducted with ten non-clinical managers employed in various patient care departments. A semi-structured interview is a research method characterized by a predetermined set of open questions, with the opportunity for the interviewee to start discussion and to propose other relevant themes (Alvesson & Ashcraft, 2012; Verhoeven, 2014).

The gatekeeper of this research, the sustainability policy advisor, was approached to gain access to several non-clinical managers. A list was conducted with non-clinical managers that were interested to participate in this study. Snowball sampling was used to supplement this

Completing the sustainability puzzle; The impact of middle managers’ sensemaking on the organisational change process towards a more sustainable hospital

Completing the sustainability puzzle

The impact of middle managers’ sensemaking on the

organisational change process towards a more sustainable hospital

Completing the sustainability puzzle

The impact of middle managers’ sensemaking on the

organisational change process towards a more sustainable hospital

Acknowledgements

Abstract

Managementsamenvatting (Voor het Radboudumc)

Table of Contents

Introduction

Chapter 2: Theoretical framework

Chapter 3: Research methodology