The Influence of Institutional Changes, Sensemaking by
Individuals and Frames of Management on Change Reaction and
Frame Appropriation
MSc Business Administration - Change Management
Faculty of Economics and Business - University of Groningen
June, 2017
Renee Boukens
s2176971
Phone: 0031-649908520
E-mail: r.boukens@student.rug.nl
Supervisor: drs. J.C.L. Paul
Co-assessor:
drs. H.P. van Peet
Abstract
The environment in the healthcare sector is constantly changing. Changes in regulation, societal changes such as the aging baby boom generation, and the fact that people want to live in their homes independently as long as possible, are factors that are putting pressure on the homecare organizations in the Netherlands. As there is an increase in need for home care, home care organizations have to respond and make organizational changes as well. This study explores how the reaction towards change and appropriation of change frames is influenced by such institutional changes, individual sensemaking and frames of management. By means of a single case study, data has been collected within a Dutch homecare organization via interviews and documents containing primary and secondary data. Following a grounded theory approach, all data is analyzed. The results show that framing by middle management, strengthening of the profession, involvement in change, professional values and cynicism toward change have influence on the change reaction and appropriation by individuals. These insight contribute to change management literature and may be further analyzed or tested in the future. Furthermore, the findings give practical contributions to change managers in Dutch home care organizations by providing knowledge that may lead to more effective implementation of change initiatives.
Table of Content
Abstract 2
1. Introduction 4
2. Literature Review 7
2.1 Institutional Theory and Institutionalization 7
2.2 Sensemaking 8
2.3 Framing, Sensegiving and Frame Appropriation 8
2.4 Institutionalization and Sensemaking 9
2.5 Sensemaking and Change Reaction 10
3. Research methodology 11 3.1 Research Design 11 3.2 Case Description 11 3.3 Data Collection 12 3.4 Data Analysis 13 4. Results 14
4.1 Institutional Changes in the Healthcare sector 14
4.2 Framing and Sensegiving by Middle Management 15
4.3 Strengthening of Profession 17
4.4 Involvement in Change 18
4.5 Professional Values 19
4.6 Cynicism towards Change 20
5. Discussion 22
5.1 Theoretical Implications 22
5.2 Practical Implications 27
5.3 Limitations and Future Research 28
5.4 Conclusion 29
References 31
Appendices 38
A - Interview Guide 38
B - Coding Scheme - Deductive Codes 40
1. Introduction
In recent years societal and political views on the healthcare system have changed significantly in the Netherlands. In January of 2015 the General Law Special Health, aimed to provide general insurance to cover the people in the Netherlands against special health care needs, was dismantled (Rijksoverheid.nl, 2015a). This led to many changes within homecare organizations. Moreover, societal changes such as the aging baby boom generation, people that are getting older and older, and the fact that people want to live in their homes independently as long as possible, are putting pressure on the homecare organizations in the Netherlands as the need for homecare is increasing (Movisie, 2016). All these changes, can be characterized as changes on institutional level.
Institutions are defined “as shared rules and typifications that identify categories of social actors and their appropriate activities or relationships” (Barley & Tolbert, 1997; p.96). As government health policies and society’s expectations change, the shared rules and typifications change which in turn means that institutions change. According to Weber & Glynn (2006), such changes that take place on the macro institutional level have influence on the micro level. This view is based on ‘a typology of social mechanisms’ model by Hedström & Swedberg (1989). The model shows how macro-level events affect individuals (type 1), how these individuals take in the impact of these events (type 2) and how multiple individuals generate macro-level outcomes through their action and interaction (type 3) (Figure 1). By conceptualizing social action in this manner, typologies of mechanisms are made, namely macro-micro mechanisms, micro-micro mechanisms and micro-macro mechanisms (Hedström & Swedberg, 1989).
Figure 1: Hedström & Swedberg, 1998 (p. 22)
action-formation mechanism, individuals assimilate the impact of the macro-level changes and do this via sensemaking processes. This happens within organizations, which subsequently can have impact on the macro-level, through the actions and interactions of multiple individuals (i.e. transformational mechanisms).
When individuals are faced with change, they actively seek for information, they try to ascribe meaning and they make assumptions about the change process. This in order to make sense of the new environment, but also in order to try to draw conclusion about possible outcomes (Ford, Ford, & d’Amelio, 2008). This results in individuals that have formed assumptions, expectations, and impressions about the change (Choi & Ruona, 2011). Sensemaking includes three processes: scanning, interpretation and action. Action involves interpretation of the information (Thomas, Clark, & Gioia, 1993) and can be seen as linked to change reaction. Change reaction is the static result of the action-formation mechanism mentioned before. In order to measure change reaction of individuals, it is possible to use a multidimensional view of responses to the organizational changes by capturing the responses along the emotional, cognitive and intentional dimensions. According to Piderit (2000) this view makes it possible to detect resistance to change and support for a change.
Not only individuals, but also organizations make sense of changes. For example, when institutional changes appear, management within organizations will have to translate these institutional discourses into policies and changes initiatives. By the use of managerial frames, management can translate institutional changes intro changes in policies and change initiatives. Framing is an activity used by management to influence the interpretations of its organizational members by changing the meaning associated with organizational situations (Chreim, 2006). Or as Fiss & Hirsch (2005) explain it: “the concept of framing captures the processes by which actors influence the interpretations of reality among various audiences.” (p. 30)
The aim of this thesis is to explore the influence of institutional changes, individual sensemaking and management framing on change reaction and frame appropriation in Dutch home care. Information will be gathered by collecting qualitative data from a traditional Dutch home care organization. In this sector, recently several institutional changes have taken place which results in home care organizations having to constantly react to those changes on institutional level. Consequently, this led to changes in home care organizations, which makes the setting interesting to do a multi-level research.
lot of research done on resistance to change and change attitudes (e.g. Ford, Ford and D’Amelio, 2006; Piderit, 2000). However connecting these processes on multiple levels and exploring the influence of all three processes on change reaction and frame appropriation has not been done yet. Therefore, gaining insights into which factors and how processes influence the change reaction and frame appropriation in the Dutch home care sector would have contribution to theory. This knowledge provides guidance for specifying and testing relationships involving change reaction and appropriation. Moreover, as the healthcare sector finds itself in a dynamic and fast changing environment, the need for more literature about change management is increasing which makes the research relevant. Also, it would contribute to literature concerning multi-level change. The research question that will be answered in this thesis is:
“How is change reaction and frame appropriation influenced by institutional changes, individual sensemaking and frames of management in Dutch homecare organizations?”
2. Literature Review
2.1 Institutional Theory and InstitutionalizationAccording to Jensen, Kjærgaard & Svejvig (2009) institutional theory describes the deeper and more resilient aspects of how institutions are created, conserved, changed and decomposed. It deals with the influence that institutions have on human behavior, and this includes the processes by which structures guide social behavior. Examples of such structures are rules, routines and norms (Jensen et al., 2009). Research done on the concept of institutionalization has generated valuable insights into the processes explaining and defining institutionalization in organizational environment. Furthermore, there have been insights in how these processes influence organizational conformity to the environment (Oliver, 1991). Institutionalization is a process in which people assign similar meanings to particular actions that are repeated over time (Scott, 1987). Moreover, Zucker (1977) argues that institutionalization is as well a process as a property variable. She states that “it is the process by which individual actors transmit what is socially defined as real and, at the same time, at any point in the process the meaning of an act can be defined as more or less a taken-for-granted part of this social reality” (p. 728).
In the early literature and research about institutional theory, the emphasis was mainly on the taken-for-granted character of institutional rules, myths and beliefs (e.g. Oliver, 1991; Zucker, 1977). This view on institutionalism assumes that organizational actors are passive recipients who use readily available scripts to structure their actions, which are given by among others, government, professionals or other institutions (e.g. Selznick, 1949). Old institutional theory analyzed formal structures as if those were static, this by focussing on its sources at one point in time (Tolbert & Zucker, 1983). The main criticism is that old institutional theory does not take into account changes and deviation (Jennings & Greenwood, 2003).
and deviation, and has two views. The first assumes internal sources from which formal structures emerge, whereas the second assumes external sources (Tolbert & Zucker, 1983). These two views are not incompatible, but rather show how changes in formal structures of the organization arise.
2.2 Sensemaking
When the current state of the world is perceived to be different from the expected state of the world, explicit efforts of sensemaking tend to occur (Weick, Sutcliffe & Obstfeld, 2005). Sensemaking is the process in which individuals try to understand and ‘make sense’ of new, unexpected or confusing events (Maitlis & Christianson, 2014). Furthermore, sensemaking requires interaction and the development of a collective mind as it is a social activity (Anderson & McDaniel, 2000).
According to Thomas et al. (1993) there are three processes of sensemaking, namely: scanning, interpretation and action. Scanning involves the information gathering; interpretation involves the application or development of understanding the meaning of the gathered information; and action is based on the interpretation of the information (Thomas et al., 1993). By extracting and interpreting cues from the environment, individuals try to make sense of what is going on when having moments of ambiguity or uncertainty. These cues lead to a likely determination of what is going on, which in turn provides order and clarification. The focus of sensemaking is on how patterns of meaning are identified and how these patterns depend on the notable cues of the environment (Fiss & Hirsch, 2005).
Social cognition refers both to the ways people understand events and to the factors that affect their understanding (Bartunek & Moch, 1987). It is likely that the primary response of organizational members towards the introduction of a new schema will be to ‘make sense’ of the new understanding being introduced, especially if it is different from and threatening to their present way of understanding (Bartunek, Lacey, & Wood, 1992). Scripts, then, provide a useful means for examining the links between cognition and behavior (Gioia & Manz, 1985). As an organization develops, one way that participants can render the experience meaningful is to develop knowledge structures that allow participants to engage in coordinated behavior that they believe is situationally appropriate (Gray, Bougon, & Donnellon, 1985).
2.3 Framing, Sensegiving and Frame Appropriation
meaning in order to mobilize support for e.g. an organization change or change in perspectives within the organization. According to Higgs & Rowland (2011), framing is “designing and managing the journey” and “communicating guiding principles in the organization.” (p. 312).
Moreover, framing is linked to sensegiving, which refers to the processes by which change is framed and spread to the organization's members (Fiss & Zajac, 2006). Whereas sensemaking deals primarily with understanding processes, sensegiving is a phase that is concerned with the process of attempting to influence sensemaking and the construction of meaning by individuals towards a redefinition of organizational reality as preferred by the ‘sense giver’ (Gioia and Chittipeddi, 1991). According to Bartunek (1984) change in interpretive schemes (i.e. framing) is in a two-way relationship with changes in structure. Institutional changes, for example, likely leads to changes on the organizational level but the way individuals interpret reality affects what type of change takes place. This relationship is mediated by the actions of individuals within the organization and their emotional reactions to change.
Frame appropriation, according to Chreim (2006), is the acceptance of a frame introduced by e.g. management. The term appropriation is used as this implies a stronger emphasis on the response of the receiver of such frame (Chreim, 2006). When individuals are resistant towards the change, a frame is not appropriated, also frames can be appropriated partially when not everything about the frame is accepted.
2.4 Institutionalization and Sensemaking
Institutional theory and sensemaking theory are distinct on level of analysis that is addressed. The first focuses mainly on macro-level structures by looking at the organizational field level and the organizational level of analysis, whereas the latter focuses on micro-level processes (Jensen et al., 2009). Even though the bulk of institutional research has focused on the macro-level, institutionalization has also been researched at micro-level (e.g. Powell and Colyvas, 2006). Moreover, sensemaking is mostly researched on micro-level, but for example Maitlis (2005) and Weber & Glynn (2006) also focus on organizational level phenomena of this process. Links between the institutionalization and sensemaking therefore can be made.
micro-micro mechanisms can be linked to sensemaking. It is the process of assimilation of the impact of the macro-level events by the individual (Hedström & Swedberg, 1989). The sensemaking by individual influences the micro-macro mechanisms, which is the third step and shows how a number of individuals generate macro-level outcomes due to their actions and interactions (Hedström & Swedberg, 1989). Sensemaking therefore, as Weick (1995) argues, can provide feedstock for institutionalization. Weber & Glynn (2006) developed a mechanism-based framework based on the model by Hedström & Swedberg (1989), in which institutions are both prior and upcoming to, sensemaking processes. Furthermore, Scott (2001) sees collective sensemaking activities as processes that may lead to the rise of new institutions.
2.5 Sensemaking and Change Reaction
As mentioned above, sensemaking includes three processes: scanning, interpretation and action. Scanning involves collecting data, with interpretation data are given meaning and action, also called learning, involves action taken (Daft & Weick, 1984). This last process, action, can be linked to change reaction (i.e. attitudes) as it is concerns ‘associated responses’. However, it should be noted that action and change reaction are not the same, as action is a process and change reaction is static.
3. Research methodology
3.1 Research DesignAs the theoretical contribution of this research is to explore and explain how reaction towards change and appropriation is influenced by institutional changes, sensemaking by individuals and frames of management, a qualitative approach is suited. The research adopts a grounded theory approach and is based on a single case-study. Data is collected via semi-structured interviews and documents containing primary and secondary data. The case study takes place in a Dutch home care organization. Exploring this phenomenon in the healthcare sector is relevant as there have been multiple institutional changes in the last decade. The level of analysis in this research is multi-level, as change reaction and sensemaking are individual-level processes, and the organizational changes and framing are organizational-level. During the whole process meetings with the supervisor of this thesis and discussions with a district nurse of another organization helped to constrain biases and enhance construct validity.
3.2 Case Description
Primary data has been collected at a Dutch homecare organization, due to confidentiality the name of this organization will not be provided. The organization consists of approximately 6.000 employees and is active in six provinces in the Netherlands. The organization has implemented a lot of changes in the last couple of years due to changing regulation, changing demographics and changes in demand for homecare. In this study, there will be a focus on two changes within the organization, which are the Fitting Care Project and Shared Governance. Both changes have been implemented at approximately the same time.
The first change, Fitting Care Project focuses on the intention of providing care that fits the needs of the client. The goal is to make the client as self-sufficient as possible, involve caregivers in the environment of the client and enhance the quality of life. It includes looking for sustainable solutions, instead of providing professional care right away. The second change in this research is Shared Governance, which is a structure that gives nurses and caregivers maximum control and ownership over quality and security of the clients. Multiple councils have been set up that all have a quality topic. These councils make care-oriented decisions about the policies concerning their quality topic. This structure gives the nurses and caregivers voice in policies and gives them the possibility to use their professional knowledge.
changes have led to organizational changes. This together with the literature found, resulted in a good starting point for developing the interview protocol. In order to explore how change reaction and frame appropriation are influenced by institutional changes, individual sensemaking and management frames in Dutch home care organizations, nine employees of this organization were selected for this case study. Five district nurses from five different teams were selected at random, together with one team member chosen by each district nurse. Unfortunately one district nurse was not able to find a team member willing to participate in this research, therefore four team members participated in total. Moreover, documents containing primary and secondary data have collected.
3.3 Data Collection
Data has been collected by conducting in-depth interviews with ten employees of the homecare organization. These interviews have taken place in April and May 2017 and include five district nurses, two nurses (level 4), two caregivers (level 3) and one change facilitator with no nursing background. It should be noted that the data collected via the interview with the change facilitator is only used as extra information and understanding about the organizational context (4.2.1) and does not add to other findings. All district nurses work in different areas in the Netherlands. Having respondents from different organizational levels and from different parts of the Netherlands enhances to the respondents reliability. The conducted interviews were semi-structured. A semi-structured interview is a direct, personal interview in which a single respondent is probed by an interviewer to uncover underlying motivations, beliefs, attitudes, and feeling on a certain topic (Blumberg, Cooper, & Schindler, 2010). An interview protocol will be used in order to enhance the reliability (Strauss & Corbin, 1990). The interview protocol has been formed based on the theory, the research question, information gained from the homecare organization and documents containing information about the institutional changes in the healthcare sector (e.g. government policies). Furthermore, as part of the interview preparation, the interview protocol has been tested on a district nurse of another company in order to determine if the questions were clear and understandable. Small revisions based on this have been made prior to the implementation of the study as advised by Kvale (2008), which adds to the construct validity. The interview guide can be found in the appendix (A). Only the interview with the change facilitator contained interview questions that were different since this person had a different role in the change implementations. The questions were focused on how the organization implemented the changes. Furthermore, some questions were based on gaps that arose during the coding phase of the first interviews.
is only little evidence that interviews via telephone lead to loss or deformation of data, or that the quality or interpretation of the data is affected (Novick, 2008). Also according to Emans (2002) the quality of interviews via telephone does not differ that much from face-to-face interview.
As mentioned before, primary a well as secondary documents have been collected. According to Chreim (2006) it is possible to use documents as primary sources when those documents fulfill conditions mentioned by Phillips, Lawrence & Hardy (2004). According to Phillips et al. (2004): “Texts that are produced by actors who are understood to have a legitimate right to speak, who have resource power or formal authority, or who are centrally located in a field are more likely to become embedded in discourse than texts that are not.”(p. 643). Data on institutional themes were taken from reform documents of V&VN, which is the largest Professional Association of Nurses and Caregivers in the Netherlands. V&VN is constantly in discussion with members, stakeholders and policy makers. The association works to support the position of the professionals and takes the lead if it is necessary and desirable in the interests of the members ( www.VenVN.nl/V-VN). Also reform documents and letters of the Government (Rijksoverheid.nl) and publications from two well-known healthcare websites have been used to get a better view on the institutional changes. These datasources have provided information for the institutional context as described in the results and serve as primary sources as they fulfill the conditions stated by Phillips et al. (2004). Furthermore, secondary data on organizational changes were taken from policies of the homecare organization. The use of interviews together with the multiple documents (primary and secondary sources) that are reviewed and examined will create triangulation, constrain instrumental bias and increase construct validity (Yin, 1994).
3.4 Data Analysis
When the aim of a study of social interaction or experience is to explain a process, grounded theory is appropriate (Lingard, Albert, & Levinson, 2008). Therefore, the approach used for data analysis in a qualitative way, is grounded theory. “The essence of grounded theory is the inductive–deductive interplay, beginning not with a hypothesis but with a research situation. Researchers start with a topic of interest, collect data and allow relevant ideas to develop.” (McGhee, Marland & Atkinson, 2007; p. 335).
were noted directly after transcribing the particular interviews as suggested by Burnard (1991). These notes contain anything that was found interesting by the researcher during this first phase of analysis, which adds to the controllability of the research. Questions or interesting topics that arose during this process, have been added to interviews conducted after that. This iterative process of data collection, data analysis conceptual theorizing is common with grounded theory (Boychuk Duchscher & Morgan, 2004), as it makes it possible to identify patterns of interaction between and among subjects. After coding all interviews, all transcripts have been analyzed in search for patterns. The individual interviews have been examined and compared via within case analysis, in order to search for commonalities and patterns between the individuals.
4. Results
In this section an overview is provided of the findings based on the gathered data. First, the context will be discussed, based on published news articles and documents from the Dutch government. Second, factors that influence the change reaction and frame appropriation of the individuals will be discussed. In total five influencers will be discussed: framing and middle management, strengthening of the profession, involvement in change, professional values and cynicism towards change. All these influencers will be discussed and underpinned with quotes from the data. This in order to reduces bias of the researcher, make research finding more valid (Sandelowski, 1994) and highlight opinions (Howarth, 1990).
4.1 Institutional Changes in the Healthcare sector
In recent years, many changes have taken place in regulation, societal view on healthcare and demographics in the health sector in the Netherlands. Home care organizations need to change along with changes.
nurses became responsible for the assessment of care. Because of this change, people in need of home care can now directly contact the district nurse. Together with the client, a nurse will assess what the needs of the client in order to stay home, by making clear what amount of care is needed (Zorg voor Beter, 2016).
Also, the need for home care has increased because of changes in demographics such as the aging baby boom generation and the fact people are getting older and older. This asks for a different approach from nurses and caregivers. According to the policies from the home care organization researched in this study, the approach has to shift from ‘taking care of people’ to ‘make sure that people get care’. In other words, getting people to be as self-sufficient as possible. When care is needed in addition to that, home care organization should first look for caregivers in the neighbourhood or family, and if there is no other option, they should provide the needed care. It should be seen as the last resort. Especially making people self-sufficient is a central theme in policies of the home care organization. Also, governmental policies emphasize this way of working, as it is a sustainable solution for the home care sector (Rijksoverheid.nl, 2015c).
4.2 Framing and Sensegiving by Middle Management
From the interviews can be assumed that the district nurses in the organization serve as middle management. Moreover, by analyzing the data it is found that middle management, via sensemaking and framing processes, positively influence individual’s change reaction and frame appropriation. Also, use of language is named as an important influencer of change reaction.
First of all, it can be assumed that district nurses in this case, have a middle management function. According to one district nurse: “Yes, that is indeed the link [between management and the caregivers] who is, of course also responsible for a team, for the care that is being provided and (s)he has to make sure that if there is a policy change, that it will be implemented in the team and that everybody takes note of it.” (4:96). Also, the team members seem to also see district nurses as middle management. As one team member mentions: “.. the district nurses get information from the
organization, and forward the documents by email to the team members”. (5:84). Moreover, even though some employees themselves search for information, they know that if it is really important, the district nurse in team will discuss it during team meeting. “If there are important details, then I will hear something via the district nurses or at a team meeting if it really is very important.” (5:96). This shows the importance of middle management during change implementation.
and frame appropriation of team members. Four out of five interviewed district nurses mentioned that they took part in communicating the changes to their team members. Moreover, one nurse mentioned the importance of this communication on the acceptance and adoption of the changes. Also, most of the interviewed district nurses mention that they discuss the changes within their team and sometimes have to explain the vision behind certain changes. By explaining and discussing the changes, the changes are appropriated: “.. the district nurses take care of this [pass through changes]. It is taken it into the team and I think the district nurses play the most important role. As an intermediary, because eventually, yes you will get emails and stuff, but by discussing it in a team, by putting it on an agenda, you will also think about it together. And then you will use it too.” (6:96). This shows that district nurses take part in sensegiving practices as they help communicating and discussing the change. Moreover, the district nurses also give sense by showing the benefits of a change helps in the appropriation of the change initiative: “ .. since the Shared Governance groups include especially district nurses, this is distant to the team. So the challenge is to introduce it to your team now and then. Like for example, [..] an oncology group, that is a specialization like psychiatry, [...] they come and tell teams something about their specialization and about a list that you can use on certain clients when you’re a palliatrist, and then they become more involved and then they actually look at the practical side too: ah that's not just for the district nurses but that's something we can also make use of.” (8:115).As the district nurses discuss the change and even show how it works, team members are more likely to use it.
Also, it can be assumed that frame appropriation will be more likely if the changes are linked to the vision of an organizational. One nurse mentioned that for the second change (i.e. Shared Governance):
“..the vision behind Shared Governance, I think sometimes you have to explain it once again. That's more about the practical part, that they see what is being done. But if you explain the vision behind it then I think people will recognize it.” (8:112). Giving the extra information as district nurse thus seems to improve the acceptance and adoption of the change. Furthermore, one nurse mentions: “Well, if a Shared Governance group, for example, has released something new, or made a certain improvement, I will continue that and tell them where it comes from. However, I will call it a quality group since they will have more in mind with that than probably with Shared Governance as a term.” (4:93). This shows that in some cases team members may not know the change by name, but may appropriate the change as the district nurses frame the change in an understandable way. Continuing the change in such a way seems to influence the change reaction of employees. This shows that by sensegiving and framing the change, that team members are more likely to appropriate the changes.
wrong names may have negative influence on following changes. For example, the organization first called the fitting careplan, ‘unburden’. This name made some individuals hesitant:“Yes, at first, it was called unburden, at [organization], in general. That's not eh, well, it just was not the right name, that was just a bit of a pity of course. In order to switch to the new vision, the fitting care plan was not easily done after explaining one time, so you have to talk to the team more often and talk about: It’s not unburdening, it is giving appropriate care that fits and what does that mean?” (8:115). Sensegiving by the district
nurse in this case was an important influence on the appropriation by the team members, as the team members were more hesitant. This shows, that even if higher management frames a change in a way that many individuals may not accept, the middle management may, by sensegiving, restore the negative experience and turn it in appropriation of changes in the future. This shows the strength of middle management in frame appropriation.
4.3 Strengthening of Profession
When the professional identity is confirmed by organizational or institutional changes, this has a positive influence on change reaction and appropriation. This interesting pattern in the appropriation of an institutional change by district nurses was directly found when analyzing the data, as all district nurses mentioned this motive to appropriate the change frame. The influence an institutional change had on strengthening on the profession, is named as main reason to appropriate to that change.
nurse said: “I think that's right and I think that's nice for the profession we are in. That it is getting professionalized.” (9:131). The findings thus show that appropriation is positively influenced by institutional changes that confirm the professional identity.
4.4 Involvement in Change
When nurses and caregivers have the feeling that they are involved in change on organizational level or institutional level, they are more likely to appropriate the change according to the interviews. In the Dutch home care organization under research, there were multiple possibilities to participate in change initiatives (e.g. quality groups, nurse advisor). The study shows that the nurses and caregivers that participated in the change initiatives, reacted positive to the change and appropriated. Moreover, the study also showed that as individuals saw that management listened to for example the quality group, that more and more employees wanted to participate. This suggests that involving employees in change and development plans, positively influences the change reaction and appropriation.
For example, one of the nurses is very active in committees on institutional level: “Yes, sure yes,
and I've also been working with V & VN, so for the ambassadorship for district nurses, so I'm very much in favor of the work. For example, I visit health insurance companies, I am in a group for quality guidelines for development and I'm really doing my best to improve the subject and to monitor the autonomy.” (4:114). (S)he appropriated both changes on organizational level and appropriates the changes on institutional level. Furthermore, the change reaction of this person is overall positive. Two other individuals have taken part in a pilot performed by the Dutch government. This also had a positive influence on change reaction and appropriation, as one caregiver said: “I participated in ERAI [pilot], which actually gave me extra information and more insight into how other district nurses work with it. And I think it's a very good initiative.” (6:30). This caregiver also appropriates the change:“Yes, it is actually mostly a habit. A habit, just to think together.” (6:45). The change reaction of the other individual was positive as well, and both organizational and institutional changes were all appropriated.
The second change, Shared Governance, was about involving (mainly) the district nurses in the policymaking process as they were seen as the professional with practical information. The involvement of the nurses in this process was appreciated by all nurses. One nurse said the involvement was in favor of the organization because of the knowledge (district) nurses have about their discipline. “ Because we are
the one with the professional knowledge and eh, we think so, especially if HBO graduates are adequately trained to determine the policy. So that's beautiful I think.” (8:64). Moreover, the perceived control makes that many nurses are willing to participate in the quality groups that influence policy making and see this as a contribution to their discipline. “That things we face or run into in our job, that you can contribute to improve it.” (4:58) . The involvement made that all district nurses appropriated or partially appropriated the change. Also, two caregivers appropriated the changes. The remaining individuals were not aware of Shared Governance and therefore were not able to answer the questions. Concluding, it can be derived from this research that involvement in change positively influences change appropriation
4.5 Professional Values
The interviews of this study imply that professional values are important for individuals in the home care sector and that these values have influence on change reaction and appropriation. Social responsibility and quality for care are for example mentioned as professional values. Those are seen as important motive to appropriate change, whereas financial motives to changes are perceived as negative. Financial motives are in those case in conflict with professional values. However, many nurses seem to accept (behavioural change reaction) the change anyway as they have the feeling that there is no choice.
When it was announced that the law that aims to provide general insurance (AWBZ) was going to be dismantled, the reactions were ambiguite. As one nurse stated:“Well, you know, you will hear about
the changes, at one point they said: yes, the AWBZ ceases to exist. I mean, it has advantages and it has disadvantages. The advantage was that we indicate ourselves and the disadvantage is that we are now being paid by the health insurers who see a lot of money in health care institutions, and actually want a lot of influence on the way we have to do our job. And also make demands.” (3:102). Many respondents perceived the increase in power for the health insurance companies as negative : “Eh, especially the power
health insurer have is getting very big. It is already very big, they already determine a lot.” (2:93). This negative perception is because the focus of such companies is on financial gains instead of quality of care:
“I think it is pity that it [financial focus] predominates and then you see that we really want to take care of quality care from [name organization]. As a result, management and directors also suffer from the fact that health insurance and politicians making choices, not based on quality care but on finance.” (8:133).
However, the cognitive and emotional reactions are more negative whereas the behavioral reactions stay positive. According to one nurse this is because: “Yes, we can also say let’s wait, but well,
the politicians and health insurers are not waiting, so that's what's going on and you will have to.” (2:42). This is shows that when individuals perceive pressure from the environment, that they may cognitively and emotionally react negative but they will behaviorally cooperate since they have the feeling that they do not have a choice. “Yes, I think, you can resist it, but I think it's just, what's the right word. It's just as it is and you'll have to deal with it [..] and you will have to be very critical about how money is spent. [..] But, I think it is insurmountable that there should be changes in the healthcare sector.” (3:96)This individual reacted negatively towards the consequence that health insurers now have more power over the homecare sectors, however (s)he is in the assumption that there is no choice as the changes are needed.
Motives to change that complement professional values can have a positive influence on the appropriation of change. Many individuals state that they want to keep healthcare payable in the future, which can be linked to social responsibility. “Yes, I think, if you want to keep care payable in the future, you will have to come up with changes.” (3:99) This is also perceived as the motive of the organization to make organizational changes: “But uh, I think we should look at how we can work as efficiently as possible and waste as little money as possible. And I think that the fitting care plan, though, that that's a nice way of packaging that. So I think [organization] is well on its way, yes.” (4:123). The fact that the employees positively look at the motives of the organization to make organizational changes, influences the appropriation of the management frames in a positive way.
4.6 Cynicism towards Change
When analyzing the interviews, it was found that cynicism negatively influences change reaction and appropriation. The amount of changes implemented over the years and bad change experiences has led to individuals being cynical towards change, which in turn leads to neutral or negative change reaction and partial appropriation. Change frames are less easily accepted by individuals that have experienced change implementations that they perceived as bad.
A frequently mentioned reason in this study to react neutral or negative towards change is experiences with earlier changes. One nurse mentions that change can be brought very nicely, but that (s)he is rather cynical about how (s)he expects it will work out. The reason for this is : “ Experience, some
things are raised beautifully and after a year, a year and a half, it just disappears. Then there are other priorities and then it fades.” (2:78) . This nurse partially appropriated the second organizational change and the institutional changes because of the bad experiences. Also another nurse said that his/her first change reaction was neutral, “Because of course, such a vision is very beautiful, but in the past I experienced that in some organizations the words sound very nice, but when executed, that is not quite real. So that is why I thought, well I have to wait and see.” (4:40) Moreover, because of the amount of changes in the healthcare sector, some individuals also mention that they are more persistent towards change, as one nurse mentions about the reaction towards change by the team members: “Well, I think, it's the ‘nth time that something is being made up. Well with some restraint.” (1:73). This nurse partially appropriated both organizational changes as well as the institutional changes.
5. Discussion
The findings provide deeper insight in how change reaction is influenced by institutional changes, individual sensemaking and frames of management. In this section the research question: “How is change reaction and appropriation influenced by institutional changes, individual sensemaking and frames of management in Dutch homecare organizations?” will be answered. This by means of theoretical implications which will be discussed and compared to existing literature. Based on this implications, propositions are drawn. Moreover, practical implications, limitations and avenues for future research will be stated.
5.1 Theoretical Implications
5.1.1 Sensegiving by Middle Management
This research shows that middle management is an important factor associated with change reaction and appropriation of change frames. This is in line with the work by Balogun and Johnson (2004), which shows the importance of middle management in developing new organizational structures and other changes. Senior management may design those changes, but how it actually operates is determined by how individuals at the lower levels behave, which is based on their interpretations of and response to these changes. The lower levels therefore are the ‘active shapers’ of the way the change initiative develops. The role of middle management is important in this active shaping and therefore important for successfully implementing organizational changes (Balogun & Johnson, 2005). This study adds to the work by Balogun and Johnson (2004), as it describes how middle managers help with changes designed by higher management. Namely, sensegiving is found to be an important way by which middle managers influence the change reaction and frame appropriation of individuals.
explains that the tacit knowledge of middle managers that is used throughout their sensemaking and sensegiving processes makes them a strategic asset of the organization. Whereas the study by Rouleau focusses on the influence middle management has on external stakeholders, this study focuses on the influence on organizational members. Therefore, this study adds to Rouleau’s work by showing that sensegiving processes by middle managers also have a positive influence on team members. By continually discussing the changes and explaining the vision behind the changes, middle management has influence on how team member react towards the changes. Moreover, it also has positive influence on the appropriation of changes.
This leads to the first two propositions resulting from this study:
Proposition 1a: Middle managers that have appropriated a change, positively influences the change reaction of their team members via sensegiving processes.
Proposition 1b: Middle managers that have appropriated a change, positively influences the appropriation of the change frame by their team members via sensegiving processes.
5.1.2 Strengthening of the Professional Identity
study. This study therefore adds to literature that strengthening of the profession has a positive influence on change frame appropriation.
The appropriation, in some cases, was so strong that consequences that were perceived negative did not have influence. This findings complements research by Morgan and Zeffane (2003), who found that when positive job changes are reported, trust in management likely to rise even when effort or stress increases at the job level. In turn trust in management, according to Michaelis, Stegmaier & Sonntag (2009), is strongly related to followers’ affective commitment to change. This type of commitment to change, can be linked to the affective part of change reaction as described in this research. Thus, literature already shows that positive job changes leads to trust in management, which in turn positively influence the affective dimension of change reaction. However, the findings in this study adds to literature that positive job changes, in this case changes leading to strengthening of the profession, also positively influence cognitive and behavioral change reaction and appropriation of the change frames.
Concluding, this leads to the following two propositions:
Proposition 2a:When an institutional or organizational change leads to perceived strengthening of the professional identity, this has a positive influence on appropriation of the change frames by an individual.
Proposition 2b:When an institutional or organizational change leads to perceived strengthening of the professional identity, this has a positive influence on change reaction by an individual.
5.1.3 Involvement in Change
involvement, performance and motivation. Also according to Oreg, Vakola & Armenakis (2011) participation influences the change reaction of recipients.
Moreover, Morgan & Zeffane (2003) found that direct consultation between employees and management is important in major change processes. According to the research, consultation leads to more trust in management, which in turn positively influences change reaction and appropriation. By consulting employees via quality groups, as is done with Shared Governance, the trust in management increases which positively influences change reaction. As mentioned before, trust in management is namely strongly related to followers’ affective commitment to change (Michaelis et al., 2009).
Even though there is already a lot of literature on the relationship between participation and change reaction (e.g., Spector, 1986; Oreg et al. 2011; Morgan & Zeffane, 2003), this study adds that appropriation of change is also positively influenced by involvement and perceived control. By involving and consulting individuals, those individuals are more likely to appropriate the change frames of management.
This leads to the following proposition:
Proposition 3: When an individual is involved in change and perceives control over a change or change process, this has a positive influence on their frame appropriation.
5.1.4 Professional Values
that adds to this central belief of professionalism in healthcare, is perceived as positive. The change reaction and appropriation is then positively influenced.
According to Scott, Mannion, Davies and Marshall (2003) professional values that have been affirmed over centuries, lead to difficulty when implementing change from the top. This is in contrast with the findings of this study. Even though the individuals negatively react (cognitive and affective) towards the financial motive of the government to change, their behavioural change reaction is positive. The reason for this is that they have the feeling that they have no choice. Implementing change from the top (i.e. government) is in this case therefore not seen as leading to much difficulties. A reason for this may be another finding of this research. Namely, even when an institutional change is perceived as not corresponding to the professional values, but the organization does implement change with the professional values in mind, the change reaction towards the organizational change are positive and change is appropriated by individuals. Taking these findings into account, the following propositions are made:
Proposition 4a: When a motive of a change initiative corresponds to professional values, this positively influences the change reaction and change appropriation.
Proposition 4b: When an organizational translation of an institutional change corresponds to professional values, this positively influences change reaction and appropriation.
5.1.5 Cynicism towards Change
When employees have negative past experiences with change or have experiences a lot of changes already, this may lead to cynicism about change. According to Reichers, Wanous and Austin (1997), cynicism towards change has a negative influence on commitment, satisfaction and motivation of employees. This implies a negative influence on change reaction on the cognitive and emotional dimension. However, the study conducted by Reichers et al. (1997) also shows that it does not necessarily lead to negative behavioral change reaction, as an interviewee in that study mentioned: “Even though I’m
the findings of this research, cynicism thus negatively influences cognitive and affective change reaction, but not behavioural.
What this study adds to the work of Reichers et al. (1997) is that also change appropriation is influenced by cynicism towards change. Multiple individuals stipulate that the moment that the organization proposes an organizational change, they may perceive the change as positive, however, past experiences lead to a hesitant attitude. They mention that they want to wait-and-see how the initiative develops and therefore do not appropriate the change yet. Cynicism towards change seems to lead to less trust in management, which in turn leads to hesitance when change frames are proposed by management. This leads to the following proposition:
Proposition 5: When individuals have bad organizational change experience, this negatively affects their frame appropriation.
5.2 Practical Implications
This paper has valuable practical contributions. The research advances our understanding of the relationship between change reaction and frame appropriation, and institutional changes, individual sensemaking and managerial framing. The findings an be used by management of home care organizations, in order to let change implementations run smoothly and be successful.
Furthermore, it is shown that involvement of individuals and perceived control leads to frame appropriation. The perceived control by individuals makes that they have more trust in management, which positively influences appropriation. Management should take this into account when thinking of change implementation. When framing a change, management should also take into account professional values. Individuals are more likely to react positively to change and appropriate frames, when it is corresponding to their professional values. Also, as change cynicism increases when individuals have bad experiences with change or when there are many changes. Management should be aware of change cynicism in order to overcome partial and not appropriated organizational changes.
The findings of this research provides organizations with valuable diagnostic information. Moreover, organizational change agents with these insights know better where to focus their energies and development efforts in designing appropriate strategies to bring about change. As a result, more effective change implementations can result in better performance.
5.3 Limitations and Future Research
As with every research, this study also has limitations that may give avenues for future research.
A single case study can be used to describe phenomena in depth in order to find rich description and understanding (Walsham, 1995). However, findings of a single case study are generalizable to other empirical settings when additional case studies are done, which test and confirm these same findings (Lee, 1989). Therefore, for future research I would like to emphasize the importance of additional research to confirm and test the findings of this research. Moreover, the focus in this study was mostly on the individual level, therefore it would be interesting to focus more on the organizational level and explore the effects of different types of framing by managements. This in order to get a more complete multi-level view on the factors that influence change reaction and frame appropriation in home care organizations.
of the organization, which results in a respondent bias and lowers generalizability. There are two types of respondent bias that may have influenced the results, namely impression management and self-descriptive positive respondent’s bias (Paulhus, 1984). The first, impression management respondent’s bias, refers to intentional effort to make an impression on an audience that is favourable. The second, self-deceptive positivity respondent’s bias, refers to the propensity to give answers that are honest but overly positive (Paulhus, 1984). For future research I would suggest exploring the influence of institutional changes, individual sensemaking and management framing, on change reaction and appropriation in an home care organization where there is difficulty of involving people in the change initiative to get a more complete view.
Furthermore, due to circumstances it was not possible to do the coding process with two or more researchers, which may have led to researcher’s bias. One of the interviews is coded together with the supervisor of this thesis in order to minimize inter-subjectivity to a certain extent and enhance validity, as suggested by Burnard (1991). However, interpretation of the data is mostly based on the interpretations of a single researcher. According to Kvale (1994), several interpretations of the same text is not a weakness, but a richness and a strength of interview research. This shows that the findings of this research do contribute, even when only found by one researcher. However, a replication of this exploratory research may be done in another home care organization in order to explore more and gain additional findings.
5.4 Conclusion
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