1 Master Thesis
Inter-Recipient Sensemaking During the Implementation of an Interactive IT Application: a Case Study in Mental Healthcare
Final version July 8, 2016
Master Thesis Business Administration - Change Management
by Sherina Kingma C.H. Petersstraat 33a 9714 CH Groningen student number: 2587696 s.kingma.4@student.rug.nl
Supervisor: dr. I. Maris – de Bresser Co-assessor: dr. M.A.G. van Offenbeek
Word count (excluding references and appendences): 12080
Key words: sensemaking, inter-recipient sensemaking, implementation of interactive IT application,
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ABSTRACT
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TABLE OF CONTENT
Abstract ... 2 Table of Content ... 3 1. Introduction ... 5 2. Literature ... 6 2.1 E-health ... 72.1.1 Affordances and benefits of e-health ... 7
2.1.2 Successful implementation of e-health systems ... 8
2.2 Sensemaking ... 9
2.2.1 Inter-recipient sensemaking ... 10
3. Methods ... 11
3.1 Case study... 11
3.1.1 The research case ... 12
3.2 Data collection ... 12
3.2.1 Interviews ... 13
3.2.2 Internal document analysis ... 14
3.3 Data analysis... 15
3.4 Controllability, validity and reliability ... 15
4. Results ... 16 4.1 Team 1 ... 17 4.1.1 Old schemata ... 17 4.1.2 Social interactions ... 18 4.1.3 Triggers ... 18 4.1.4 Summary ... 19 4.2 Team 2 ... 19 4.2.1 Old schemata ... 19 4.2.2 Social interactions ... 20 4.2.3 Triggers ... 21 4.2.4 Summary ... 21 4.3 Team 3 ... 21 4.3.1 Old schemata ... 22 4.3.2 Social interactions ... 22 4.3.3 Triggers ... 22 4.3.4 Team characteristics ... 23 4.3.5 Summary ... 24
4.4 Cross-case analysis: successful implementation – differences between teams ... 24
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4.4.2 Old schemata ... 25
4.4.3 Social interactions ... 26
4.4.4 Triggers ... 26
4.4.5 Team characterstics ... 27
5. Conclusions and discussion ... 27
5.1 Summary of results ... 27
5.2 Discussion ... 28
5.3 Theoretical and managerial implications ... 29
5.4 Research limitations and further research ... 29
5.5 Conclusion ... 30
Acknowledgements ... 31
References ... 32
Appendix 1: Interview Guide Team Leader ... 37
Appendix 2: Interview Guide Team Member ... 39
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1. INTRODUCTION
Multiple social developments, such as an aging population and an increasing number of long-term conditions, and technological developments, like improving health technologies, have resulted in combination with rising expectations of healthcare to pressure on healthcare resources (Murray, Burns, May, Finch, O’Donnel, Wallace & Mair, 2011; Alpay, Verhoef & van Wely, 2015a). There is a shift in the definition of ‘health’: in 1948 the World Health Organization (WHO) defined ‘health’ as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. Nowadays, the definition of Huber (2011) is more often used. She defines ‘health’ as the ability of people to adapt and to self-manage in the face of physical, emotional and social challenges. In this context, self-management and self-management support are important developments in healthcare. Opportunities for the development of self-management and self-management support are enhanced for patients and healthcare providers by electronic health (e-health) (Alpay, Verhoef, Smeets & van Wely, 2015b).
However, the implementation of e-health applications regularly fails, or only partly delivers the expected results regarding quality improvement and service efficiency (Murray et al., 2011; Mair, May, O’Donnell, Finch, Sullivan & Murray, 2012). There has been significant variability in the success of health implementation: projects face delays, budget deficits and sometimes the implementation of e-health negatively impacts quality and effectiveness of care. The variation in success is often not caused by new strategies or goals itself, but by the way an e-health application is implemented (Greenhalgh, Robert, Macfarlane, Bate & Kyriakidou, 2004). Boddy, King, Clark, Heany & Mair (2009) state that many e-health applications fail to become used as part of everyday working practices. According to Boonstra, Boddy & Fischbacher (2004) social groups do have significant influence on failure of e-health applications. Social groups respond to different aspects of the context, and interpret them in unique and subjective ways. People are likely to accept a solution if they have developed a common set of shared meanings and understandings about the situation. However, Boonstra et al. (2004) do not define which behavior in these social groups influences the success or failure of the implementation of e-health applications. In this research, a sensemaking perspective is used in order to explore the behaviors of group members when implementing an e-health application.
6 share with their peers about these experiences, shape their interpretations of how they should execute the change. Change interventions and plans are translated into action through the mediation of inter-recipient processes, turning top-down intended change into emergent and unpredictable processes (Balogun & Johnson, 2005). The process Balogun & Johnson (2005) describe here is called sensemaking. ‘Sensemaking involves the ongoing retrospective development of plausible images that rationalize what people are doing; it is about the interplay of action and interpretation’ (Weick, Sutcliffe & Obstfeld, 2005, p.409).
Most of the research about sensemaking in organizational change literature focuses on sensemaking between change agent and change recipient (Jensen & Aernestad, 2007; Sonenshein, 2010). Jensen and Aernestad (2007) state in their conclusion that a more detailed study about sensemaking among users of such a system, the change recipients, is needed. This is in line with the findings of Balogun and Johnson (2005) who state that besides informal middle management processes (in absence of senior managers) inter-recipient sensemaking processes seem to have great impact in change situations. However, previous research is not elaborating which factors are influencing the process of inter-recipient sensemaking. This research aims to contribute to the existing literature about sensemaking by exploring the process of inter-recipient sensemaking. The results of more practical interests are interesting for project leaders and change agents: knowing what is going on in your team, how to recognize and what the impact of those phenomena is on change processes is essential in change situations. Expanding the knowledge on this topic can help to make the implementation of future e-health systems more successful, and therefore lower the delays, budget deficits and the negative impacts which the implementation of an e-health system can bring along (Murray et al., 2011; Mair et al., 2012). This research consists of two phases. In the first phase sensemaking processes are identified. The main question in this part is: What is the inter-recipient sensemaking process during the implementation of an e-health system? In the second phase we relate these sensemaking processes to the successfulness of the implementation of an e-health system. The main question in this second part is: How does this process differ in a successful implementation from a less successful implementation of an e-health system?
This thesis is structured as follows. The next chapter discusses literature about e-health implementation and sensemaking. In the third chapter the case which is used for this research is elaborated and the research method will be discussed. Next, in the fourth chapter, the results of the case-study will be discussed. This thesis ends with a discussion and a conclusion of the research.
2. LITERATURE
7 phenomenon the distinction has been made between individual sensemaking and inter-recipient sensemaking.
2.1 E-health
To start with the definition of e-health, Oh, Rizo, Enkin and Jadad (2005) found that nearly all definitions of e-health in literature include the concept of ‘health’ and most definitions refer explicitly to healthcare as a process instead of healthcare as an outcome. A quarter of the studies which have been researched by Oh et al. (2005), mention in their definition of e-health explicitly the improvement of healthcare outcomes. Therefore, they state that e-health refers to ‘the process of providing healthcare via electronic means’ (Oh et al., 2005, p.3). Eysenbach (2001) states that e-health refers to the delivery of healthcare with support from various information technologies, such as the electronic health records, telemedicine, clinical decision support and computerized provider order entry systems. Chaudhry, Wang, Wu, Maglione, Mojlca, Roth, Morton & Shekelle (2006) are more specific and made a definition for e-health applications: these are health information technologies that support the delivery of care, however, they do not in themselves alter states of disease or health. In this research there has been made use of a combination of definitions of e-health by Oh et al. (2005) and Chaudry et al. (2006): e-health refers to providing healthcare via electronic means that support the delivery of care, however they do not in themselves alter states or disease or health. By using this definition, the focus is on the electronic means with the supporting role of this means in healthcare.
2.1.1 Affordances and benefits of e-health
8 benefit categories of e-health: quality, access and efficiency. Quality improvements are facilitated by five factors: informed citizens and caregivers, information designed to streamline healthcare processes, timeliness of care, safety and effectiveness. Access refers to the potential of e-health to improve the availability and accessibility of healthcare to those in need. Efficiency refers to potentially improved productivity of healthcare practitioners, avoiding waste and optimizing resource utilization and costs contained to budgets.
A prerequisite to reach the above mentioned possible affordances and benefits of e-health is that the e-health systems are successfully implemented. Therefore, it is necessary to define the factors that influence successful implementation of e-health systems.
2.1.2 Successful implementation of e-health systems
In IT literature Markus (2004) emphasizes the importance of technochange when a new IT system is implemented. Markus (2004) describes the differences between IT projects, organizational change projects and technochange: in IT projects the focus is on technical performance, while technochange involves great potential impacts on the users. ‘Users’ consist in this definition of the people, processes and organizational performance. Technochange differs from traditional change programs as well because information technology, information technologists, and technical methodologies are so prominently involved in technochange, which they are not in organizational change projects. Markus (2004) defines technochange as a technology-driven organizational change.
When looking at literature specifically about IT implementation in healthcare, research about critical success factors in implementing e-health applications has been done in a broad range of themes. For example, Murray et al. (2011) researched the alignment between technology, organizational goals and existing skills of staff; Boddy et al. (2009) and Boonstra and Van Offenbeek (2010) focused on stakeholders in e-health implementation; Zammuto, Griffith, Majchrzak, Dougherty and Farsj (2007) concluded that interaction between the technology and organizational features is crucial; Greenhalgh et al. (2004) researched the organizational culture in relation to the implementation of e-health applications; Battilana, Gilmartin, Pache and Alexander (2010) and Greenhalgh et al. (2010) emphasize the role of leadership characteristics; Ramsey et al. (2016) identified primary barriers for use of technology-based therapeutic tools. This research adds to these critical success factors with exploring the aspect of inter-recipient sensemaking processes as a critical success factor.
9 in the usage of the IT system. For mandatory used systems IT adoption is reflected in the overall user acceptance. (Tsiknakis & Kouroubali, 2009). In this research a voluntary used e-health system has been researched. This system is used as a supportive tool in mental healthcare. Therefore, the usage of the IT system has been taken in consideration and the overall user acceptance is left behind. Spoel (2008) states that e-health usage refers to the way that therapists use online sources: it is not merely having the necessary access, but how people make health decisions based on their online efforts compared to more traditional, face-to-face efforts. Therefore, in this research the relative use of e-health is defined as: the use of e-health compared to the use of other methods used by therapists.
2.2 Sensemaking
According to Boonstra and Van Offenbeek (2010), actors in the technological change have interpretative flexibility; they develop their own reasons and motivations for their actions. Greenhalgh et al. (2004) state that people are not passive recipients of innovations. Rather, they seek innovations, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, work around them, gain experience with them, modify them to fit particular tasks, and try to improve or redesign them. This happens often through dialogue with other people according to Greenhalgh et al. (2004).
The activities mentioned by Greenhalgh et al. (2004), have similarities with the phenomenon sensemaking. Greenhalgh et al. (2004) state that sensemaking involves individuals engaging in retrospective and prospective thinking in order to construct an interpretation of reality. It includes extracting particular behaviors and communications out of streams of ongoing events, interpreting them to give them meaning, and then acting on the resulting interpretation. The above mentioned definition of Greenhalgh et al. (2004) indicates interrelated phenomena between individuals as well. Sonenshein (2010) underlines that sensemaking is simply a tool to shape your own understanding.
10 other. Individual schemata, social processes of interaction, interpretations and triggers are important factors in this process.
Figure 1: Sensemaking process by Balogun (2006)
2.2.1 Inter-recipient sensemaking
Looking at Figure 1, Balogun (2006) describes that sensemaking has to do with schemata, which are “the mental maps or memory models that individuals have about their organization.” (p. 31). Labianca, Giuseppe, Gray and Brass (2000) define schemata as the mental models held by individuals that affect the events individuals respond to and how. During times of stability, individuals respond in a largely preprogrammed, almost taken-for-granted way to events occurring around them leading to co-ordinate actions and behavior. However, during times of change, such ways of behaving are likely to break down. People have to adopt new job roles, new technology, new working practices and so on. Their behavior has to become less preprogrammed and more considered, although at the time individuals seek to re-establish shared patterns of behavior and return to more stable working practices. Individuals have to move to a more conscious sensemaking mode to assess what is going on around them. Developing schemata, new schemata, are the interpretations that change recipients arrive at through their social processes of interaction of what change is about.
11 ‘organizational interpretive schema’: ‘a set of shared assumptions, values, and frames of reference that give meaning to everyday activities and guide how organization members think and act’ (p. 578). When it comes about schemata, in this research the philosophy of Weick (1995) and Rerup and Feldman (2011) is used: individuals’ schemata leads to an enacted reality at group level, this enacted reality results in the organizational interpretive schemata.
During change there are related initiatives, activities and events which individuals cannot understand through their existing schemata, which act as sensemaking triggers. Individuals move to the more conscious sensemaking mode to make sense of the differences they are experiencing, typically by sharing their experiences with others. Individuals do this by engaging in a variety of social processes of interaction. These social processes of interaction include communication both written and spoken and formal and informal. Examples are discussions, negotiations, gossip, stories and rumors. Through these interactions individuals try to make sense of the event of behavior that triggered the conscious sensemaking and then act on the basis of their interpretation (Balogun, 2006). In 1995, Weick described the phenomenon inter-recipient sensemaking. He stated that the commonality between individuals’ schemata tends to an enacted reality at group level in the form of routines, rituals, systems, norms, assumptions and beliefs. Research shows that sensemaking plays a central role in change (for example, Gioia & Chittipeddi, 1991; Balogun & Johnson, 2005).
The schemata’s (and interpretations belonging to this schemata), sensemaking triggers and social interaction mentioned by Balogun (2006) will be examined in this research. In this research was central what the sensemaking process in inter-recipient consists of, concerning at these three concepts and what will be probably more, to make a clear description of the inter-recipient processes during the implementation of an interactive e-health system.
3. METHODS
In this section are the research methods used for this research described. First, the concept case study and the research case will be described. After this the research methods, data analysis will be explained. Furthermore, the controllability, validity and reliability of the used research methods in this research will be discussed.
3.1 Case study
12 context (Van Aken, Berends & Van der Bij, 2012). This case study focused on group-level analyses and consists of one case including multiple teams. In this research three teams participated. By approaching this three cases as separate cases, cross-case analysis has been made possible. Furthermore, this research has an evaluative character because it evaluates a change which already has taken place.
Yin (2009) states that within case study the data collection needs to be gathered from multiple sources of evidence, in order to have complete and correct data. The inter-recipient sensemaking phenomenon in this research is explored via interviews and analyses of internal documents. This will be explained later in this section. Besides, this research focuses on theory building, based on the arguments of Eisenhardt (1989). One of the main steps in theory building by Eisenhardt (1989) is ‘triangulation’. In short, this implies that this study used multiple data collection methods, namely, semi structured interviews and internal documents analysis. According to Eisenhardt (1989), making use of multiple data collection methods provides a stronger substantiation of constructs. Furthermore, the grounded theory method has been used. Grounded theory method relates on continuous comparison of data and theory, beginning with data collection. The method emphasizes both the emergence of theoretical categories solely from evidence and an incremental approach to case selection and data gathering (Mortelmans, 2009). Therefore, the findings of this study are compared to existing literature.
3.1.1 The research case
The case that is extensively researched in this research concerns the implementation of an e-health application at Lentis, a large mental e-healthcare organization in The Netherlands. This mental healthcare organization recently (the pilots started in the beginning of 2014) implemented an application, called Minddistrict. It is a technology-based interactive therapeutic application. This application is used in mental healthcare therapies in a voluntary manner: therapists can determine whether they are using the application or not. When this application is applied, patients can work on their therapy not only in face-to-face sessions with therapists at the office of the therapists, but also in their home situations, which will help them with their recovery. The application has a supportive role, besides the regular therapeutic sessions. Patients can log in at the Minddistrict systems at their homes, and can get information about their disease and exercises that are part of their therapy. The progress of these exercises are tracked, therapists can give feedback to their patients and send messages to them. Where e-mail is not allowed because of safety risks and internal rules, sending messages through this system is allowed. Giving feedback and sending messages make this application an interactive e-health application.
3.2 Data collection
13 that participated in this study are active in specialized healthcare, the so-called secondary care. In total, 117 employees are able to make use of the Minddistrict application for their patients. These 117 employees are divided over ten teams. The size of the teams varies between five and seventeen employees. The researched organization was contacted via the personal network of the researcher. In the early stages of this research, introductory interviews took place with the e-health manager. Based on these interviews, suitable teams were selected and the e-health manager contacted the team leaders of these teams. All ten teams were asked by the e-health manager to participate, the three participating teams signed up voluntary to this research. Other teams were not willing to participate in this research because of other priorities in their schedules, caused by high work pressure.
The team leaders helped the researcher with planning interviews with the particular team members. Of each team the team leader, the formal driving force and two other team members were interviewed. Every team had a formal driving force during the implementation phase. This person is change recipient and change agent at the same time: while he or she has to learn how to work with Minddistrict, he or she has to motivate the colleagues in the team to use the system too. Of this person is expected that he or she is the expert in the team about Minddistrict, the person who can answer basic questions about how to use the system. Besides, this person has a couple of times contact with the e-health manager and other driving forces in the organization. The interviewed team members were chosen based on their availability through their schedules.
For the internal document analysis, information of several systems used by the teams participating in this research was necessary. These systems were accessed through the e-health manager, who can be characterized as ‘super user’ of the e-health systems in the organization. He delivered the statistical information which was necessary for this research.
3.2.1 Interviews
14 team leaders are aware of individual experiences and influences of human behavior, because each team consists of a maximum of seventeen employees.
The interviews were held on a one-to-one basis, in the offices of the participant, so the participant was able to share information. The interviews were of a confidential nature and were anonymous to stimulate the participant to share their information and opinions. The interviews were held in Dutch due to the fact this was the mother language of all the participants. The interviews were recorded (with permission of the participants) to make it possible to transcript the interviews and to code them. The interviews had an evaluative character in this retrospective case study: questions concerned the experiences of respondents during the implementation of the Minddistrict application. It is assumed that the respondents were able to give a representative view of what happened during the implementation period and what individual experiences were during certain events. The interviews were held before the data about the use of the Minddistrict system by the different teams was available, to avoid biases and to make the data of the interviews comparable.
3.2.2 Internal document analysis
The internal document analysis was carried out to find answers on the second part of this research. It consisted of analyzing the statistics about the use of this application to determine the successfulness of the implementation. Therapists, of which the sample group exists, have to register all their patient contacts in a system with a code. Based on Tsiknakis and Kouroubali (2009) in chapter 2, in this research successful implementation is defined as the relative use of the IT application. Therefore, the relative use of Minddistrict was important: the use of online contacts compared with the more traditional legacy face-to-face (ftf) contacts. Nowadays, online contacts are at Lentis only possible by the use of Minddistrict. E-mail, for instance, is only allowed by e-mailing through Minddistrict. Together with the e-health manager was investigated which measurements exist in the systems, and based on this investigation was decided to measure how many percent of the total amount of contacts were online contacts with the formula:
𝑎𝑚𝑜𝑢𝑛𝑡 𝑜𝑓 𝑜𝑛𝑙𝑖𝑛𝑒 𝑐𝑜𝑛𝑡𝑎𝑐𝑡𝑠 𝑤𝑖𝑡ℎ 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑡𝑜𝑡𝑎𝑙 𝑎𝑚𝑜𝑢𝑛𝑡 𝑜𝑓 𝑐𝑜𝑛𝑡𝑎𝑐𝑡𝑠 𝑤𝑖𝑡ℎ 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 (𝑜𝑛𝑙𝑖𝑛𝑒 + 𝑓𝑡𝑓)
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3.3 Data analysis
The data analysis started with coding the interviews. The coding was done in the program Atlas.ti. The method for coding is based on Mortelmans (2009). In this method the first step is open coding, which consists of isolating separate meaningful wholes, considered as relevant by the investigator to answer his demand investigation. The codes in this step were based on using inductive and deductive strategies (Thomas, 2006). Deductive codes were developed from the existing literature and inductive codes were developed based on new insights in the interviews. Inductive codes are more sensitive to subjectivity. An example of a deductive code is ‘process of sensemaking – triggers’, with several subcodes, for instance ‘external pressure’. An example of an inductive code is ‘characteristics of team’, with the subcode ‘size of team’. The results of open coding are loose codes. The next step is the process of axial coding. Axial coding is defined by Mortelmans (2009) as connecting the loose codes to a whole. Various concepts are defined which are elaborated by using the open codes. Thereafter, in the selective coding process, the concepts of axial coding were linked to each other, resulting in integration and refining the theory. The results of this process can be found in the codebook in Appendix 3.
After the interviews were analyzed, the statistical information from the internal documents was analyzed. First, the data of the employees who are not working with Minddistrict were removed. Thereafter, the formula of the previous paragraph was applied to the statistical information to measure the relative use of online contact. The third step was to sort the data of the formula on group level, count averages and sorting the list from highest to lowest relative use of online contacts. The fourth step was an ANOVA test to test the significance of the statistical test.
The last step in analyzing data was combining the information, which was gathered through analyzing the interviews with the information of the statistics of the internal document analysis. The rankings from the internal document analysis were compared to the data of the interviews to define if there were differences in the inter-recipient processes between the teams of which members are relatively often using the Minddistrict application and those who were relatively made less use of the Minddistrict application.
3.4 Controllability, validity and reliability
16 Reliability is ensured by minimizing the potential biases. The research biases are controlled due to two reasons, (1) the interviews were recorded and (2) each interview is conducted by the same researcher. The interviews were recorded (voice) and transcribed. This records created the opportunity to re-hear elements which were possibly overlooked during the interview. This construction gave the researcher the chance to be more an observer during the interview. The questions and the interpretation of the answers were the same in each interview, since only one researcher conducted all the interviews. Furthermore, the interpretation of the answers in the interview and the questions asked were the same. Interviews with twelve participants delivered 77 pages of transcripts. The transcripts were coded, to make comparisons possible. Every respondent got a code, which refers to the team they are working in and their function: for example, team leaders got the code P1.0, P2.0 and P3.0. Their team members got the codes P1.1, P1.2 and P1.3.
By the use of multiple research methods the instrument biases were controlled. This can remedy the specific shortcomings of these instruments by complementing and correcting each other (Van Aken et al., 2012). Finally, the reliability of the respondents was remained by including the team leaders in the interviews as well, and by internal document analysis: do team leaders and team members agree on how individuals behave while implementing an interactive information system? Are the outcomes of the internal document analysis in line with the statements of the employees, with regard to the utility of interactive information systems? For instance, a respondent can state in the interview their team is ‘using Minddistrict very much compared to the other teams in the organization’, however, the statistics of the internal document analysis should show the same to make this statement reliable and control the instrument biases.
Internal, external and conduct validity were ensured as well. Internal validity is ensured when possible chances of alternative explanations were ruled out as much as possible, this has been done by the use of multiple perspectives (team leaders and team members). Construct validity was assessed by the use of multiple research methods: interviews and internal document analysis. External validity has been ensured by the use of different teams for interviews.
4. RESULTS
17 when people heard for the first time that they have to work with Minddistrict, new schemata is the schemata after the social interactions and triggers.
Second, the cross-case analysis results are presented. This consists of the results of the internal document analysis combined with the comparison of the results of the within-case analysis. Again, the structure of this analysis will be based on the sensemaking factors defined by Balogun (2006).
4.1 Team 1
Team 1 consisted of twelve team members who have the ability to work with Minddistrict. However age was not measured in this research, all the respondents of all teams mentioned it as a factor which is influencing sensemaking processes and the successfulness of the implementation of Minddistrict. Respondents of this team agreed that this team was relatively old: as estimated by the team members, three of the twelve team members who can make use of Minddistrict were below their 40s, the rest of the members were above the 40 years old. This team offers specialized healthcare in a specific region in the Northern of the Netherlands.
4.1.1 Old schemata
On the question: ‘what were you thinking when you heard about the Minddistrict implementation’, in team 1 was mentioned Minddistrict was not something new: it was something old in a new jacket. The function e-health has to fulfill, people working at their homes on their therapies, is according to respondents in team 1 not something new because previously patients were working on their therapies at home as well, for example by keeping diaries. This was a shared assumption in this team. In all three researched teams the topic ‘something new again’ was mentioned: Minddistrict was not the only innovation which was introduced in the past period.
18 About the nature of work P1.3 states: “I prefer face-to-face contact with my clients. No computer program can replace the therapies I am giving. My job requires talking, listening, seeing, smelling, etcetera to do it in a good way.”
4.1.2 Social interactions
The formal social interaction in team 1 was limited: people in this team are working independently. Collaboration is not very often required. Every respondent in this team described the team as ‘loose sand’: people are working individually. Meetings about patients are not with the whole team, as they were previously. Nowadays only the therapists who are involved in the therapies of the discussed patients are allowed to be present in the meetings. The frequency of this meetings is every two weeks, and the compositions of this meetings are varying. Every six weeks there is a policy meeting with the whole team. In practice, not everyone is present because there are various part-time employees in this team. In these meetings there is attention for the implementation of Minddistrict: the driving force (whose role is described in section 3.2) tries to get attention for Minddistrict and brings information about new developments of the application.
The informal social interaction in team 1 was limited as well. For example, people are having breaks individually. P1.1 states: “However, lunching together or social things in the morning are not things we are doing here.” Once per two weeks some colleagues are lunching together, however, this means only four of the twelve team members who are lunching together and having social interactions at that moment.
This little amount of contact with colleagues lead to less opportunities for social interaction in which inter-recipient sensemaking can take place. However, two of the four respondents of this team argue they do not feel the need for more informal social interactions. This lies in their personal characteristics.
4.1.3 Triggers
Besides the attention which the driving force of this team asked in meetings for Minddistrict, education was a very important trigger in this team for the implementation of Minddistrict and sharing stories in which the use of Minddistrict was successful.
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4.1.4 Summary
To summarize the inter-recipient sensemaking processes in team 1: all the innovations in the organization, in combination with the shared assumptions about the organization and its management and the work nature, have led to tiredness of change. In this situation people are relying on their experience and are valuing the high autonomy in their jobs even more. This tiredness of influences the sensemaking processes towards the implementation of Minddistrict: in this team the inter-recipient sensemaking processes rarely occur caused by lack of formal and informal social interactions. The inter-recipient sensemaking processes which occur are mostly complaining about the organization and decision making in the organization and the work pressure team members are experiencing. However, the driving force of this team has a positive influence in inter-recipient sensemaking, because of her Minddistrict is ‘on table’ sometimes and in this moments people are making sense together of by sharing their own schemata with other team members.
4.2 Team 2
Team 2 consisted of five team members who have the ability to work with Minddistrict. Comparable to what was stated in team 1, this team was estimated relatively old: two team members who have the ability to make use of Minddistrict were below their 50s, the rest of the team members were above the 50 years old. The team leader describes this team as ‘grey’: referring to their hair color. This team offers specialized healthcare in a specific region in the Northern of the Netherlands. Due to reorganization the location of this team, and therefore this team will not exist as a team anymore by the end of 2016. The team members will work at another locations in another teams or are going to leave the organization.
4.2.1 Old schemata
The old schemata about interactive e-health are different among the team members in team 2. P2.3 mentioned about his first impression about interactive e-health: “Well, I have always thought that individualism also means that patients want to spend their time and activities at their own pace and in their own way. Minddistrict is a very easy way to do so.” However, this interpretation was personal: other team members were not thinking this way in this team. A shared assumption among other team members in this team was that Minddistrict was an idea of the health insurance, as P2.1 mentioned: “It is all trendy and modern. People in this team think that the health insurances thinks that it [working with Minddistrict] is more efficient and therefore cost-effective. However, they dislike the pressure which comes with it.”
20 P2.1 states: “I do not like new things. I like new things which I can do, but I really dislike it if these new things are on the computer.” Also in this team the ‘something new again’ argument was mentioned.
The schemata about the organization and its management and schemata about work nature which are described at the section 4.1 are influencing sensemaking about implementation Minddistrict in this team as well. In all the teams there is a cynicism towards the management of the organization. P2.1 described about the social interactions in this team: “A little bit cynical about the organization, a little bit cynical about new people on new places who state something again, and they have other ideas than the previous one. This, and this way Lentis has been for years.” In this team people believe that having a high degree of autonomy, own responsibilities, are high values in their work circumstances. They believe they are able enough in their tasks, and therefore should have the choice by their own in which therapy techniques and therapy tools to use for their patients. Interference of management by giving suggestions for new therapy methods are not appreciated. As P2.1 explains: “And at work I think, I am doing my job, and I am doing this job in a very good way. Not so much fuss at my job. And if I think it is necessary, I oppose to changes.”
4.2.2 Social interactions
The formal interactions in team 2 consist of meetings on a weekly basis in which new patients are discussed. These meetings are having the same constructions as meetings have team 1. In this team people have to collaborate more compared to team 1. As P2.0 described: “At this place, one patient is treated by two or three therapists, and they have to consult sometimes” In this collaboration the distinguish has been made between ‘head’ practitioners and ‘normal’ practitioners. According to P2.3, who has not the qualification to be a head practitioner, he is dependent of the head practitioner to make use of e-health in his therapies. In the consults they have they discuss Minddistrict and its features, and in this way they both make sense of the system. P2.3 names himself optimistically about the system from the start of, however, he says he does not have the personal capabilities to influence the sensemaking of his colleagues about Minddistrict.
Informal social interaction is not much happening in this team, P2.0 states “Content-wise people are working together sometimes, but lunching or drinking coffee together is not something we do. Furthermore, in this team people are real individuals in a team.” The atmosphere is called ‘reserved’ by three of the four respondents from this team.
21
4.2.3 Triggers
Triggers which stimulate the use and the sensemaking processes of Minddistrict are for this team education and intrinsic personal motivation. The team leader sent some people who refuse to make use of the system for the second time on training to motivate them to make use of the system, for example P2.1. P2.1 states: “Now I have done the training for the second time I think Minddistrict is so less complicated than I remembered and maybe even imagined in my head.” Less successful in this team was the planned question time session. P2.0 stated: “On every Tuesday in the afternoon we blocked our agendas to work with e-health in this time, so we were able to ask questions to each other and help each other. However, I noticed people were using this time for other things than e-health. So, in the beginning we tried to motivate people but it did not work out the way we hoped. Therefore, we stopped with this planned question time. Besides, the driving force in this team has no real authority: besides the driving force herself and the team leader none of the respondents knew there was a driving force of Minddistrict in this team. The team leader stated that before someone else was the driving force, however, this person was not able to do this job. Team 2 is relatively small, it consists of five persons who are able to work with Minddistrict. According to the team leader none of the team members has the capabilities to act as a real driving force. The triggers are more influencing the individual sensemaking processes than the inter-recipient sensemaking processes.
4.2.4 Summary
To summarize the inter-recipient sensemaking processes in team 2: In this team autonomy is seen as a very important value in the characteristics of the work of the therapists. This autonomy, in combination with rare formal and informal communication leads to rarely occurring inter-recipient sensemaking. Hierarchy, combined with the distribution of tasks (‘head practitioner’ – normal practitioner’) seems to be very important in this team: this structure should be there in every team working with Minddistrict, however, it was mentioned in all the interviews in this team, while it was in the other teams mentioned only once. Some of the individuals in this team are somewhat enthusiastic, however, they do not share this with their colleagues: sensemaking processes are in this team mainly individual sensemaking processes. In the scarce moments inter-recipient sensemaking processes occur, these are mostly complaining about the organization and decision making in the organization and the work pressure team members are experiencing.
4.3 Team 3
22
4.3.1 Old schemata
In team 3 in the old schemata the features of the system were predominant: in this team the team members like the fact that the organization finally was doing something with e-health. P3.0 explains: “Definitely in a couple of years from now, it is necessary. Nowadays patients are googling their diagnosis. The health insurance wants I now, however, I think the patients are going to ask for it not in a so far feature.” However, in this team as well, the topic ‘something new again’ was mentioned. Nowadays there are a lot of changes in the work of therapists, and by mentioning the implementation of Minddistrict was this the first thoughts of the most of the therapists in all the teams. As P3.3 mentioned: “We were inundated with a course about this, a seminar about that, training about suicide prevention, training in resistance. All these courses we have to do besides our normal jobs, in combination with the production pressure.”
4.3.2 Social interactions
Besides the formal social interactions, which consist of meetings of the same structure and regularity as team 1 and 2, in this team there are more informal interactions than in the other researched teams. People are (most of the days) having breaks together, P3.2 explained: “Most of us are having a break between noon and half past noon. And we are trying to go to the canteen with each other in that time.” In this time the conversations are, all tough people try not to, most of the time work-related. In this time sometimes Minddistrict is passing by as a topic, in the form of a joke or success story when someone asks another therapist about the therapy of one of the discussed patients. However, P3.1 states that these conversations were back in the days, nowadays Minddistrict is not often discussed anymore. She thinks this happened because the extra attention towards Minddistrict and triggers are nowadays not done anymore and because other topics are more important, like the new round of budget cuts in this team.
4.3.3 Triggers
23 already. This were serious threats, and therefore there was much more effort on the implementation of Minddistrict in this team than in other teams.
The planned question time, which was not a success in team 2, was in team 3 a great success. Every respondent of this team remembered this time. P3.1 stated: “What we did here was open the doors for one hour and in this hour everyone was mandatory to work with the e-health system. And someone of Minddistrict was walking around to answer questions. At this time everyone’s attention was to Minddistrict.” This planned question time caused an evolution in the individual and the inter-recipient sensemaking process: people were talking about this with each other and exchanging opinions and tips and tricks, and in this way they were adjusting their schemata towards the implementation of Minddistrict.
The team leader of this team was also using numbers as a trigger to use Minddistrict. Every month he was getting an overview from the e-health manager about the use of e-health in his team, and the use of e-health in other teams. He shared this information with his teams. P3.0 explained: “I observed that some people feel the need for numbers. Besides they are doing using the systems to help their patients they like to see how e-health develops. Older employees who were not yet working with it were influenced by such numbers as well.” In some way, the numbers were motivating the team members to talk about Minddistrict. Besides, the numbers were stimulating because people liked to see the comparison between the use of e-health by their team to use by the other teams.
In this team the driving force was giving attention in formal meetings to Minddistrict and was promoting the use of this system. P3.0 states: “She is the driving force in our team. She has done a lot of promotion activities to motivate this team. And she uses Minddistrict herself a lot. That has a snowball effect, I can see that.” Besides, the person who was the driving force in this team had authority. P3.0 explained: “She is someone who has a lot of experience. It is visible that people accept whatever this person states.”
4.3.4 Team characteristics
24
4.3.5 Summary
To conclude the inter-recipient sensemaking processes in team 3: the old schemata of team 3 were more positive towards the implementation of Minddistrict than in the other teams. Besides, there seems to be more informal interactions in this team compared to the other teams. In this team the use of the system was not completely voluntary, there was an external pressure which was threating with budget cuts. Social interactions and triggers were influencing that the people of this team became even more enthusiastic for using e-health than they already were in their old schemata. Time has been invested to make Minddistrict part of their daily routines. However, a several people in this team were not that enthusiastic in the beginning: they need the triggers to be reminded about the existence of the system and the way they could use it. The driving force with authority and several triggers played a role in this.
4.4 Cross-case analysis: successful implementation – differences between teams
In this section the successfulness of the implementation across the different teams will be compared. The successfulness of the implementation of Minddistrict is defined as the relative use of Minddistrict (compared to face-to-face contacts). Thereafter the differences in the teams on the several inter-recipient sensemaking factors will be described.
4.4.1 Relative use of Minddistrict per team
25
Table 1: Percentages of relative use of Minddistrict on team level
Table 2: Anova test
Table 1 shows that throughout the whole organization, on average 4,5% of the contacts with patients are online contacts through Minddistrict. Of the researched teams team 3 has used between January 2016 and May 2016 relatively seen online contacts the most, team 2 the least. With 4,9% of the contacts through Minddistrict team 1 can be mentioned as average using team. Table 2 shows that the differences in Table 1 cannot be considered as significant. In the following paragraphs the differences between the teams on all inter-sensemaking topics will be described.
4.4.2 Old schemata
In old schemata the schemata about the organization and the management of this organization and the schemata about work nature were having a big influence. In all the teams people were cynical about the management. However, in team 1 and 2 this was leading to more resistance towards using Minddistrict than in team 3. In team 1 and 2 the schemata about doing a good job, the work nature, was more focused on face-to-face contact and listening than in team 3, in which self-reliance was seen as important. This difference could influence the average amount of use of the system in the teams.
In all the teams the ‘something new again’ was mentioned at the start of the implementation of Minddistrict, pointing to the many changes going on in their work. However, in team 3, the most of the people had from the beginning a positive attitude towards the system and were using it quite soon. In team 1 and 2 people were not from the beginning convinced of the added value of the system. People were having arguments against the content of the change, and the process of the change. In these teams some of the people had hard times to start working with the application.
26
4.4.3 Social interactions
About social interactions is notable that team 3 the only team in this research was in which informal social interactions took regularly place, for example in the joint breaks. In all teams formal social interaction took place, however, in all teams was mentioned that this is different than a couple of years ago: back in the days every team member was allowed to join in meetings about clients. Nowadays, because of budget cuts, only the therapists who are involved in the therapies of a client are allowed to join the meetings. People have to work more individual. Therefore, social interactions do less take place, which causes less opportunities for inter-recipient sensemaking processes about, for example, the implementation of the e-health system.
4.4.4 Triggers
Table 3 below shows an overview about the triggers for inter-recipient sensemaking processes about the implementation of Minddistrict which were mentioned during the interviews.
Table 3: Triggers
Trigger Team 1
Respondents who state this was a trigger
Team 2
Respondents who state this was a trigger
Team 3
Respondents who state this was a trigger Attention in meetings P1.0; P1.1; P1.2 P2.0 agree
P2.1; P2.2; P2.3 disagree
P3.0; P3.1
Driving force as trigger
All P2.0: state it failed All
Education All All P3.0, P3.1; P3.3
External pressure P1.0; P1.2 P2.0 All
Numbers as trigger None None P3.0, P3.1. P3.3
Planned question time None P2.0: failed P3.0; P3.1; P3.3:
success
27 the most triggers are used, and this team is using Minddistrict relatively the most. Using more triggers can be perceived as a higher success.
4.4.5 Team characterstics
Team 3 is the team which is using (of the researched teams) Minddistrict relatively seen the most. This team differs in personal characteristics from the other researched teams in a several components: this team has the most people who are able to make use of the system, and the average age is estimated the lowest by the respondents. Besides, in this team people respondents stated about themselves or their colleagues that they were intrinsically motivated to make the implementation of Minddistrict a successful one. They favor innovation and are curious for trying new things. This was something which was not part of the interview format, however, it was mentioned by the team members without asking. Respondents were talking about a ‘snowballeffect’, which can be explained in sensemaking through sensemaking: because some people are so enthusiastic peoples’ new schemata is more positive about e-health implementation. The team leader of team 2 also recognized team characteristics as an influencing factor on inter-recipient sensemaking processes. She states: “at some locations of Lentis, Minddistrict is really successful. In the way I see this teams, one or more people are so enthusiastic about e-health, and they are infecting others with their enthusiasm. I think the e-health acceptation depends in this organization on persons and affinity with the theme. In [name location] there is a young woman who is so enthusiastic about e-health, well, such a type I want in my team too!”
5. CONCLUSIONS AND DISCUSSION
This section starts with a summary of the results of this research through which there will be answers given to the main questions. Second, theoretical and practical implications of this research will be defined. This section ends with the limitations of this research and suggestions for further research.
5.1 Summary of results
28 In the second phase the inter-recipient sensemaking processes were related to the successfulness of the implementation of an e-health system. The main question in this second part was: How does this process differ in a successful implementation from a less successful implementation of an e-health system? In this research there were three teams researched: team 3 had a relatively successful implementation, team 1 had a relatively medium successful implementation and the implementation at team 2 can be characterized as relatively not successful. In the successful implementation the most triggers were used, and it was the only team in which external pressure played a role. Besides, the old schemata were more positive towards the implementation than the old schemata in the other teams. In other teams sensemaking on side issues like the organization and its management and the sensemaking on work nature were playing a more present role. In social interaction, team 3 was the only team which was having ordinary informal social interactions. This team has the (estimated) lowest average age of team members. Personal characteristics in this team, as affinity with IT, curiosity and innovativeness seem to play a positive role on inter-recipient sensemaking in this team and a positive role on the successfulness of the implementation. The team with the least successful implementation was the smallest team and the team with the highest average age of this research. Remarkable in this team was that the driving force had no authority and was not playing a visible role in the implementation phase of this research. In this team individual sensemaking processes were taking place, however, the inter-recipient sensemaking processes occur rarely.
5.2 Discussion
29 About the triggers: the role of the driving force in inter-recipient sensemaking processes can be compared with the literature about sensemaking processes between change agent and change recipients: for example Jensen and Aernestad (2007) and Sonenshein (2010), because of the required authority of the driving forces. For voluntary used systems a measure for success is the use of the system. When imposing people to make use of a system, the success measurement can be extended by, for example, theories about adaptive system use (Sun, 2010).
5.3 Theoretical and managerial implications
This research has shown how schemata, triggers and social interaction interplay in inter-recipient sensemaking. It has shown how these process play a role in successful and less successful implementations of an e-health system. Therefore, this research enhances a deeper understanding of how the factors in inter-recipient sensemaking can have an influence on implementing an interactive IT system in mental healthcare. This research elaborates upon the gap mentioned by Jensen and Aernestad (2007) and Balogun and Johnson (2005), who focused in their researches on sensemaking between change agents and change recipients. This research has tried to fill this gap by researching the inter-recipient sensemaking processes.
There are several managerial implications of this research. To start with, this research enables implementers of interactive IT systems in mental healthcare to benchmark and create awareness of which subjects are important. The knowledge gained through this study can be helpful in creating an implementation strategy or improvement program for IT applications. Having a driving force with prevalence, good training and numbers (statistics) as trigger seems to be necessary to create inter-recipient sensemaking which has a positive influence on the successfulness of the implementation of an interactive IT application. Besides, personal characteristics seems to have an influence on this.
5.4 Research limitations and further research
30 What also is a limitation is that all the respondents are working as therapists (in varying degrees). This profession has not much collaboration. For other disciplines in healthcare the inter-recipient sensemaking process while implementing an interactive e-health application are probably totally different. Future research should pay attention to more professions than only therapists.
Another limitation is in the second part of this research. The statistics are based on what therapists register: there can be some bias because probably not every activity is registered precisely. Future research should find a way to limit this bias.
Factors that may be incorporated in future research are the influence of job characteristics and personal characteristics on social interaction in teams. A second possibility for further research is using more research methods, like observations and interviewing more team members. A third possibility for further research is researching sensemaking activities while implementing an interactive IT system in another industries, for example in education or in public- and profit sectors.
5.5 Conclusion
31
ACKNOWLEDGEMENTS
32
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APPENDIX 1: INTERVIEW GUIDE TEAM LEADER
Start
Thank you for your time, and thank you for having me doing this interviews in your team. As I said a little bit before in the e-mail / by telephone, I would like to do this interview for the purpose of my master thesis in Business Administration - Change Management at the University of Groningen. In this organization I am at the moment researching the implementation of the application Minddistrict. In special I am interested in what happened in the teams while implementing this system. The purpose of this interview is getting to know the sensemaking processes in this team during the implementation. In total, I am going to interview twelve people, employees and team leaders of three teams.
I expect the interview will take 45 minutes to 1 hour. The results of this research will only be used for my master thesis. The interview is anonymous, I will not use any names in my research. I would like to record the interview so I can transcribe the information. After finishing this project the recording will be destroyed.
Are you okay with recording this interview?
Do you have any questions at this moment?
Interview questions General
What does your function as team leader mean? What are you doing in your daily work? For how long are you doing this job?
Were you doing this job during the implementation of Minddistrict as well? If not, what was your job? What does this function means?
Team
How would you describe your team?
Of how many people does the team exist? How do people in the team interact? How do you interact with your team? How would you describe the culture of Lentis?
Implementation Minddistrict
What were you thinking when the organization decide to implement Minddistrict?
38 What were the people in your team thinking when Minddistrict was implemented?
Have these opinions changed over time? In which way?
What were reasons for this change?
What was your role during the implementation?
Sensemaking
What do you think it were important moments during the implementation of Minddistrict? What do you think it were difficulties during the implementation of Minddistrict?
Which moment(s) during the implementation makes you think? Can you explain why?
What happened in the team during the implementation of Minddistrict? Formal developments (team composition, training, communication) Informal developments
How was the interaction (communication) in the team in this period?
To which extent was your own behavior influenced by the behavior of coworkers? In which way?
Were the team members influencing each other? In which way?
Successfulness of implementation
To which extent do you think the implementation of Mind district can be called successful? What was going well during the implementation of Minddistrict?
What will be improvements for implementing systems like Minddistrict?
Ending
