Emergence and spreading of workarounds in healthcare

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Emergence and spreading of workarounds in

healthcare

effects of communication and learning

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2 Abstract

So far, the underlying mechanisms of the emergence and spreading of workarounds in

healthcare settings still remains unclear. This study aims to increase insight in this by looking at communication and learning process in this regard. For richness of data the research approach was chosen to be qualitative, entailing interviews with 10 different, highly

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Introduction

More and more IT systems are being implemented in healthcare settings. This development is forcing a group of professionals, who likely prioritise providing qualitative care over IT work, to engage and familiarize with new systems. As their main task is helping people, it is likely that in some cases they might not find the time or space to do this and therefore create their own ways of working. Up until this point however, it remains vague how workarounds emerge in IT change in healthcare situations. This is relevant because the emergence of workarounds can have especially high consequences in a healthcare setting. The general healthcare setting is highly protocolized to guarantee optimal quality care (Petrakaki & Kornelakis, 2016). The tension between routinization and autonomy of professional is very important in healthcare settings as professionals need space to perform their job properly, but at the same time are limited by protocols that force their tasks into a routine that can be measured and controlled (Petrakaki & Kornelakis, 2016). Although workarounds do not necessarily have negative consequences, in fact they can have positive outcomes as well (Barret & Stephens, 2017), workarounds in healthcare settings can lead to partially abandoning the established protocol. If this happens the quality of care can no longer be guaranteed and control over the processes that are being executed is lower than wished for. Workarounds can be defined as the informal practice that is intended to avoid or circumvent difficult aspects of an information systems change (Varpio, Schryer & Lingard, 2009). To gain a better insight in the antecedents of workarounds it is helpful to look at the research concerning adaptation and appropriation of IT systems. How employees react to change initiatives can vary greatly. The way people deal with change of any form can be seen as coping. The coping strategy people use is partially based on how the situation is being appraised. In this appraisal process the person forms an attitude towards the change; the person decides, so to say, if the change will be a threat or an opportunity for him and the person reviews the amount of control he thinks to have over the situation (Beaudry & Pinsonneault, 2005). In case of a perceived threat coming from an IT system people get motivated to disengage with the system or invent other ways of working with it to minimize threats they perceive. This resembles the definition of workarounds according to Varpio, Schryer and Lingard (2009) this paragraph started with. Bala and Venkatesh (2016) found that the cognitive appraisals people develop about the change will influence the adaptation

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5 well as job satisfaction. This means that appraisals could result in lower job performance which could be problematic in a healthcare setting.

This explanation of workarounds only focuses on the individual level, this is something that can be seen in this current field of study a lot. Up until now, most studies mainly look at workarounds on the individual level (Varpio, Schryer & Lingard, 2009; Barret & Stephens, 2017), although this probably does not cover the full picture as people do not only interact with the system, but also with the people around them. The social information processing theory takes this into account as this theory states that attitudes and behaviours towards technology do not only have a base in individuals, but are in fact socially constructed (Salancik & Pfeffer, 1978). Accordingly Schmitz & Fulk (1991) found that co-workers influence each other greatly when adopting new technologies and that the use of technology of supervisors has way less influence on the degree to which they will adopt the new

technology. However, in most research so far the influence of social dynamics is

underestimated in this regard (Barrett & Stephens, 2017). This is also being emphasized by Varpio, Schryer and Lingard (2009) who state that there has not been sufficient attention in research aiming at understanding how communication is being influenced by IT systems. So far in research there has been a lot of emphasis on the communication between the change agent and change recipient, but not at the influence of communication between co-workers in change adaptation processes (Simoes & Esposito, 2014). In a meta-analysis study Marlow, Lacerenza, Paoletti, Burke and Salas (2018) found that the quality of communication among team members has a positive influence on performance, where the frequency of

communication was found to have significantly less effect in this regard. As this highlights that inter-professional communication is an important aspect in achieving and maintaining high quality of care (Campbell et al., 2001), so it is highly relevant to further explore this field of research.

This focus in research on the individual is also being reflected in the general

perception that exists regarding learning new behaviours. The adaptation of workarounds can be seen as a form of learning as people start using the system in another way than was taught. The individual view of learning, as is prominent in research, results in the view that

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6 being seen as a possession of the individual but as the result of the interactions a person has with his or her social and material contexts. The knowledge is believed to be in the interaction with these social and material rather than in the individual itself (Fenwick, Nerland & Jensen, 2012). This social-material perspective on learning could help in gaining a better

understanding of how workarounds emerge and spread. This perspective looks both at the interaction of people with their peers and the materials (systems) they are using. This is higly relevant for enhancing the understanding of workarounds, but even within this perspective aspects are being underemphasized.

A relevant line of research to follow for gaining more insight in communication

processes within teams can be found in the emergence and spreading of resistance behaviours. Simoes and Esposito (2014) emphasise the importance of dialogic communications in

preventing of and/or dealing with resistance behaviours. They found increased dialogic communications in which the different interpretations are taken into account positively relate to a decrease in resistance behaviours. Yuxia (2013) explained that insufficient

communication and involvement in a change situation can lead to employee cynicism which can spread throughout teams and so creates a negative attitude towards the change resulting in resistance. This resistance can for example lead to people abandoning the system, which is seen as a workaround. The exact mechanisms however, still remain unclear.

Still a lot remains unclear regarding the underlying mechanisms of the emergence and spreading of workarounds. So far the focus has primarily been on the individual, resulting in limited knowledge and insufficient acknowledgement of social influences in this regard. As social influences and communication are likely to influence behaviour, and therefore also workarounds, it is important to gain more insight in these mechanisms. This study is therefore aimed to answer the following question:

How do workarounds emerge and spread within departments in a healthcare setting?

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Literature review

In this section the current available literature is reviewed to create a hypothetical model to help answer the research question. Building on the previous section it is relevant to deepen our understanding of workarounds and link this to current theories regarding communication and socio-material learning. By linking these theories we aim to create a theoretical basis in understanding how communicational and learning processes might influence the emergence and spreading of workarounds.

Workarounds

As described earlier, for this study we define workarounds as the informal practice that is intended to avoid or circumvent difficult aspects of an information systems change (Varpio, Schryer & Lingard, 2009). In this study we emphasize the emergence of workarounds and therefore it is important to look at different reasons why people might engage in the creation of workarounds. Literature in this field might sometimes be confusing as the interpretation of workarounds differs greatly (Spierings, Kerr & Houghton, 2016). A meta-analysis reviewing literature in the field of workarounds defined over ten different reasons for why people create and perform workarounds. Based on that, he also defined a variety of ways workarounds can be interpreted (Alter, 2014). These interpretations can be roughly classified in two categories; interpretations based on the idea that workarounds are bad and will only have negative

consequences on performance and interpretations based on the idea that workarounds are useful (in short or long term) and can have both positive and negative effects on performance. In this study workarounds are interpreted as the second category described above. We decide not to define workarounds as positive nor negative, as this might influence the perception of emergence and for this study, looking into emergence and spreading of workarounds, the effects on performance are not particularly relevant.

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8 decrease in effectiveness (Drum, Standifer & Bourne, 2015). There is also a line of research seeing workarounds as creative behaviour that can possibly optimize current ways of working, contrary to the more common negative association that exists. For example Barrett and

Stephens (2017) found that co-worker support and feedback facilitated employees in adopting workarounds that had positive influence on the perceived change success. In this case, the workarounds helped employees learning to use the system and helped them see the change as more positively. By adopting workarounds people perceived higher levels of control when working with the new system and so the threat of this system decreased. Vestal (2008) states that workarounds increase effectiveness and efficiency of practices established in the

organization he looked into. For workarounds to increase noticeably efficiency and/or

effectiveness the workaround almost always has to be adopted by different people. However, it does not become clear how these workarounds spread throughout the team.

Communication and learning

The previous section helped us understand why people would engage in the creation of workarounds, although it is good to realize the reasons behind this behaviour it does not immediately tells us something about the how of the creation and spreading of these workarounds. To gain better understanding in these underlying mechanisms we look at theories regarding communication and social influence among peers. The choices we make in daily life are greatly influenced by others, as this counts for all things we do this also is true for choices we make in the work setting (Gershman, Pouncy & Gweon, 2017). The underlying idea is that people that belong to the same groups have generally homogenous preferences and so copying behaviours from peers will have more positive consequences. Therefore we are more likely to engage in the same decisions as people around us do (Gershman, Pouncy & Gweon, 2017). This could also be one explanation for the spreading of workarounds

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9 react upon it.

The creation and adaptation of workarounds can be seen as learning new behaviour and acquiring new skills. In this regard it is useful to look at mechanisms explaining how people learn. Just like most theories explaining why people engage in workarounds, this is mostly being approached from an individual perspective. From this perspective learning happens in the ‘isolated individual’ and then the newly acquired knowledge or skill is being transferred throughout different contexts. In this study we however approach learning from a socio-material perspective which sees the people and the material with which the individual interacts as inseparable from learning (McMurtry, Rohse & Kilgour, 2016). Learning is not being seen as an internalised mental or behavioural property but as a more dynamic and relational process. According to this socio-material perspective on learning, what people learn is greatly influenced by the people they interact with (Oates, 2016). This learning by

interacting can help people adapt new technology as well as create workarounds. There are five different types of this collaborative team learning; (1) diverse contributions; (2) social interactions and relationships; (3) synthesis of professional ideas; (4) integration of material elements, and (5) connections to large-scale organizations (McMurtry, Rohse & Kilgour, 2016). In these different types the emphasis on both the social as the material are being reflected. Diverse contributions emphasizes the value of diversity in teams and the exchange of knowledge within teams by openly articulating ones expertise. Social interactions and relationships is learning by interacting as this type of team learning entails people knowing whom to turn to for advice and knowing and using each other’s strengths and weaknesses. Synthesis of professional ideas means that new procedures emerges from working together and team knowledge evolves. Integration of material elements means that the team adapts their thinking or practice when relating with new technologies or ways of working and they learn to incorporate their current ways of working with new artefacts or systems through their participation with the team. The last form of team learning, connections to large-scale

organizations, entails that well performing teams can gain respect and power within a larger context. In this way knowledge for example can spread throughout teams and organizations. In all these aspects of collaborative team learning interaction (with others or materials) has a central role.

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10 the people they interact with which creates a network of people linked together in different ways. In this way it becomes insightful which people interact with each other and which people may link different subgroups in the network with each other. This theory states that there are two important aspects regarding communication, the source and the content. People that are closer to you are seen as a more influential source, what these people say, do and think have way more influence on you than people that are less close to you in the network. It would therefore be likely that people choose to adopt the same workarounds as the people they are closely related to in the network, which is often the case in (work) teams (Sykes & Venkatesh, 2017).

Figure 1

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11 Social interaction and social information are both always present in the organization and therefore these factors could influence the provoking examples employees perceive.

Interaction with peers could for example make people aware of negative aspects of the new system or make people aware of their lacking skills in using it.

When employees feel they have a reason to change their behaviours contrary to what is being expected from them they try to invent new ways to deal with the situation. We

believe that this happens through social influence. We define the social influence mechanisms as the social information the individual gets and social interaction he or she engages in. Social information leads to salience of relevant information regarding expectations of the individual and the consequences of this behaviour and it helps constructing meaning. In this way the social context teaches the individual what is appropriate and what is not, so this can lead to learning. If the social context shows that it is okay for people to use systems in the way they like, the creation of workarounds is being enhanced.

Social interaction is the second underlying main mechanism that is being identified. This directly influences learning as it is believed that through communication within teams (between peers) learning is facilitated. This relation however is expected to be mediated by closeness as people value opinions from others close to them higher than from others that are less close to them, as is also explained earlier by social network theory (Sykes & Venkatesh, 2017). Social-material learning theory helps us explain how and why people can create workarounds, as this theory states that people learn by interacting with people and materials around them (McMurtry, Rohse & Kilgour, 2016). Workarounds can be seen as newly learned behaviours because they are being invented to interact with a system in new, not expected, ways.

Methods

Research approach

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12 need of enrichment of understanding of underlying mechanisms (Eisenhardt, 1989). This need for enrichment became apparent after reviewing the literature which is currently available in the field. Qualitative research is most appropriate for filling the gaps in the literature as in this type of research participants can freely speak and ventilate their ideas and opinions, which might be resulting in insights that would otherwise not have become clear. The choice for this type of research will have consequences. As the study is being performed in a team with certain characteristics the generalizability of this study might be limited. Construct validity in this study is being realized by carefully constructing interview questions and reviewing and discussing this together with other researchers in the field. To be able to get reliable results the participants are being carefully selected from different sub teams and different disciplines within the team will be represented.

Case description and case selection

For increasing the knowledge about workarounds in healthcare settings, the main requirement when selecting a case was that the case should be at a healthcare setting with recently adjusted IT systems. The case that was selected is a team within a mental healthcare institution that offers care to children and young adults up until the age of 23. Because we want to gain insight in social processes underlying or influencing workarounds we chose to look at the dynamics within a team. The team that was being selected is especially useful because the team exists of a group of specialists that works at different locations. This shared specialism makes the team quite close. The relational closeness and amount of interaction however differs within the team as team members are in this case not necessarily the co-workers that are interacted with on a daily bases. This is being assessed by asking participant which peers they mostly work with and how they evaluate the relation they have with them.

Data collection

Data will be collected using a qualitative instrument, namely semi-structured interviews. The rationale for using this type of instrument is that interviews can provide insights into causes, inferences and explanations regarding the research subject. Although semi-structured

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13 be influenced, acknowledging and awareness of its influence can help the researcher put results in perspective. To be able to gain comprehensive insight regarding the communicative patterns in a team, we will interview different team members from one team, with varying expertise and working at different locations.

When conducting interviews the well-being of the interviewees are the first priority. To guarantee well-being of the interviewees some measures have been in place. The interviewee chose the time and location of the interview so that he or she feels as comfortable as possible during the interview. Another important aspect is that the purpose of the interview is clearly explained and confidentiality is guaranteed, so the interviewee can talk freely without any consequences. Finally, interviewees are being asked to give permission for recording of the interview. After the interview the interviewee is being asked if he or she would like to receive the transcript of the interview and or the final results of the study.

The interview outline is being created based on the different theories that are wished to be investigated. The interview protocol can be found in appendix 1. Interviews will be conducted according to the guidelines Myers and Newman (2007) defined. Firstly it is important to situate both the interviewer as the interviewee. The interviewer does this by shortly

introducing herself and explaining something about the study. The interviewee is being asked about his or her role in the team and since how long he or she has been part of the team. As described earlier, it is very important for the interviewee to feel comfortable, and in terms of Myers and Newman (2007) to minimize social dissonance. To optimize this the researcher needs to approach and dress appropriately. Besides first impressions, also in the questions this is being reflected by starting each topic with more general questions so the trust is being built before potentially sensitive questions are being asked. Furthermore it is important to value various ‘voices’, which is being realized by interviewing team members from different locations and different disciplines within the team. In the interview it is important for the interviewer to be flexible so the participants can talk freely and interesting things that come up in the conversation can be further explored. This is why a semi-structured interview is being used as this structure allows flexibility. During the interview the interviewer will make use of mirroring the interviewee to focus on the world of the interviewee and encourage him to describe his experiences in his own words.

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14 on the preferred time and location of the participant. The interviews have been held during a three week time frame. During the interviews people were willing to share their opinions and experiences.

General characteristics of participants

Ten people, from a variety of locations from the specialized team working with eating

disorders, participated in the study. As this teams contains of different members with varying specialisms, we tried to incorporate different specialists as their view might vary. Among the participants therefore there are specialist for the inpatient as well as the outpatient part of treatment. The disciplines that are included are social worker, psychologist, cognitive

therapist and a family therapist. Besides their main disciplines, some of the interviewees also had side tasks within the team, one of them for example is chairwoman of the whole team and another was leading the members of one location. These people were included partly for their -expected- closer ties to management which again could influence their perspective. To guarantee anonymity of participant we chose not to label their codes to their participant number but only to the location they work at. In the table below the distribution of participants over the different locations, and their main functions are being displayed. Important to notice is that location 1 is defined as the main location of the team as in this location the vision and work procedures are mainly being developed. Location 4 is the only location in which clients receive inpatient treatments, all other locations only provide treatment in an outpatient setting.

Table 1 Participant nr Location Function 1 1 Cognitive therapist 2 1 Cognitieve therapist 3 1&2 Psychologist

4 1&3 Head of team + psychologist 5 2 Psychologist + head of subdivision

6 2 Psychologist

7 2 Psychologist

8 3 Family therapist

9 4 Social worker

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15 Data analysis

The interviews will be transcribed and inductive as well as deductive codes will be used to analyse the answers that were provided by the interviewees which will result in a codebook including the different codes matched with the matching quotes from the interviews. The codings will be based on the theories described in the previous sections. To be able to achieve a valuable theoretical outcome both inductive and deductive codings have to be applied, this means that codings will be based on both the results from the interviews and the underlying theories. According to Urquhart and Fernandes (2013), the closeness to data that goes with qualitative research is valuable but to be able to create a proper theory it is necessary to keep a close link with theory. By using both these coding methods the codebook was developed. The coding will take place in two steps, based on the ideas of Hay (2005). The first step will be basic coding in which different themes will be distinguished. In the second step will entail in depth coding which will result in the ability to identify more specific patterns. The codebook with the original quotes (in the same language as the interviews; Dutch) can be found in appendix 2.

Results

The systems of interest

The interviews indicated that there are two different systems that are being actively used in daily practice and are relevant for this study. The first system is the Electronic Patient Dossier (EPD), which is used to report progress of clients and to read updates from co-workers on a specific client. This system is being used a lot in healthcare organizations like for example hospitals and mental health facilities. When clients are being referred to the institution the administration department immediately opens a EPD for them in which all available

information will be saved. During the intake and possible treatment phase all new available information will be added.

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16 the therapy sessions. The process for this system is somewhat different compared to the EPD. For this platform clients only get an account when they start treatment, so after the intake phase. This means that in practice the client has already had contact with a therapist before getting access to the platform which often results in the client getting contact information from the therapist outside of the platform (a phone number or email address).

Attitudes

To be able to gain insight in the emergence and spreading of workarounds it is important to look at how people evaluate different things in their work life, like the team they are working in, their attitudes towards change and the systems they are working with. The degree to which people positively evaluate the team is remarkable. All participants described their team and the collaboration with team members very positively. One participant even stated ‘the team is

the main reason that I am still working at this organization’. Reasons that the team is liked so

much vary from ‘there is always someone willing to make time for me if necessary’ to ‘we

really have a lot of fun together, and I highly value that’. Team members perceive low

thresholds to approach colleagues if they need help, this for example reflected in ‘difficulties

are being seen by my team members, and it’s okay that they are there, it does not matter if these difficulties are work related or personal. I feel the space to share and I feel supported by my co-workers’.

The attitudes towards change are significantly less positive, but there is at the same time a wider range of responses. Different interviewees indicated that changes go too fast to keep track, one person stating for example ‘it is too much, too fast’. The team has been through various changes in the past few years, including a switch in locations. Most interviewees experience some struggle with changes. The main reason for them is ‘things keep changing all

the time, it is just too much’. Another reason that came up various times is the relation and

communication with management, one person stated ‘top management does not pay any

attention to what happens on the work floor’ and someone else told that ‘in the past things have happened that lead to a lack of trust in management and I think some co-workers are still affected by that’. According to these interviewees this affect the way people in the team

perceive change and sometimes even resist it. But not all of them feel this way, two

interviewees were quite excited about change and stated ‘when things need to change I like it

to think about new processes and procedures’. Although change is not always liked, all

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17 Overall, participants evaluate the systems they work with positively. This reflects in statements like ‘I am happy with it’ and ‘in general it just works seriously well’. Updates in systems are being perceived as a positive thing as ‘changes mostly make my work easier’ and

‘changes in systems are just really important’. However the updates are generally being seen

as important different participants indicate that they cannot always keep track. The main reasons that were given are ‘it just does not have my priority’ and ‘I cannot always find the

time to catch up with all the changes’. The skills of participants do vary ranging from ‘I am not very good at it’ to ‘I feel comfortable using it and I am able to let the system work for me’.

Beyond the general appreciation of the system there are also small irritations being identified, the main irritation being a lack of integration of the different systems resulting in employees reporting in three different systems. People do not like this as ‘it is a lot of clicking’ and ‘it

just makes it very cumbersome’.

Workarounds

During the interviews several workarounds were identified. In the table below an overview of all described workarounds is presented. Remarkable is that most reasons to engage in

workarounds are result of limitations of the system or result from employees not prioritising that specific use of the system and doing it the way that is most convenient for themselves.

Table 2

Workaround Explanation Location Number of people describing Reason to engage in workaround Saving documents in another place in the EPD

Documents can only be added to the EPD under ‘correspondence’, while they might fit better at another place; for example in the reporting section.

2 1 ‘it is necessary to be

saved somewhere and the system does not give other options’

e-mailing via Outlook instead of ‘Jouw Omgeving’

Instead of corresponding via the secured system ‘Jouw Omgeving’ participants use the ordinary e-mail programme.

1, 2, 3, 4 7 ‘it is just easier’

‘parents and clients do not want to log in for everything’ ‘I use Outlook the whole day’

Copying notes throughout systems

There are 3 systems which need to be updated by employees. Instead of updating each system separately people copy/paste notes.

1, 2, 3 4 ‘I don’t have time to

write it again and again’

Outsource making series of

appointments

Instead of making new client appointments in the

1 1 ‘it takes less time to

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18 session, secretary is being

asked to plan a series.

find out how it works myself’

Using items from the online

treatment protocol separately

Compile a custom online treatment for a client by using different items from different protocols.

1 1 ‘I want to keep it easy

for both the client and myself’

Avoiding use of ‘Jouw Omgeving’

Not engaging with online treatment and not using the corresponding function of the secured system.

3 1 ‘up until now, the

system is just too unclear to me’

There was one workaround that really stood out during the interviews as most participants (7/10) could identify with engaging in this workaround. The case was that people do not always use the secure system (Jouw Omgeving) when corresponding with clients or their parents. Participants used Outlook instead, which is not secured. This workaround is particularly interesting as it is a sign of partly abandoning the system while the team sees itself as a team that is quite leading in the use and adoption of systems in their work. It was stated that ‘one of the main functions of Jouw Omgeving is being able to safely interact with

clients and important others’, but as it appeared this important functionality is not being used

to its full extent. There were different reasons given for not using the system for messaging with clients ranging from ‘I do not get notifications of new messages, therefore I cannot

always adequately respond’ to ‘I do a lot through Outlook, it is inconvenient when I need to switch systems just to send one message’.

When summarizing these reasons the conclusion at hand is that most interviewees find it inconvenient to use the system, although they know it has significant security benefits. Based on the different interviews different underlying mechanisms can be de defined, contributing to the emergence of this workaround. As explained earlier, clients only get access to the system when the actual treatment starts. This often leads to therapists sharing their contact

information with clients and/or parents beforehand so in case of emergency they can

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19 The second workaround identified and recognized by different participants is copy-pasting notes through the different systems that are being used in daily work. There are three main systems participants work with, the EPD, ‘Jouw Omgeving’ and a system in which they register actions to justify their work. Every action that is being performed in ‘Jouw

Omgeving’ also needs to be reported in the EPD and the justifying system. Although all these systems need somewhat different information, four participants said they just copy-paste their notes from one system to the others because they do not have time to keep adjusting their reports. This results in less clarity in the patient dossier as the ways of reporting are not coherent for the different types of interactions (i.e.; mail, feedback on assignments, face to face contact) with the client and this makes reading reports of clients from co-workers more difficult to understand. Reasons that were reported for doing this primarily were related to a lack of time to properly do it in all systems. And as the input information for the different systems at base is quite similar, interviewees indicated they did not see the added value of doing it precise and separately for each system.

The other workarounds that the participants came up with were only recognized by one person. One of these workarounds stands out because in this case a participant indicated that he or she tried to avoid using the system ‘Jouw Omgeving’ as much as possible. This person does not make use of the online treatment options, nor is he/she corresponding via the system with clients or parents. Main reason that was given for avoiding this system that ‘it is still too

unclear and I am not really good at all those computer things’. This firstly indicates an

inability to make adequate use of the system. Besides that, the person indicated not really perceiving the need to utilize the system, as ‘my current way of working works as well’. This interviewee really was different from all the others, as everyone else adopted the system and is actively working with it on a daily basis. From the interviews it did not really become clear how it happened that this person did not engage in the same learning process as all other interviewees did.

Communication

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‘there is always someone sitting next to me whom I can ask a question’ and ‘when I do not know something I just ask out loud and wait who will respond’.

In other locations this is somewhat different as they do not all have a co-working space. In these locations members stay in their own rooms for most of the day, making it somewhat difficult to easily interact with co-workers. When in need of help, at these locations

interviewees send e-mails to colleagues asking questions or walk to each other’s rooms. One person from this type of location stated ‘I first have to e-mail my colleagues when I have

something to discuss, most of the time we just do not run into each other’. This makes

knowledge sharing more one on one, instead of team-based. All people from this location however still are happy about their team and perceive low thresholds to approach colleagues. Two participants have shifted locations in the past from a location with a co-working space to a location without them. They both indicate having less direct contact with their colleagues now compared to when they were working at the other location. Quotes like ‘I would like to

have more direct contact with my co-workers’ indicate they would prefer a working situation

with a co-working space over the current situation. Another interviewee who does not have experience with different locations also states ‘I don’t like that I see my co-workers this little,

I would like to experience more togetherness in the work situation’.

In the inpatient setting it is different as well as in that setting there are shifts of 2 people at a time. This leads to a situation in which two co-workers share a lot together, but to a lesser degree with other members of the team. In this way the transmission of knowledge is partly dependent on who the co-worker is for that day. People state ‘I know whom to turn to when I

have difficulties using IT systems’, but if that person is not available that day due to different

shifts this takes longer. Learning

As was shown in the section above, the ways and intensity of communication differ in the locations, which in turn also leads to differences in learning. Interviewees indicate that when there are big changes in systems or a new system is being implemented the organization provides training to all employees. Different people indicate that this is not sufficient, for example stating ‘the real learning starts when I start using the system’. When elaborating about how participants familiarize with new systems or system updates it becomes clear that most of them are learning by doing, several participants make statements like ‘I especially

learn a lot by just trying’. Besides learning by doing, people indicate that they are learning a

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21 and less skilled with handling systems. The participants who have a high skill level learn most by just trying new things. These people can be seen as early adopters of the system. They quickly integrate changes in the system in their work processes and after the training they find out most things themselves. The medium skilled people do also learn by doing and

experiencing, but learn a lot from co-workers as well. This is reflected in quotes like ‘I learn a

lot from others, but I also teach the things I know’. These participants stated they learn more

from interacting with others than from a training. The low skilled participants do not actively contribute to knowledge and skills regarding the system, as they only learn from others. Most low skilled interviewees admitted that they are not very proactive in finding out ways to deal with the system and they wait for their colleagues to find out the best way of working so they can learn it from them. Most of these people actively approach co-workers with their

questions about the system but they differ in the priority they give to learning this, ranging from ‘I am not that good at it, so I ask a lot of help from my colleagues’ to ‘I only ask when it

really becomes a problem for me, so not that often’.

When looking for an explanation for the spreading of workarounds it is highly relevant to further look into how participants learn from each other exactly. From the responses that were given can be concluded that learning happens mostly spontaneous, especially in the locations with co-working spaces. This learning happens without a plan or an underlying idea.

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22 are physically working together, for example when they are sitting together to discuss a client they are both involved with. However, as they spend most of their days apart from co-workers this type of learning is not as prevalent as in the other location. Another way of learning is just asking for help when experiencing problems with the system. This is different than the

spontaneous expressions of frustration that were described above, as in this type of location people have to actively search for co-workers to ask for help. This is most of the time only being done when the person really experience problems with system use. When this is perceived, there are two ways of getting in touch with colleagues; this can be done by either sending an e-mail or walking to someone’s room if this person is available (this can be checked in the system). An important difference between the types of locations is that in the latter type people are less likely to become aware of the ways of working of their co-workers. This could lead to people working with the system inefficiently without knowing, where there are people in their team that have found more optimal ways of working.

Discussion

In this study we tried to deepen insight in the emergence and spreading of workarounds within teams in a healthcare setting. By engaging with the existing literature in the field and

developing and conducting interviews we want to provide an answer to the question; ‘How do

workarounds emerge and spread within departments in a healthcare setting?’. Interviews

have been conducted with 10 people from an highly specialized team treating eating disorders in children and adolescents.

Interview data suggested that workarounds start to emerge when members of the team think their old ways of working are easier and the new ways of working are not sufficiently beneficial. Important to note here is that in this case people had access to two system that could be used for the same task, making it very easy to hold on to old ways of working. Previous research has already confirmed that habits can be a strong factor in staying with old ways of working or relapsing in old habits instead of changing as intended (Jasperson, Carter & Zmud, 2005). Another reason for not engaging in the new work processes is being

described by Beaudry and Pisonnault (2005), who think this type of avoidance happens because people think that they are also being able to complete their tasks without engaging with the system. Looking at the interview data, it is quite likely that this is a fitting

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23 to deliver high quality care, leaving little time and space for strict use of systems and

familiarizing with new features. The priority of all participants lays at delivering high quality treatments for their clients, prioritizing treatment can therefore be seen as the group norm. This likely entails that the group norm regarding IT is that it is less relevant and this could explain that engaging in workarounds is being socially accepted in this team. This consensus is also interesting as Kraut et al. (1998) stated that the more people using the system the higher the value of that system gets. In this case it can be stated that there was some form of consensus regarding not using the system, which in this line of thought might lead to a decrease in system value.

However, this does not explain how workarounds emerge. High-skilled participants indicated that they just start using the system and learn a lot by trying. The initial emergence of a workaround therefore seems to happen at the individual level, where people find ways to make their interactions with the system easier. How this works within the individual did not become fully clear in this study. This learning by doing corresponds to the idea of experiential learning has been existent in literature for quite some time (Beard, 2018). Although

experiential learning can be valuable, it might also be the case that this increases the

development of workarounds. Even though learning capabilities might result in the creation of workarounds, it is essential for successful adoption of IT systems. Avgar, Tambe and Hitt (2018) argue that work practices that complement IT systems can increase how quickly employees learn to work with these new systems. They found that when employees have a high degree of discretion, learning by doing is being enhanced, and so help employees to familiarize with the system more quickly. So this type of learning might enhance efficiently working with the system as well as enhance the creation of workarounds. This however is only a suggested link which should be further investigated in the future. The need for

experiential learning could also be interpreted as a knowledge gap between what participants have learned at the training and what they need in their daily work. Bostrom, Olfman and Sein (1990) already argued that the learning style of the employee is important for the

effectiveness of the training. They therefore state that, to overcome ineffectiveness in training programmes, it is essential to match training to individual differences in learning style. With respect to the underlying mechanisms of the spreading of workarounds it was found that as was expected, communication and learning played an important role in this process.

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24 spontaneous learning seemed to happen more in locations at which participants worked in a co-working space. This makes sense as in these cases people are sitting next to each other instead of everyone sitting in their own room all day. Parrino (2015) found that exchanging knowledge was enhanced in situations where co-workers worked in physical proximity of each other, but only when they collaborated with these co-workers anyway. In the case that was being studied this certainly was the case as all participants worked together on the same specialized team. This however is only a trend that is being recognised but has no solid base yet, so future research should investigate to which degree the sharing of knowledge is being enhanced when you put co-workers in a space in which they work together. By further

looking into this hopefully more insight can be gained in the social aspects that influence how people deal with systems. This is very relevant for optimizing adaptation and appropriation processes in the future, which is also being acknowledged by Olschewski, Renken and Mueller (2018). Based on this study we however cannot come up with clear

recommendations, future research should aim at building on these findings and so creating more and more insight and knowledge in this regard.

When interpreting the findings, it is important to also be aware of the limitations this study has. One of the most important limitations of this study is that workarounds that came up later in the interviews could not be checked by all participants. Things that later interviewees came up with could not be verified by participants that already had been interviewed before. Therefore we cannot state with certainty that some workarounds do not occur a lot, as we do not know which earlier participants would have recognized themselves in a particular workaround. Furthermore, the generalizability is limited as only ten people from one team participated in the study and the team of interest is a team that is highly specialized and therefore cannot be easily compared to any other team. These factors make that we have to be careful interpreting results.

Conclusion

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25 by people working together in the same co-working space. This could mean that working in such a setting enhances learning, but this needs to be further investigated.

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26 Campbell, S. M., Hann, M., Hacker, J., Burns, C., Oliver, D., Thapar, A., & Roland, M. O. (2001). Identifying predictors of high quality care in English general practice: observational study. BMJ (Clinical Research Ed.), 323(7316), 784-787.

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27 Oates, M. (2016). Socio‐material theory: An alternate view of interprofessional team

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28 Yuxia, Q. (2013). Beyond the BOHICA Syndrome: Social Construction of Employee

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Appendix 1: Interview protocol

Introductie

Fijn dat je wat tijd voor me hebt kunnen vrijmaken. Ik zal eerst kort iets uitleggen over mijn

onderzoek. Mijn onderzoek gaat over het gebruik van systemen in de gezondheidszorg. De vragen in dit interview zullen daar dus allemaal mee te maken hebben. Dit interview is vertrouwelijk, en de data zal op een veilige manier worden bewaard. Om de data goed uit te kunnen werken zal ik dit gesprek opnemen, is dat oke voor jou? De opnamen zullen zonder in verband gebracht te worden met jouw naam opgeslagen worden op een beveiligde schijf van de universiteit. Alleen algemene conclusies en geanonimiseerde quotes zullen gedeeld worden in het uiteindelijke onderzoeksrapport. Verder wil ik nog even benadrukken dat er geen goede of foute antwoorden zijn, het gaat puur om jouw ervaring. Heb je verder nog vragen voor we beginnen?

Vragen

Algemeen

Hoe lang werk je al bij deze organisatie en wat is je functie? Hoe zou je jouw rol binnen het team omschrijven?

- Rang

- Speciale taken/functies

Ervaring met collega’s

Met welke collega’s werk je veel samen? En hoe verloopt die samenwerking? - Voorbeeld

- Rol

Hoe is de band met jouw directe collega’s? - Feedback

- Gevoel vragen te kunnen stellen

Interactie (groep)

Kan je beschrijven hoe jullie binnen het team met elkaar omgaan? - Voorbeeld

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29 - Emoties/gevoelens

- Waar ben je blij mee - Waar ben je minder blij mee

Hoe werkt het in jullie team als er een nieuw systeem wordt geïntroduceerd? - Wordt dit veel besproken?

- Staan mensen ervoor open of juist niet? - Wat is jouw eigen houding?

Systeemgebruik

Kan je me uitleggen hoe jij gebruik maakt van het systeem? - Voorbeeld

- Verschillende stappen

Hoe ervaar jij het werken met de huidige systemen/programma’s? - Epd/jouw omgeving

- Wat is fijn en waarom - Wat is niet fijn en waarom - Aansluiting bij taken

Tegen welke problemen loop je aan bij het werken met deze systemen? - Wat werkt goed en wat niet?

Hoe heb je geleerd met deze systemen te werken? - Zelfstandig/training/van elkaar leren - En hoe verliep dit proces?

Zijn er ook dingen die jij op je eigen manier doet? Dus anders dan je bijv. hebt geleerd tijdens trainingen?

- Welke

Een systeem kan het werk makkelijker maken, maar soms ook juist niet. Hoe werkt dat voor jou? - Kan je een voorbeeld noemen van hoe het systeem jouw werk gemakkelijker maakt? - Heb je wel eens het gevoel gehad dat een systeem je werk lastiger of omslachtiger maakte? - Voorbeeld

- Waar loop je tegenaan? Hoe los je dat op? Hulpbronnen?

Afsluiting

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30 Ik ga nu aan het werk om het interview uit te werken. Zou jij nog het transcript willen ontvangen? En als je geïnteresseerd bent kan ik je mailadres noteren zodat ik het onderzoek kan opsturen naar je als het is afgerond. Zou je dat willen?

Bedankt!

Appendix 2: Codebook

Label

Definition

Quote

Communication

Medium The medium people use for

communication with co-workers, i.e. face-to- face/talking, or e-mail

‘I use e-mail a lot to get in touch with co-workers’

Evaluation How people evaluate their communication with co-workers

‘we communicate effectively’

Threshold How high participant

experience the threshold to approach co-workers if they need help

‘The open work atmosphere makes it easy to give your opinion or ask for help’ Learning

Formal learning Learning initiated by

management through trainings or information e-mails.

‘We got a training to work with the updated EPD’

Informal learning Learning that happens spontaneously

‘If I run into something that bothers me I ask one of my colleagues to explain it to me’

Informal teaching Teaching co-workers new skills or tricks to optimize their way of working

‘When I see someone

struggling I explain how I deal with that’

Synthesis of professional ideas (McMurtry, Rohse & Kilgour, 2016)

New procedures emerges from working together and team knowledge evolves

‘together we develop how healthcare should be in the future and how we need to adjust our work processes accordingly. ‘

Diverse contributions (McMurtry, Rohse & Kilgour, 2016)

The exchange of knowledge within teams by openly articulating ones expertise

‘We use new research we executed immediately for improving our ways of working’

Social interactions and relationships

(McMurtry, Rohse & Kilgour, 2016)

Learning by interacting, this type of team learning entails people knowing whom to turn to for advice and knowing and using each other’s strengths and weaknesses.

‘When I struggle with PC things, I know which colleague to turn to for help’

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31 Towards change How participants see change ‘I understand we need to

change, but everything

changes too often and too fast’

Positive attitudes towards IT The way people see the systems they work with as positive

‘It is fantastic how the system can empower my clients’

Negative attitudes towards IT The negative sides people perceive from IT

‘I cannot keep up with all the changes’

Workarounds What people do that

circumvents regular processes

Emergence and spreading of workarounds in healthcare