IMPLEMENTING EXCELLENT CARE
A multiple case study at three long-term health care organizations
Master Thesis, MscBA, specialization Change Management University of Groningen, Faculty of Economics and Business
June 30th, 2014 Jasper Martijn Fritzsche Student number: 1532154 Gerard Doustraat 6-1 1072 VP Amsterdam Phone: +31 (0) 611477085 Email: j.m.fritzsche@student.rug.nl Supervisor / University Dr. J. Rupert
(Co-) Assessor: Dr. H. Grutterink
IMPLEMENTING EXCELLENT CARE
A multiple case study at three long-term health care organizations
ABSTRACT
This research concerns the implementation of an organizational change named
‘Excellent Care’ (EC) in three long-term (health) care institutions in the Netherlands and was commissioned by the Dutch nursing organization ‘V&VN’.
The research contains a case study in the three institutions where the factors change process, leadership, communication and participation and their respective influence on the success of the planned and emergent change implementation methods are researched. The results were derived through semi-structured interviews and concurrent coding.
The results suggest positive relationships between change process, leadership, participation and the change success. Mixed results were found for communication, which was the result of a moderating effect of informal communication (using open, direct communication and shared vision making) on the relationship between under-communicating by the interviewees in organization X. Furthermore, the role of the external environment and management turnover/succession on the implementation is discussed. The research ends by suggesting several practical implications from these results that can contribute to new organizations that will endeavor implementing EC or a similar organizational change initiative.
Keywords: Organizational change, change implementation, planned change, emergent change, change process, sequencing, phases, pace, direction, leadership, communication, participation, external environment, management succession, management turnover
Research theme: Implementation of cultural change Supervisor University: Dr. J. (Joyce) Rupert
CONTENT ABSTRACT 3 CONTENT 4 1. INTRODUCTION 5 1.1 Excellent Care 6 1.2 Management question 9
1.3 Research question and conceptual model 9
2. THEORETICAL FRAMEWORK 12 2.1.1 Planned change 12 2.1.2 Emergent change 13 2.2.1 Change process 13 2.2.2 Leadership 16 2.2.3 Communication 19 2.2.4 Participation 20 3. RESEARCH METHOD 22 4. RESULTS 28 4.1 Organization X 28 4.2 Organization Y 34 4.3 Organization Z 40
4.4 Influence of other factors 45
4.5 Change success 47
5. CROSS CASE ANALYSIS 48
5.1 Cross case analysis 48
5.2 Influence of other factors 51
6. CONCLUSION 51
7. DISCUSSION & FURTHER RESEARCH 52
1. INTRODUCTION
As societies change, so do governments, sectors and organizations. Heraclitus already named ‘change the only constant’. As Burke (2010) suggests, change in organizations occurs constantly. It is therefore interesting to research how organizational change develops and is practiced. Pettigrew, Woodman & Cameron (2001:709) state the following on researching organizational change: “Never was a field of research such as
organizational change better placed to deliver combinations of ‘what is’ and ‘how to’ knowledge. But the ‘how to’ knowledge is a question of not just the more rigorous exposure of continuous change processes through time and in context, but also of a more
sophisticated and demanding engagement with practice”. Therefore, this research will
focus on the ‘what is’ and ‘how to’ questions of organizational change in three selected cases. In other words: what is the type of change that has taken place, how has it occurred and what can one recommend for practical implementation? To be able to do so the research is focused on process indicators, type of leadership, communication and participation in the organization.
This thesis will start with an overview on change theory and how these are connected with this research. It will continue on the work done by Burnes (2004; 2009) who provides a large overview of the main change theories that have been developed from the late 1940’s until the late 2000’s of which two dominant and contrasting approaches can be distinguished: planned and emergent. This research is based on the view that planned and emergent change both have gone through changes themselves, therefore it is interesting to research how planned and emergent change are applied in practice. This research views that planned change has developed from a phased, participative, democratic and humanist nature (Cummings & Worley, 2009), towards a more phased, prescriptive and top-down form of organizational change (Burnes, 2009).
done in the manner in which planned change has developed or in an emergent manner? Therefore this research defines planned change as phased, prescriptive, standardized and top-down oriented and emergent change as democratic, participative and less stringent in both the outcome and the manner in which to get there. To be able to determine this in the researched organizations, characteristics need to be determined that can define change and typify as planned or emergent. Three organizations that have voiced to have the same goal are researched on how they have shaped the change, how factors as leadership, communication, participation and change process have influenced change success, and if these changes can be typified as planned or emergent change. 1.1 Excellent Care
The Dutch healthcare system is going through turbulent times. Due to considerable reforms (Rijksoverheid, 2013) long-term health care is under a constant debate in politics and in the field. On top of this, nursing staff is believed to suffer from pressures to meet the demands set by management in order to cope with these governmental demands and uncertainty (NOS, 2013-a). Furthermore, patient care is considered to suffer under increasing administrative burden for nursing staff (NOS, 2013-b). The aim of these imposed changes is to provide for high quality care in a more efficient manner in order to reduce costs (Rijksoverheid, 2012). An ambitious challenge, one could presume.
As the (long-term health) care sector was going through reforms, the Dutch nursing association ‘Verpleegkundigen en Verzorgenden Nederland’ (named V&VN) is looking for ways to assist nursing staff and its organizations to meet these pressures. The introduction of one of these new initiatives, Excellent Care (‘EC’), is the subject of this research. EC is the Dutch translation of an American organizational model named ‘Magnet (hospitals)’.
During a time span of 20-30 years, the term ‘Magnet’ has become a standard of high quality health care in the United States and has come to the attention of the V&VN in 2008. Initial research on how to provide better work environments for nursing staff to retain and attract more nursing staff, as well as provide for higher-quality health care, was initiated by the American nursing association, ANCC. This resulted in the
focus were introduced as essential criteria by which nursing and therefore hospitals could excel in their operations (Pastorius, 2007). This accreditation system should eventually lead to overcoming these nursing shortages and provide for better quality care (Frellick, 2011). The term ‘Magnet’ stems from the attraction organizations with ‘Magnet status’ have on both nursing staff and patients.
1.1.2 Translated for Dutch implementation
The V&VN has translated the Magnet model to be applicable to the Dutch health care system and culture, and has introduced it through pilots in several health care
institutions (V&VN website). With the same aim as the American program which is to provide for a better work environment for nursing staff and for higher quality health care (V&VN, 2012-a). The V&VN (2012-a) has stated the following goals:
1. Providing for excellent care, not only in terms of objective treatment, but also to the extent of the patient’s experience of care.
2. Providing nursing staff and other caregivers, a ‘healthier’ and more attractive work environment.
3. Creating a patient-oriented environment, or culture, in which nursing staff and other caregivers play central roles.
1.1.3 Translating the model
Forces of magnetism (ANCC) EC characteristics (V&VN)
Quality of leadership
Collaborating with capable colleagues
Organizational structure ‘Good’ relationship with specialists Personnel policies Autonomy
Professional model of care Support of direct supervisor
Quality of care
Influence on own professional practice
Quality improvement Educational possibilities Management style Sufficient number of staff
Consultation and resources
Patient oriented culture of health institution Autonomy Community involvement Nurses as teachers Image of nursing Collegial relationships Professional development
TABLE 1.0: COMPARISON BETWEEN MAGNET FORCES (ANCC) AND EXCELLENT CARE CHARACTERISTICS (V&VN)
1.1.4 Starting Excellent Care (EC)
The V&VN found several organizations willing to serve as pilot institutions to implement EC. Six hospitals that act under the umbrella brand ‘Santeon’ have put the EC program into practice. Six long-term healthcare organizations were also found willing to
implement the program. Three of these long-term healthcare institutions are being studied in this research.
The change itself contains an initial measurement using a measurement tool on the 8 EC characteristics to assess to what extent the institutions were ‘excellent’ on these characteristics at the starting point of EC introduction. After the measurement, the institutions were ‘free’ to choose their own implementation method for the change and the V&VN would not interfere with internal proceedings. However the aim of the change was the same; to provide for better healthcare and higher patient and employee
1.2 Management question
In order to learn from the current pilot implementations, the V&VN finds it vital to know how the implementation has proceeded in the organizations, not only in terms of how the characteristics have improved, but also in how the change itself has developed. With the derived information they would like to advise and assist new organizations that show interest in the program. The management question is therefore:
“What can the V&VN learn from the case study results and which change approach shows to be appropriate for further implementation of ‘Excellent Care’ in other health care
organizations?”
1.3 Conceptual model & research question
In order to be able to characterize the change approach used in practice in the three changes and understand it in the continuum of planned to emergent change methods, four indicators were identified: change process, leadership style, communication and participation. These indicators were based on the theory of Whelan-Berry &
Sommerville (2010) and Dunphy and Stace (1988:1991).
Lewin (1947) discussed driving and restraining forces to organizational change and the need to identify them. These characteristics are defined by Whelan-Berry & Somerville (2010:179) as change drivers: “events, activities, or behaviors that facilitate
the implementation of change’ (Whelan-Berry et al., 2003a)”. According to Whelan-Berry
Change driver Summary definition
Accepted change vision
Embracing the change vision as positive for employees, stakeholders and/or the organization.
Leaders’ change related actions
Actions by the community of leaders throughout the organization that signal the importance of the change vision and its outcomes and support its implementation.
Change related communication
Regular, two-way communication specifically about the change initiative, its implementation, related successes, challenges and their resolution.
Change related training
Provides an understanding and necessary skills, values and/or frameworks concerning the change initiative.
Change related employee participation
Involves employees in tasks specifically related to the change initiative, such as pilot groups.
Aligned human resources practices
Aligns human resources practices, such as performance appraisal and rewards; and recruitment, selection, and socialization of new employees with the change initiative.
Aligned organization structure and control processes
Aligns organizational structure, organizational outcome measures, planning, budgeting and reporting systems.
TABLE 2.0 CHANGE DRIVERS Whelan-Berry &Summerville, 2010:181-182)
Based on the work of Dunphy and Stace (1988:1991) and Whelan-Berry & Sommerville (2010) four characteristics were identified. The first three are leadership,
communication and participation which Dunphy and Stace (1988:1991) named
characteristics of planned change. In a different theoretical expression however, these can also have the ability to characterize emergent change. In other words, by
determining the type of leadership, communication and participation these will have the ability to determine emergent change as well. The fourth variable is change process as each of their defined drivers go through various stages (Whelan-Berry & Somerville, 2010). These are: moving the change to the group and individual level, individual employee adoption of change, sustaining the momentum of change implementation and institutionalizing the change. Thereby showing the importance of change process as a separate variable. Together these four components reflect the main content of the change drivers of Whelan-Berry & Sommerville (2010) and the characteristics of Dunphy and Stace (1988:1992), which allows us to determine the extent to which the change implementation was emergent or planned.
‘participation’. Training, human resources and aligned organization structure and control processes under ‘change process’ as these are practices typical for the different stages a change process goes through. This leads to the following research question and conceptual model:
How do the dimensions change process, leadership, communication and participation influence change success and define the planned and emergent change approaches of
implementing Excellent Care in organizations X, Y and Z?
The conceptual model shows the four variables (change process, leadership,
communication and participation) and one dependent variable (change success). Next to this these four variables will contribute to the determination if the change in the
organizations can be typified in planned or emergent change. This adds value to the theoretical contribution of this research, as it can help determine if planned and
The following additional questions will be answered to make this possible: 1. What change process was used, how has it influenced change success and
determine a planned or emergent change approach of organization X, Y and Z? 2. How has the leadership style influenced change success and determine a planned
or emergent change approach in organization X, Y and Z?
3. How has the communication style influenced change success and determine a planned or emergent change approach in organization X, Y and Z?
4. How has the participation style influenced change success and determine a planned or emergent change approach in organization X, Y and Z?
2. THEORETICAL FRAMEWORK 2.1.1 Planned change approach
Planned change begins with the work of Lewin (1947) who identified several elements of importance in organizational change in general. It describes a phased, participative and democratic approach in which, among other things, the need to plan change, to identify forces that drive and restrain change and to have a strategy on how to implement change (unfreeze-move-refreeze) are important. Planned change has progressed in the Organizational Development (OD) school (Burnes, 2009) and is
defined by Cummings & Worley (2009:2-3) as: “a system wide application and transfer of
behavioral science knowledge to the planned development, improvement and reinforcement of the strategies, structures and processes that lead to organization effectiveness.”
Dunphy & Stace (1988: 317) add: “On the whole, the O.D. model presents an ideology
of gradualism, for effective change is seen to proceed by small, incremental adjustments. Usually change is seen also as synonymous with growth, and the strategies for
organizational change advocated typically involve widespread employee participation to ensure emergent consensus among the key parties affected”. However, OD has
show that OD always will have certain stages, but that these are not always followed. The critique on OD is not with the theory itself, but how current practitioners, who have specialized in certain techniques and have executed it more prescriptive and top-down oriented. Therefore neglecting parts of the OD theory. Thus, there shows to be different forms of planned change and has evolved to more prescriptive and ‘how to’ approaches.
Dunphy & Stace (1988) define four different planned change types with
collaborative and coercive modes in either an incremental or transformational change strategy, being: participative evolution, forced evolution, charismatic transformation and dictatorial transformation. One is not considered better than the other, or mutually exclusive, but depending on the situation of the organization and it’s environment (Dunphy & Stace, 1988,1993; Stace & Dunphy, 1991). Thus, these different styles of planned change can be equally successful.
Burnes (2009) mentions four criticisms that the literature shows on planned change. Firstly, OD would not be suitable for turbulent environments organizations are faced with currently as more flexibility in the change approach is needed in those environments Secondly, planned change would not be suitable for discontinuous and transformational change. Thirdly, it would ignore the political element of organizational change. And fourthly, it would presume that one change approach is suitable for more than one situation. However, perhaps the most noteworthy criticism might be that planned change proposes a linear change process, where in fact this does not occur so in reality (Burke, 2010).
2.1.2 Emergent change approach
The former mentioned criticisms on planned change are also the main components of emergent change. “The emergent approach tends to see change as driven from the bottom
up rather than from the top down; it stresses that change is an open-ended and continuous process of adaptation and to changing in conditions and circumstances; and it also sees the process of change as a process of learning, and not just a method of changing
organizational structures and practices” (Burnes, 2009: 355). Weick & Quinn (1999) and
Weick (2000) typify planned change as episodic and emergent change as continuous. According to Weick (2000:237): “emergent change consists of ongoing accommodations,
to do so.” This potentially alternates the role managers have in change processes, as it
now needs to find the patterns in these changes and should look differently towards change. Furthermore, Weick (2000) stressed the importance of employees being encouraged to change outdated job descriptions and requirements, implement new strategy and get into a dialogue when they feel that things are not going as they should be. It stresses the point of employee participation and open, direct communication in the organizational culture to allow emergent change to be effective.
2.2.1 Change process
“Change process has to do with how the change is planned, launched, more fully
implemented, and once into implementation, sustained” (Burke, 2010: 25). Or, as (Burnes,
2009:600) defines: “the methods used to move an organization from one state to another”. Burke (2010:25) distinguishes change process from change content as the ‘what’ and the ‘how’: “the what, provides the vision and overall direction for the change, and the process, the how, concerns implementation and adoption”. Implementation, adoption and direction can be done in various ways, as the following paragraphs will show. These can distinct planned from emergent approaches to change.
Some theories define processes by the use of clearly defined phases or an order in which change should take place (Kotter, 1995). Others show that focus can also be aimed at the pace in which change can take place (Kanter, 1992) or the direction in which the organization changes and on what factors change is aimed (Beer & Nohria, 2000). Or as Armenakis & Bedeian (1999) summarize the 1990’s change literature in 2 lessons: first, change happens mostly in steps and takes time. Second, missing steps or cutting corners slows progress or can even deteriorate it.
2.2.1.1 Sequencing the change process
coalition, creating a vision, communicating the vision, empowering others to act on the vision, planning for and, creating short-term wins, consolidating improvements and producing more change and institutionalizing new approaches. Winum, Ryterband & Stephenson (1997) take a more integrative approach considering both the usage of phases and pace as important and suggest that their model is neither exhaustive, nor orderly, when suggesting that change takes place in three phases and three mindsets. Burnes (2009) notes that phases of change are related to planned change as “distinct
states through which an organization moves as it undertakes planned change”.
In contrast, when one takes the views of Weick and Quinn (2000) on emergent change one will argue that emergent change will not have distinguishable phases, a clear set-up plan in advance and will be about ongoing alterations in the process., Thus, this research finds that planned and emergent change can be distinguished by the usage of clear and distinguishable phases and the order and rigor in which they are used in the change process.
2.2.1.2 Pace in the change process
Kanter et al. (1992; through Burnes, 2009) discuss the importance of pace variations in organizational change and name two different change methods: ‘bold stroke’ and ‘long march’. Which have three dimensions: objective, timescale and involvement. Bold strokes relate to large strategic and economic decisions where only senior management is involved and long marches are related to smaller, behavioral and/or cultural changes that need involvement of the complete organization and should be viewed as
complementary (Kanter et al , 1992; through Burnes 2009). This shows resemblance with Weick & Quinn’s (1999) research which also views the pace, or tempo, in change as important when focusing on episodic vs. continuous change and add importance of pace related to scale and further confirm the importance of aiming for continuous change in the organization.
Armenakis & Bedeian (1999) discussed risks involved when considering short-term and long-short-term scope in change. Only focusing on the bottom-line could show results in the short-run but can negatively influence organizations in the long run.
Weick & Quinn (1999) find episodic change related to planned change and continuous to emergent. This research assumes the same is applicable to bold stroke of Kanter et al. (1992; through Burnes, 2009) and Armenakis & Bedeian’s (1999) short-term scope.
Thus, this research will distinguish planned from emergent change by
determining if a bold-stroke or long-march, an episodic or continuous, and/or if a short- or long-term scope is used.
2.2.1.3 Direction and focus in the change process
Beer & Nohria (2000) show that there are two areas organizations in a change process can direct attention towards; shareholders (’E’) or organizational capabilities (’O’). These two directions provide different methods on how to change. ‘E’-focus directs attention towards top-down, structural, planned, financially motivated change, where an ‘O’-focus directs attention towards bottom-up, cultural, emergent and commitment focused change.
Sirkin, Keenan & Jackson (2005) acknowledge the importance of focus in organizational change, but find the focus in recent literature to be too much on the organizational capabilities side, or ‘soft side’. Only focusing on the ‘soft’ factors will not provide for successful change, more focus should lie on the ‘hard’ factors of
organizational change. Sirkin et al. (2005) hands four elements that change should focus on: duration, integrity, commitment and effort. As the name of the elements suggest, they are less ‘hard’ and show for ‘soft’ elements that are also considered in Beer & Nohria (2000). Therefore, this research relates Beer & Nohria’s (2000) ‘E’ strategy to planned change and ‘O’ to emergent change.
(2007) when discussing top-down and bottom-up approaches to change further support the importance of combining these approaches. Therefore the following question will be answered:
What change process was used and how has it influenced change success and determine a planned or emergent change approach in organization X, Y and Z?
2.2.2 Leadership
Burnes (2009:598) defines leadership as: “The process of establishing goals and motivating others to pursue and achieve those goals”. Leadership behavior influences change success (Higgs & Rowland, 2005). Kotter (2005) assumes that 80 percent of producing change is about leadership: establishing direction, aligning, motivating, and inspiring people and 20 percent on management: planning, budgeting, organizing, and problem solving. He thus, distinguishes leadership from management and mentions that although 80 percent of producing change is on leadership, most of the time
organizations put 80 percent on management and 20 percent on leadership.
Kleinman (2004) concludes in his literature review that there are two main types of leadership: transformational and transactional. Burns (1978; through Burnes, 2009) argues that these two types of managerial, or leadership styles, are applicable on the two basic states of organizations: those that are stable (convergent) and those where stability is not present (divergent). Transactional would suit convergent and
transformational divergent organizations.
The transactional form is focusing on maintaining a status quo, by relying on task-completion and efficiency of current processes where the transformational form is focused on charisma and vision sharing. (Burnes, 2009). Bass (1999) describes 3
distinguishable dimensions for transactional leadership. First, ‘contingent reward’: rewarding followers that meet set standards, active or passive. Secondly, ‘management by exception’: correcting and sanctioning in order to meet set standards. Thirdly, ‘laissez-faire’: avoiding decision-making. And discusses 3 dimensions of
treating every employee individually. The latter will require different and new skills for leaders.
Kanter (1989) suggests that as organizations change towards more flexible structures, the role of managers also changes and therefore the skills they need to possess in order to cope with this role also change. She argues that managers need to become integrators and facilitators instead of watchdogs and interventionists. In other words: become more supportive and facilitative and less controlling. Higgs & Rowland (2005) underline this by concluding that leadership behavior is moving towards what they call more enabling and facilitating styles and moving away from leader-centric behavior. Beer & Nohria (2000) suggest the embracement of opposite leadership styles to direct from the top and engage employees from below, but one of the most important aspects of leadership remains to motivate others.
Higgs & Rowland (2005) conclude that there are three types of leadership behavior: shaping, framing change and creating capacity. Shaping concerns a more leader-centric approach, which involves what leaders say and do, making others
accountable, thinking about change and using an individual focus. This is considered to have a negative effect on change success. ‘Framing change’ and ‘creating capacity’, they continue, concerns establishing starting points for change, designing and managing the change journey, communicating guiding principles, creating individual and
organizational capabilities and communicating and creating connections are correlated to change success. Thus, successful change requires managerial behavior that facilitates and creates change instead of dictates. These behaviors are: ensuring recognition of the need for, understanding of, engagement in, sustaining and facilitating developing capabilities for the change (Higgs & Rowland, 2000;2001: through Higgs &
Rowland,2005). Weick (2000) concluded when reviewing the main differences between planned and emergent change by stating that it changes the way in which managers look at change. Planned change is easier to control but harder to ‘walk the talk’, thus showing exemplary behavior. Therefore, when making an argument for emergent change, Weick (2000:238) concludes: “In a newer code, management doesn’t create change. It certifies
change.”
leadership behavior of which one is more associated with planned and others with emergent. This research views leadership styles that are shaping and transactional more associated with planned change and facilitating and transformational leadership styles with emergent change. Therefore the following question will be answered:
How has the leadership style influenced change success and determine a planned or emergent change approach in organization X, Y and Z?
2.2.3 Communication
The importance of communication is evident and seen as a critical factor to implementation, although it is found difficult to communicate change, by change managers (Frahm & Brown, 2005). Under-communicating is seen as one of the eight mistakes organizations make when changing (Kotter, 1995) and therefore shows its importance to organizational change success. However Kotter (1995) discusses communicating only from the point of view of vision, where communicating plays a more substantial role for organizational change success in several other theories. Price & Chahal (2006) mention poor communication as one of the main reasons for change failure. They suggest a 6-step program in which a big role is laid out for communication in: preparing, developing a vision and plan, checking for support, communications and workforce engagement, implementation and evaluation. Beer & Nohria (2000) show support for open communication when they suggest explicit naming of certain tensions that can exist when implementing ‘E’ and ‘O’ change and thus favor open communication throughout the change process. Sirkin et al. (2005) also acknowledge the importance of communicating in creating commitment. As O’Shea, Mcauliffe & Wyness (2007:118) conclude: “Organizational communication processes cannot be taken for granted. It is
necessary to devise and monitor a specific communication plan for the change process”.
This can be accomplished, among other things, through mission sharing (Kanter, 1989). Burnes (2009:605) describes the process of creating a vision as: “an iterative process
competences needed to achieve these”. Which tends to suggest that senior management
should develop the vision and includes the ‘mission’ as a part of ‘vision’.
According to Dionne, Yammarino, Atwater & Spangler (2004:184) mission sharing corresponds with transformational leadership: “Creation of shared vision will
positively impact team cohesion, and will partially mediate the relationship of idealized influence/inspirational motivation leadership with team performance.” Kotter (2007)
makes a strongpoint of vision sharing as well, which can be distinct from making plans and is seen as a fundamental element of organizational change. Kanter (1983) discusses individual prime movers that are powerful, hold the vision and communicate this vision continuously. Thus, transformational leadership contributes to successful change
through motivating, vision sharing, and keeping the focus of the change in line with the goals of the change by communicating the change continuously.
It can therefore be assumed that communication will be more open in emergent change processes and more closed in planned. As in planned change, the course of action is set and plans will be made in advance. In emergent change processes there will be a more interactive communication, between employees and within an organization, in which plans and results will be more flexible. This research assumes that an open
communication style where a vision is shared and developed with the workforce associated with emergent change and a communication plan with no shared vision building process and more directive and pre-planned communication is associated with planned change. Therefore the following question will be answered:
How has the communication style influenced change success and determine a planned or emergent change approach in organization X, Y and Z?
2.2.4 Participation
Participation is defined by Burnes (2009:600) as: “the process of involving people in
decision-making and change activities within organizations”. Participation is a process,
2006) and to improve commitment (Sirkin et al., 2005) trust and confidence Sminia & Van Nistelrooij, 2006) and thereby improve the chance of change success.
Price & Chahal (2006:250) suggest several areas in which participation can contribute to change success: “Greater degree of consultation and worker participation, both in the
development of the strategic vision and the implementation of change, should increase ownership, thus reducing anxiety and stress that often drives resistance to change.” Their
view is supported by Whelan-Berry & Somerville (2010) that suggest employee involvement in areas related to the change focus groups, pilots, shaping the
implementation and designing training for the change. As this participation can help to move the change vision from individual to group level. The higher the level of
participation throughout the change process, the more it is assumed to be associated with emergent change. Therefore the following question will be answered:
3.RESEARCH METHOD
In order to examine how the considered factors influence change success and determine planned and emergent change methods, a case study in the three selected organizations was performed to collect the data.
3.1 Multiple case study
Qualitative research can contribute to current theories, as it is appropriate for researching processes in organizations and by interpreting the meaning of different phenomena (Bleijenbergh, 2013). Therefore a qualitative approach was chosen for this research in the form of a multiple case study. According to Bleijenbergh (2013) multiple case studies contribute to theories as they provide for practical implications on these theories. Yin (1984; in Eisenhardt & Graebner, 2004), mentions that multiple cases make replication possible by using them as separate experiments. Making them “…more
generalizable and better grounded than those of single-case studies” (Eisenhardt &
Graebner, 2004:368).
Case studies are defined as: “rich, empirical descriptions of particular instances of
a phenomenon that are typically based on a variety of data sources” (Yin, 1994; in
Eisenhardt 2007:25). “Building theory from case studies is a research strategy that
involves using one or more cases to create theoretical constructs, propositions and/or midrange theory from case-based, empirical evidence” (Eisenhardt, 1989b; in Eisenhardt,
3.2 Case selection
Case studies are not aimed at providing for a representative sample, but should be selected on their theoretical contribution, not their statistical (Glaser&Straus, 1967; through Eisenhardt, 1989). Thus, to select cases which add value to present or emergent theory (Eisenhardt, 1989). It is therefore suggested to use theoretical sampling, which means cases are selected because of their suitablity of highlighting relationships and logic between constructs (Eisenhardt & Graebner, 2007). The selected organizations have been suggested by the V&VN for their assumed different approach to implementing EC. In order to be able to draw conclusions on the case studies, there have to be different change methods for the same implementation in similar organizations.
All three organizations provide for long-term healthcare, are publicly owned and therefore have assumed to have similar goals, purpose and environment or playing field. Their aim and purpose is providing ‘care’ not ‘cure’. All three have similarities in
providing more than one service or patient population. Ranging from elderly demented, children, home and day care, mentally ill or disabled. Care is provided in either the domestic areas of the clients or in specialized centers. All three provide care in different regions and locations within their own province or throughout provinces. The number of employees ranges from 1000 to 6000. The core employees have had lower and/or higher nursing educational backgrounds, with a smaller group of specialists in the form of physicians, masters in nursing, psychiatry or psychology.
According to Mintzberg (1980) organizations can be typified in 5 different types by reviewing 5 criteria’s. When relating those to the long-term health care organizations researched, one can argue that they should be most similar to professional bureaucracy. Which suits, for instance, hospitals and social work agencies. These organizations have many skilled professionals performing non-routine tasks, therefore requiring autonomy and relying on the coordinating vehicle of standardization through the skills of the employees (Mintzberg, 1980). This also shows the importance of the aim of EC. Which suggests the importance of aiming focus to the professionals. Therefore these
3.3 Measures
Internal documents of the V&VN and preliminary conversations with the project managers of the chosen organizations were used to become familiar with the topic at hand and the organization sample. After these introducing activities a questionnaire was prepared and interviewees were approached and selected.
3.4 Data collection: sample
In all three organizations interviewees have been selected. The project
managers/leaders in the three organizations for EC and nursing staff directly linked to the EC process has been selected by their show of interest in and their contact with EC implementation. According to Baarda, de Goede & Teunissen (1995) a representative sample size has been reached when the data shows information saturation in the content of the sample. This is assumed reached when a new interviewee does not provide for any new insights on the subject matter. As the results will show, this has been reached.
Informants should be selected that have viewed the subject from different angels whom can be from all sorts of different positions both horizontally and vertically, from within and outside the organization (Eisenhardt & Graebner, 2007). By having preliminary talks with employees from the V&VN and introductory talks with project leaders a representative sample has been reached.
The aim was to interview at least 1 project manager, 1 nurse manager and 3 nurses that have cooperated in the implementation of EC. This results in a total of 4 project managers, 2 nursing managers and 5 nurses that have been interviewed over a span of three organizations. As is shown in the following table:
project leader(s) nurse manager(s) nursing staff
org. X 1 3
org. Y 1 2 1
org. Z 2 1
3.5. Procedure
11 interviews were held in a 2-month period (october and november 2013). Each interview took between 45 and 60 minutes. They were held at the working location of the interviewees and one time on an external location. The project leaders have suggested nurse managers and nursing staff that, in their opinion, would provide for data rich interviews. After these suggestions, the researcher has approached the
interviewees individually to provide for discretion. Anonymity is therefore not reached. However, by not sharing which interviewees in the end took part in the research
discretion and confidentiality is provided. Furthermore, the transcripts of the interviews are shared with none of the parties involved and it was mentioned to all participants that the interviews would be anonymized so that none of the results could be linked to an individual participant.
The interviews had a semi-structured profile with open-ended questions to ensure consistency throughout the interviews and room for the interviewees to give elaborate and data rich answers as the interviewee can answer in their own way and with their own selection of words and interpretation (Bleijenbergh, 2013). Questions started with several introductory questions considering function, years of working experience, experience in the organization and age. After these questions, there have been asked probing questions considering the opinion of the interviewee regarding the change. The interview ended with questions on each of the independent and the
perceived influence on the dependent variable in order to research the influence of the independent variables on change success. This set-up is consistent with Baarda et al. (1995) and Bleijenbergh’s (2013) view on semi structured interviews. Interview questions were composed using the theoretical framework as a basis. The focus laid on the formulation of open questions. Questions between brackets were asked when
elaboration was felt necessary by the researcher to come to sufficient answers regarding data richness. Other factors were not neglected. Questions regarding additional factors were included in the questionnaire to make sure that all factors relevant to
3.6.1. Dependent variable (Change Success)
Change success is not clearly defined in organizational change literature. Therefore success is broadly defined in this research on the basis of the perception of the
interviewees. ‘Success’ itself, is defined in the dictionary as "the accomplishment of an
aim or purpose". In this case the implementation of EC. Jones, Jimmieson & Griffiths
(2005) determine change implementation success by system usage and user
satisfaction. User satisfaction is defined there as: “the extent to which users believe the system meets their needs” (Ives et al. 1983; through Jones et al. (2005:369). As this research does not concern a system implementation but a broader organizational change, success will be determined by user satisfaction only: overall satisfaction with the change and perceived success by the employees that have to deal with the
organizational change on a daily basis. As perception is thus the basis to determine change success, an open question has been formulated which is then used to ask follow-up questions to provide rich transcripts.
3.6.2. Independent variables
The theoretical framework has been used as the basis for formulating the questionnaire. On purpose, questions are not asked with a great amount of detail. By asking clarifying questions and examples, it was possible to extract rich transcripts and code them accordingly.
3.7. Data analysis: coding
Interview transcripts have been coded in order to analyze the influence of the four variables on change success. Interviews have been decomposed to fragments that are coded in correlation with the research question and the variables, as is mentioned in Baarda et al. (1995). Segments of different interviews regarding the same topic have been integrated (Jick, 1979; Yin, 1980; through Yin, 1981). Using both within and cross-case analysis.
developed until no more new codes seemed appropriate to label new fragments. Codes were related to the discussed literature in order to be able to relate codes to literature soundly. Samples of coding can be found in appendix A and in the result section. The researcher has been the sole coder. All interviews have been coded both inductively and deductively. To make sure that the fragments were not only relevant to the mentioned literature, but also to address factors outside the theoretical framework.
3.8. Within- and cross case analysis
Within case analysis provides for detailed descriptions of the pattern that emerge in the cases independently, cross case analysis results in a comparison of these patterns to generalize them (Eisenhardt, 1989). This research has chosen to use Eisenhardt’s (1989) approach to select dimensions to discuss similarities and differences between cases. To secure internal validity the underlying reasons why similarities and
differences between cases and between the results and existing literature are described as suggested by Eisenhardt (1989).
After the results were derived and concluded, these are compared with relevant literature on the subject matter. Both correlating and non-correlating findings were discussed in order to improve internal validity, generalizabilty and higher conceptual levels of the findings (Eisenhardt, 1989). Which can be found in the conclusion and discussion part of this thesis.
3.9. Validity
4. RESULTS
In this section the three cases will be analyzed on the results derived from the interviews. It starts with the analysis of the cases separately on the characteristics shown in the conceptual model. The second part will consist of a cross-case analysis that concludes with the answering of the research question and the proposed sub questions. 4.1 ORGANIZATION ‘X’
Organization X has been studied by interviewing four employees all involved in the change process. Some have been involved from the start and others in later stages. One project leader and three nurses (of which one is the project leaders’ successor) were interviewed.
4.1.1 Change process
To summarize from the literature review: “change process has to do with how the change
is planned, launched, more fully implemented, and once into implementation, sustained”
(Burke, 2010: 25). This has been distinct in the sequencing (distinct use of phases), pacing (bold stroke vs. long march) and direction (‘E’ vs. ‘O’ orientation).
When analyzing the interview transcripts of the four interviewees, it becomes apparent that the project has introduced phases and amended year planning to accustom the change. However, all four interviewed mention that the planning has not (always) been followed as the following quote from the project leader shows: “yes, we did have a year
plan…but I have to say I am not very good at planning. I am somebody who acts on situations that occur in an ad-hoc fashion. That’s nice, but also difficult. For yourself, but also for your environment, as they aren’t always able to understand” Therefore it can be concluded that
although a planning was developed upfront this has not been followed by the project leader and therefore has not showed on the work floor as the following quote
exemplifies: “It is laid down at the team, what the team is up for. And there…I don’t see a
themselves, they do not perceive a clear strategy or what the plans are in the expert team and they do not receive deadlines for implementation. All four interviewees have shown coding that suggests that phases were not always perceived as clear for the organization.
Coding through all four interviews shows clear examples of a long-march process. The organization follows a chain of small continual changes that lead to the implementation. ‘Calm tempo’ and ‘slow reform’ coding show the gradual approach chosen as the
following quote further illustrates: ”we are taking little steps”. This not only illustrates how a long march approach of small continual changes is perceived to have been implemented, but also the perceived positive effect is has had on the change outcomes as the next quote clearly shows: “I think that the tempo has been good, … bit-by-bit things
are introduced and I don’t think it is going too fast, but you shouldn’t have too much time between each event either. But for me it went very well
All four interviews show a clear bottom-up change, using what is typified by one of the interviewees as: “… a big contagion model, the way it has been implemented” Which can be related to an ‘O’-type change. However in the earlier part of the change process, concerning the decision phase and the early preparation for the measurements by the first project leader, three out of four interviewees suggest an ‘E’-type change as shown in the following quote: “very formal, down the line. Yes, in that sense we are a very
hierarchically structured company and it all went through the directors, management and board of directors” Suggesting they perceived a formal, structured and hierarchical
decision process. , that resulted in the appointment of the project leader.
However, despite this first part of the process, all four interviews showcase clear
examples of ‘O’-type change. Which does not show irregularity in the results, but a clear change in focus the implementation has taken when there was appointed a project leader: “And at a certain point, I deliberately made the choice to really work from the
bottom together with (managers) that were part of the management to get things moving”. This quote shows a clear decision to use a more bottom-up approach in the
implementation, which is supported in all four interviews: “No, that whole process of
bottom-up…But you can really notice that they very much want to work bottom-up” Thus, a
bottom-up approach to change is perceived.
Thus, no clear phases or sub goals were perceived to be construed, or when construed, were followed. The process chosen was one concerning a self-proclaimed ‘contagion model’, in which a low tempo of small reforms was introduced. In the change strategy the implementation consisted of a focus on the work floor in which a bottom-up
approach to change was introduced. The influence is exemplified by the following quote:
“So, I do think it has been good that the bit-by-bit fashion in which information and content has come to us, where every time you aim at a different piece of the change process”. Thus,
there is an overall feeling by the interviewees that the change process has positively influenced change outcomes.
4.1.2 Leadership
As can be deducted from the literature review, leadership is defined as: “The process of
establishing goals and motivating others to pursue and achieve those goals” (Burnes,
2009:598). Which can be divided in two broad categories; transactional and
transformational (Bass, 1999;Kleinman, 2004; Burnes, 2009). Transactional leadership focuses on task-completion and efficiency, where transformational focuses on the motivational ability of the leaders to let employees be able to identify themselves with the vision of the charismatic leader (Burnes, 2009). The research views transactional leadership styles related to planned change and transformational to emergent change. The leadership style, perceived by the interviewees as portrayed, can de defined as transformational. Words that are shown repeatedly in the coding, and in all four
interviews, are: facilitating, motivating, inspiring: “I was the initiator and inspired for… by
transformational leadership style as defined by Bass (1999) and the framing and creating capacity style of Higgs & Rowland (2005). The managers do not show focus on efficiency, but on motivating and inspiring behavior. By the nursing staff, this is seen as a break from the leadership style prior to the change: ”Cost-controlling…by which an
enormous period of controlling behavior where everything was aimed at costs and
productivity and the content of the profession was smothered…” Which are assumed to be
characteristics of a transactional leadership style of correcting by Bass (1999) and the shaping behavior of Higgs & Rowland (2005).
Thus, the aimed transformational leadership style by the project leader is clearly
perceived by all interviewees. It is coded as inspiring others, motivating, facilitating and providing for connections between different layers in the organization. This makes sure that the directors can see what happens on the work floor, but can also present
themselves as regarding the change as positive. The transformational leadership style is perceived by the interviewees to have had a positive influence on change outcomes as the following quote exemplifies: “Yes, I do prefer a leader that explains and thereby
motivates and challenges me and furthermore asks me what I need to make it happen and how do you feel about this? That’s also what I find to be the Excellent way” This shows, that
transformational leadership not only positively influenced change outcomes but also is suitable for the aimed outcomes of the change process.
4.1.3 Communication
As can be deducted from the literature review under communication (Kotter, 1995) or poor communication (Price & Chahal, 2006) is considered a threat to successful change. This research views an open communication style where a vision is shared and
developed with the workforce associated with emergent change and a communication plan with no shared vision building process and directive communication associated with planned change.
have really missed information and what one noticed is that through the layer of (middle management), they also translated it for themselves, therefore not providing clarity on the work floor” Which could be explained by the lack of communication strategy also
mentioned in two interviews: ”No. We did not have a clear communication strategy.” The many communication channels used in the change, of which two are viewed to be very positive, might explain why under-communication did not prohibit
implementation. The first is direct communication through a personal approach, such as conversing and interactive presentations that allow Q&A and the sharing of suggestions:
”I have been on the road with teams and powerpoints, mainly in the first year…concerned with inspiration, because that was the message in the first period. ‘Guys, this concerns our profession’. ‘We are allowed to become professionals again and it is important that we show our opinion’. Yes, it was revolution, that’s how it felt” The second, is the shared
development of the vision and a card that had the vision printed on it: “The biggest
success of EC, in my opinion, has been the vision on care. Research was performed by
employees…they have presented an advise…from that point I have invited employees from all regions to discuss what’s in your view characteristic of good care…that has been officially handed to the direction and management and they have started to work on it and that has been an immediate boost to EC”. This is shown to be an effective format, not only to make
the vision clear in the own organization, but also to explain the vision to the
stakeholders that employees deal with on a day-to-day basis: “Because there was a very
simple A5 card with the vision stated and the important issues … and they have taken that to municipals, insurers and collaborating partners... That has given a tremendous boost to EC.”
Although the assumed under-communication is not mentioned to prohibit successful implementation, interviewees do state that more communication through formal
channels would have lead to a smoother progression in the change process: “I think that
could have been done better. If we would have communicated more, also through (existing channels)… you could have already created more movement”. As a communication strategy
was not developed, communication was done in an open non-directive fashion and there was a shared vision development. This communication style is viewed related to
4.1.4 Participation
As is shown in the literature review, participation is defined as: “the process of involving people in decision-making and change activities within organizations” (Burnes,
2009:600). The higher the level of participation throughout the change and throughout and within all organizational layers, the more it is viewed to be associated with
emergent change.
All four interviewees have perceived a high level of participation in the change
implementation: “The fact that EC was adopted as a direction, has altered the behavior of …
actually all organizational levels. The element that sparked it was the question to develop a vision on care. That was felt to be really special. So, we as the expert team, have developed that in collaboration with a large group of nurses and caretakers, which resulted in a gradual shift” This has happened both in de development of the change and in the actual
implementation as well: “No, there was room for suggestion. There are constantly asked
questions in that group too: management, teamcoaches and to us…” Participation is thus
not only perceived high between certain layers in the organization, but is throughout and between all levels: ”I think that when you state that EC is a movement to create a good
working place for the professional, then you need to involve the professional. And I have always felt that. There was nothing decided over our heads”. Coding shows, consultations,
involving, open to suggestions, asking and probing, which are regarded by the interviewees as positively influencing the change process. This shows that a high
participative form of change has been implemented which can be related to an emergent change implementation.
4.1.5 Emergent or planned change in organization X?
the philosophy behind the change cannot be considered planned. The emergent change is perceived by all interviewees to have positively influenced the change.
4.2 ORGANIZATION Y
Organization Y has been studied by interviewing four individuals, of whom one was the project leader, two were managers and one nurse. Two have been involved from the start of the project and two have become in later stages.
The implementation of change in organization ‘Y’ can be divided into two projects. The first considers implementing Excellent Care and the second is a spin-off from the first. As the results will show, two different approaches have been adopted to introduce change.
4.2.1 Change process
The two interviewees involved from the start of the project, both show in their answers that there has been developed clear plans both sequencing: “Yes… we made a complete
plan ... just as in the’ year plans’, we have worked on redirecting all protocols on EC…” in
pacing: ”Also a planning in time” and protocols are reviewed and rewritten. However, all interviewees, excluding the project leader, cannot deduce a clear approach: ”No, no
follow-up steps. That has never been clear.” The result is shown in the last fragment that
states that due to an unclear approach and unclear plan, the implementation has faded:
“and that’s how it slowly fades” Thus, sequencing is attempted, but not followed through.
Variety in the coding existed, which made the analysis difficult. During the start of the change, the pace of the change is considered fast and the change is introduced through a project group, through ‘year plans’ and with decision making in the top-layers of the organization in a large episodic manner, as shown in the interviews of the interviewees involved from the start: “Yes and they made suggestions to the directors: look, this is what
we would like to have, just as the essentials in the year plans, and in the beginning everybody was enthusiastic and it went easily and progressive.” All interviewees, except the project
I also remember that is has also been communicated in the organization. Somewhat top-down, from MT to management what EC entailed.”
However all interviewees, excluding the project leader, show in their interviews
perceived an unclear and undesired pace of the change process: “Slow, yes just slow. The
whole time just a little bit. When employees were asked to fill in the questionnaires the whole time, there was quite some tempo behind it.” Which indicates that the pace is not
perceived to have had a positive influence on the implementation: “Yes, and then we
wanted to pick it up again. But that has never been realized. If I’m honest.” Thus, the three
interviewees, excluding the project leader, perceive the pace as fast with clear actions that are then followed by a period that lacks tempo.
The aim of the change is directed on changing procedures, which are delegated top-down through the different layers of the organization: “yes, they basically just told me”. This is viewed to be an ‘E’-type change direction. However, the following quote shows the installment of an advisory committee which seats nursing staff: “The NAC (Nursing
Advisory Council) was really established as an advisory council ... Specifically on health care.”
This could be considered an ‘O’-type direction, as it consults those involved to catalyze commitment. However as the next quote shows, because of a lack of trust in the
capabilities in the advisory committee this is not used as intended when it was installed:
“But at a certain moment the management thought that the level in the NAC, which included nurses and caretakers, was insufficient to look broadly at the concerned issues. The NAC had to be able use a helicopter view to look at the organization as a whole”
(1st project)
One can deduce from the above shows results, that the implementation shows signs of planned change. There has been developed a clear plan that has been introduced
through adapting procedures, in a top-down manner. The results also show that this has had a negative influence on the implementation process: “You know, honestly, it is not a
good example of an implementation project…” Furthermore, two of the interviewees
one would have accomplished a lot more and would have had a more enthusiastic group than has now been the case. But, that is my conclusion.”
(2nd project)
As the following quote will show, according to the two interviewees involved in the second initiated project can be seen as a spin-off from the first project, and is perceived by them to have handled the implementation in a vastly different manner, using a clear O-direction: ”However, from the positive elements, we have set up the project again. We
have investigated how we should introduce it ... We have constructed four pillars…We have dedicated a whole week on ‘working experientially’…every department focuses on one pillar each half year…we change each time and celebrate successes. Like you do when working in projects. What are we doing well, what is not going well, how can we improve? …one notices it on the work floor and comes back in team meetings.” Using a long-march approach: ”we have decided to implement it step by step. Small changes.” which are perceived by the
interviewees involved as having positively influenced the implementation of the second project.
4.2.2 Leadership
Both transformational and transactional forms of leadership have been present in the implementation. As the following quote shows, the organization leaders were not able to determine if feedback derived from questionnaires could be shared with the employees:
”That was difficult all of a sudden in the organization. Because now executives were
addressed publically on what was going wrong and well. Were we allowed to share this with the complete organization, and how are we going to tell them, and were team members allowed to hear that some people might thought negatively about their executive…?” This is
When feedback is shared in a transformational manner, this is perceived to have
positively influenced the implementation: “Eventually…all executives have spoken with the
teams…together with me…and we have stated ... We should have discussed it faster, but we do want to discuss the matter … how it was … and how it is now and what we can learn from it and … can take with us, … to work on. … that resulted in real good feedback, good
collaboration, people still wanted to go for EC…” However, the transformational style,
which is assumed because of the supporting style shown by the project leader, can also be seen as leader-centric as the project is clearly carried by the project leader and is not passed on to others involved: ”when the project leader was gone it all faded a bit, that was
my perception…A good project shouldn’t depend on just one person, off course.” Resulting
in a potential reason why continuation lacked when the project leader left the
organization. The interviews show a clear pattern of transactional, shaping and leader-centric behavior: “It came across as if the leader of the project … was the decision maker.” where transformational leadership is shown in the interviews to be desired and when portrayed, is perceived to positively influence the implementation process. Therefore, the results show that the leadership style in the implementation has negatively
influenced the implementation. It is characterized as transactional and therefore related to planned change.
(2nd project)
The leadership style, here, is perceived as vastly different as an interviewee exemplifies by reviewing the behavior of their direct manager: “ ‘Well then I will also be there’, ‘Do
you want to discuss things beforehand on what to expect?’, ‘Do you need the website?’ There is a real collaborative spirit”. It shows that the leadership style is perceived as aimed at
enthusiasm and facilitating, which can be related to transformational leadership
behavior of individualized consideration, framing and creating capacity. This new style of leadership also shows a perceived positive influence on the change outcomes of the second project and a change in leadership as an interviewed manager states: ”Well to lay
clearly shows transformational leadership styles in which responsibilities are laid out lower in the organization and employees are asked how managers can facilitate them. This is related to emergent change and is perceived to have positively influenced the change implementation process in this organization.
4.2.3 Communication
The communication strategy was perceived as unclear and the vision of the project was perceived unconnected with the organization as the following quote shows:” It was written down. Not discussed, but I’ve read it. But I didn’t think much of it… it was
secluded from the organizational vision. The vision needed to become a part of it, still...” The perceived negative influence this has had on the implementation is best showed in the sentiment that is present on the work floor, where the project has a bad reputation even before it was completely implemented: ”So actually, the project already had a bad
name, before it was actually started? Yes” Communication channels are formal: … through
the newsletter... Mostly, through channels concerning year plans, in meetings.” but those are perceived to not have reached the work floor: “But beforehand, nothing was known?
No.”
The fact that formal communication has the potential of positively influencing
implementation was shown when a personal letter is sent to all individual nursing staff to apply for a visit to a US organization that has implemented a similar change. This is for many nurses the first acquaintance with EC: ” ’Oh does that also exist here?’… ‘ oh a
study trip at (name organization) that’s something we have never done’. You know what I mean?” The used communication style perceived can be described as directive and using
formal channels, which is related to planned change. 2nd project
There is vast critique on the implementation of the first project, which three interviewees show in their answers. Specifically to communication one of the
motivate people to win them over. Thus, I think that is should be very clear what that means, what it is and what it will mean for you. You can only move people if it beneficial for them. That has never happened.” This shows the desire to include the work floor more in the
communication and vision-development. This is confirmed in the following quote: ”Yes.
That was the result of the meeting…you sat in groups and propositions were dropped ... That was then presented and taken on board in the vision.”
This project shows that a more open communication style is perceived with shared vision making, which is perceived to have had positive influences on the
implementation. The vision is discussed and developed with the employees who can amend and suggest content for the vision. This style of communicating can be seen as more open and with clear, shared vision making characteristics and therefore viewed related to emergent change.
4.2.4 Participation
All interviewees acknowledge that both nursing staff and managers have participated in both the implementation and the project group. Although nursing staff is only added later to the project group. There is room for suggestion of ideas in the project group. However, these come from management and team managers, not from the work floor:
”There was… room for suggestions, but not from the work floor. That came from the MT, the management level, but …it should have come from the work floor. But it just wasn’t vivid there...” This shows that not all levels in the organization are participating in all phases
of the development and implementation of the change. Although participation is aimed for and attempted, this is not followed through and high participation is not perceived. Therefore, participation in the first project is regarded related to planned change. 2nd project
A high degree of participation is perceived within and between all organization levels. In both the implementation and development of the change: ”Yes. Everybody was
