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Inter-domain collaboration within the
healthcare sector
How shared frameworks of understanding are
created between heterogeneous domains
University of Groningen
Faculty of Economics and Business
MSc. Business Administration
Change Management
First supervisor
Dr. J.F.J. Vos
Second supervisor:
Dr. H.C. Bruns
Fabian Schurink
S2746344
f.schurink.1@student.rug.nl
Word count: 11903
2 ABSTRACT
Inter-domain collaboration has become increasingly important within the healthcare sector to provide effective services while having a reduced budget. Many issues seem worthy of attention, because inter-domain collaboration comes with numerous difficulties. This study examines how shared frameworks of understanding between heterogeneous domains are created, as it sets the basis for effective inter-domain collaboration. To get a fuller understanding of the phenomenon, two cases on inter-domain collaboration were analyzed. A process model of how shared frameworks of understanding are created was developed in this study. This model divides understandings into three distinctive layers. Each layer having its own significance in inter-domain collaboration. The first layer provides an action focus for boundary spanners. This was established through an identification of a shared problem and/or raison d’être. The second layer aims to clarify each other’s domain. This was be established through a clarification of one another’s assumptions, philosophies, workstyles, interests, strengths, weaknesses, and goals. On the last layer, boundary spanners should focus on the integration of their resources, skills and knowledge. This was established through discussions about trade-offs. This study finds that aligning frameworks of understanding does not only synthesize integrated solutions to complex healthcare problems, it also speeds up the collaboration process due to effective communication.
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TABLE OF CONTENTS
Introduction 4
Literature review 7
Boundary management 7
Boundary objects and subjects 8
Interpretive schemes 10
Methodology 12
Research approach 12
Case selection and participants 12
Data collection 15
Data analysis 16
Results 17
Case 1: Towards inter-domain collaboration between organizations 17 Case 2: Toward inter-domain collaboration within an organization 21
Cross-case analysis 24
Discussion 27
Discussion of findings 27
Theoretical implications 29
Practical implications 31
Limitations of the study and future research opportunities 31
Conclusion 33
Acknowledgement 34
References 35
Appendices 42
Appendix I: Interview protocol 42
Appendix II: Change story case 1 44
Appendix III: Change story case 2 49
Appendix IV: Codebook Case 1 54
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INTRODUCTION
Inter-domain collaboration has become increasingly important within the healthcare sector to provide more effective services while having a reduced budget. Much of today’s demand of care originates from problems in domains such as education, school, work, or living environment (Galea et al., 2001). In order to survive as a societal organization, they have to assess how their services will add value to clients and society. Additionally, they have to re-think what their raison d’être is in the region. Many issues seem worthy of attention, because inter-domain collaboration comes with numerous difficulties. These are uncertainties around who is responsible for what, rigid and misaligned performance patterns, domain thinking and behavior, costs and benefits spreading over different domains (Jones, Thomas & Rudd, 2004; Schippers & Van Rijn, 2016), and difficulties in resolving differences of power, resources and philosophy between agencies (Jones et al., 2004; Carnwell & Buchanan, 2005; Rycroft-Malone, Burton, Bucknall, Graham, Hutchinson & Stacey, 2016). In terms of collaboration, particular attention should be paid to identifying what those differences in philosophies are about, then to target the issues that may exist among the members, and finally work towards more shared frameworks of understanding (Ariño & Ring, 2004; Nowell, 2009). The aim of this paper is to clarify how such shared frameworks of understanding between domains are created and therefore sets the basis for effective inter-domain collaboration.
The literature has shown that there is little agreement as to how to define collaboration, because a wide range of definitions exist. In this research I chose to adopt the definition of Hardy, Lawrence and Grant (2005:58) in which they define collaboration as ‘a cooperative, (interorganisational) relationship in which participants rely on neither market nor hierarchical mechanisms of control to gain cooperation from each other’. Furthermore, Hardy et al. (2005) state that effective collaboration depends on the relationships among participating organizational members, which are negotiated on an ongoing basis throughout the collaboration. It represents a complex set of ongoing communicative processes among individuals who act as members of both the collaboration and of the separate organizational hierarchies to which they are accountable. An important point to consider is that collaboration needs to be viewed as a process as well as an outcome (Ansari, Philips & Hammick, 2001). Collaborative arrangements are seen as helping organizations acquire a pool of resources, skills, and new knowledge that allow synergistic solutions to complex problems, for example the rising healthcare costs (Hamel, 1991; Williamson, 1991; Anand & Khanna, 2000; Kale, Singh & Perlmutter, 2000; Gulati, Nohria & Zaheer, 2000; Weiss, Anderson & Lasker, 2002). However, the focus in the literature has largely been on the outcomes of collaboration and little academic attention is given to the social processes underlying it (Tsasis, 2009). We know little about the process by which relationships and contacts among people and organizations from different domains are established, nurtured, and used for mutual benefit.
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different occupations, organizations and domains (Huzzard, Ahlberg & Ekman, 2010). It entails transforming local domain knowledge into collective knowledge among the various participants involved. Actors from different local contexts are involved in a process of sharing work experience, interpreting and comparing different understandings of work aspects and constructing shared meanings on the performance of their work tasks (Huzzard et al., 2010). Furthermore, the role of boundary spanning is fulfilled by boundary spanners. They are representatives of a particular domain (Tsasis, 2009). Boundary spanners work at the boundary of their own domain to interact with other domains. They are actors who cross the boundary of their own domain to collect valuable information, interpret this information, and disseminate it throughout their organization (Tsasis, 2009). Boundary spanners interact with other domains, while representing their own domain. Moreover, they also act as agents of influence to both internal as external parties, creating social connections and building relationships across their organizations. In cases of inter-organizational collaboration, these boundary spanners can be directors and managers. Yet in other cases such as inter-professional or inter-group collaboration they can be professionals and specialists, such as community workers and social workers. This implies that boundary spanning and boundary spanners play an important role in the establishment of inter-domain collaboration.
Furthermore, inter-domain collaboration tend to be more difficult in the healthcare sectors than in other sectors. Healthcare problems are often interrelated and involve many domains such as community work, healthcare, education, government, and living environment (Galea et al., 2001). It also involves many stakeholder groups such as volunteers, clients, family and the general public (Rycroft-Malone et al., 2016). Each domain and stakeholder group brings a different cognitive and emotional representation on a particular issue and is shaped by different experiences and interests. Furthermore, the healthcare sector is characterized as a professional bureaucracy (Mintzberg, 1980). Professionals in such organizations are highly specialized and work autonomously (Brock, Powells & Hinnings, 1999; Maylone, Ranieri, Griffin, McNulty & Fitzpatrick, 2011). Professionals do not wish to be dependent on one another or may believe that they know best (Taylor & Hawley, 2010). The professional bureaucracy therefore may inhibit collaboration and integration between domains. While inter-domain collaboration is one of the most desired phenomena in the healthcare sector, it is also one of the most challenging phenomena to establish.
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A theoretical and practical gap exists when it comes to collaboration between heterogeneous domains (Nowell, 2009; Huzzard et al., 2010). This research aims to close the gap on how boundary spanners from heterogeneous professional domains establish shared frameworks of understanding for inter-domain collaboration. The foregoing leads to the following research question: ‘’How do boundary spanners from different domains create shared frameworks of understanding for inter-domain collaboration?’’
The current paper argues that shared frameworks of understanding are needed to pursue effective inter-domain collaboration. The rising healthcare costs along with the belief of governments that ‘local inter-organizational collaboration is essential to deliver improvements in people’s quality of life’ (Department of health, 2005; Schippers & Van Rijn, 2016) makes it inevitable for societal organizations not to collaborate in the healthcare sector. This research develops a process model to create shared frameworks of understanding between boundary spanners with heterogeneous domains, therefore contributing to a solution for this need.
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LITERATURE REVIEW
To get a deeper understanding of boundary spanning, the approaches of boundary management will be explained. It sets the basis for this research. Secondly, the tools that can assist boundary spanners in aligning their frameworks of understanding will be explained. The next section provides an in-depth explanation on how frameworks of understanding can be conceptualized. In the final section, the theoretical perspectives will be integrated into the predominant logic for the rest of this paper.
Boundary management
The concepts presented in this section elaborate on three complex approaches to describe and analyze the construction of shared frameworks of understanding. The works of Shannon & Weaver (1949) and Carlile (2002, 2004) form the theoretical foundation for this explanation, which conceptualizes the nature and relational properties of boundary management. I will argue that their work can be used for the construction of shared frameworks of understanding across domains. Although boundary spanners from heterogeneous domains may want to tackle specific healthcare problems, it does not automatically imply that they have the same understanding of that problem nor the same philosophy on how to tackle it (Bartunek, Rousseau, Rudolph & DePalma, 2006). Therefore, when understandings are shared, boundary spanners can integrate their knowledge and experience in order to tackle complex inter-domain problems. In order to do so, boundary spanners have to understand one another, they have to adopt the same meanings and strive towards collective goals. This underpins the framework of analysis for this paper.
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consideration when analyzing the conveyed meaning and interpretations of boundary spanners (Leonard-Barton, 1995; Nonaka & Takeuchi, 1995; Von Hipple & Tyre, 1996). It should specify the differences and dependencies at a boundary (Carlile, 2002). Finally, the last approach is the pragmatic approach and revolves around transforming knowledge. Here, transforming knowledge refers to ‘a process of altering current knowledge, creating new knowledge, and validating it within each function and collective across functions’ (Carlile, 2002: 445). In terms of inter-domain collaboration, it can be understood as the blending of single domain-knowledge into collective domain-knowledge in order to complex inter-domain problems. Furthermore, in the process of transforming knowledge, boundary spanners will not wait passively for the outcomes of particular trade-offs (Van Offenbeek & Vos, 2016). They will rather try to sell their philosophies through engaging in voluntary, discretionary behaviors so that attention is focused towards their domain.
According to Huzzard et al. (2010), the semantic and pragmatic approach described above should be adopted in the early stages of a project – when boundary spanners establish an action focus for collaboration. Moreover, the semantic approach revolves around constructing shared meanings (Huzzard et al., 2010). It is a process where learning about and translating domain-specific knowledge from each other is key. A product of this approach should be the establishment of common meanings Also, it should be clear for the boundary spanners involved to share and assess each other’s knowledge (Carlile, 2004). A pragmatic analysis is faced when trade-offs become apparent in the discussion between boundary spanners. Within this approach, it is required to negotiate and transform domain-specific knowledge into collective knowledge across the boundary spanners involved. Common interests should be developed that allow boundary spanners to address the consequences, differences, and dependencies of each other’s domain-specific knowledge (Huzzard et al., 2010). This research will address where meanings and interests meet or diverge in inter-domain collaboration between boundary spanners.
Boundary objects and subjects
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Additionally, Carlile (2002) argues that boundary objects can be models or maps, artefacts, standardized methods, or repositories. Maps (e.g. Gantt charts, process maps, workflow matrices) help clarify the dependencies between different cross-functional problem-solving efforts that share resources, deliverables and deadlines. Models (e.g. sketches and drawings) depict or demonstrate current or possible form, fit and function of the differences and dependencies identified at the boundary. Standardized methods provide a shared structure or language that makes defining and categorizing differences and potential consequences more shareable and less problematic across different domains. Repositories (e.g. cost databases, parts libraries) supply a common reference point of data measures or labels across functions that provide shared definitions and values for solving problems. Carlile’s (2002, 2004) research was predominantly focused on the manufacturing sector and within organizations. Whether the same boundary objects are used within the healthcare sector and/or between organizations remains unclear. Therefore, the aim of this paper is to investigate which boundary objects were used to create shared frameworks of understanding in the healthcare sector and between organizations.
Moreover, one of today’s contentions is whether an individual can act as boundary object – so-called boundary subjects (Huzzard, et al., 2010). According to Huzzard et al. (2010), boundary objects are of nature passive and a tool to connect boundary spanners. The question arises whether individuals can ‘actively’ mediate across professional and organizational perspectives. According to Star & Griesemer (1989), boundary spanners acting from their own domain cannot act objectively in times of inter-domain collaboration, because of the possibility that they are politically motivated and manipulate the situation to their own advantage. Huzzard et al. (2010) explored the role of action researchers as boundary subjects who mediate between boundary spanners. In their research, they found that action researchers bridged the boundary spanners and their corresponding domains. Boundary subjects facilitated shared frameworks of understandings by enabling boundary spanners to participate in new forms of dialogue, reflect on alternative interpretations of reality, and collectively create new knowledge (Gibbons, Limoges, Nowotny, Schwartzman, Scott & Trow, 2000).
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shared frameworks of understanding. Therefore, it is interesting to investigate the role external consultants and how they work in the facilitation of shared frameworks of understanding.
Interpretive schemes
In this research, the concept of interpretive schemes is utilized to define frameworks of understanding. This research adopts the definition of Balogun & Johnson (2005: 1575) in which they define interpretive schemes as ‘fundamental shared assumptions that determine the way members of an organization currently conceive their organizational environmental context, their organization, and how they act in different situations’. This is in line with the perspective; where individuals from different domains have assumptions about their field of activity, and act and behave based on these assumptions. Furthermore, research states that interpretive schemes provide meaning to the everyday activities of organizational members (Labianca, Gray & Brass, 2000). Once interpretive schemes have been established, they tend to endure and are resistant to change, even when disconfirming information is presented (Ross, 1977; Nystrom & Starbuck, 1984; Reger & Palmer, 1996). However, interpretive schemes may and can change over time (Isenberg, 1987), yet they may also change if an organizational leader articulates a new vision for the organization (Bartunek, Lacey & Wood, 1992). According to Bartunek (1984) and Ranson, Hinings & Greenwood (1980), to achieve strategic change it is necessary for organizational interpretive schemes to change as well.
Research has indicated that individuals in different groups (Meyerson & Martin, 1987) or with different status levels (Smith, 1982) may perceive the same event very differently. These differences are particularly prevalent when certain subgroups feel that their interests are being overlooked (Labianca et al., 2000). Therefore, there is no reason to assume that stakeholders from different domains share the same understandings (Bartunek et al., 2006). The same intervention can be interpreted quite differently, creating distinct experiences and differences in action focus, thus inhibiting effective collaboration (Kanter, Stein & Jick, 1993). So, there is an underlying need to have shared frameworks of understanding among the different individuals, groups or organizations involved.
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motivational states and performance (DeChurch & Mesmer-Magnus, 2010; McComb & Simpson, 2013). Based on the foregoing, shared interpretive schemes are a desired state in order to effectively pursue inter-domain collaboration.
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METHODOLOGY
In the methodology section discusses the methods which are used in this research. This section pays attention to the selection of cases and participants, collection and analysis of data.
Research approach
The aim of this study is to gain a deeper understanding of how boundary spanners create shared frameworks of understanding for inter-domain collaboration. The existing collaboration literature has largely been focused on the outcomes of collaboration, while little academic attention is given to the social processes underlying it (Tsasis, 2009). This study adopts a multiple case study approach to capture the complexity, relevant topics and rich details of particular phenomena (Eisenhardt & Graebner, 2007). Furthermore, this approach is used to enhance explanations and create theoretical framework about how shared frameworks of understanding can be created.
Using multiple cases allows this study to create a more robust theory (Eisenhardt & Graebner, 2007). Furthermore, by applying this method propositions are more grounded in varied empirical evidence. Additionally, Yin (2003) argues that results of a multiple case study are more grounded than those of single case studies thereby increases the external validity. Furthermore, multiple cases enable a broader examination of research questions and theoretical exploration (Eisenhardt & Graebner (2007). This research explores how boundary spanners create shared frameworks of understanding between and within organizations.
Yin (2003) also argues that each case in a multiple case study should be selected so that it either predicts similar results (a literal replication) or produces contrary results for predictable reasons (a theoretical replication). This research aims to produce similar results and therefore cases with similar settings were chosen. I will explore two cases. In the first case, I will explore how boundary spanners who represent organizations create shared frameworks of understandings. Thus, involving inter-domain collaboration between organizations. In the second case, I will explore how boundary spanners who functions within organizations create shared frameworks of understanding. Thus, it involves inter-domain collaboration between professionals. The cases were, first of all, similar in a sense that the need for change originated from budget cuts. Secondly, boundary spanners were faced with uncertainty, because the budget cuts raised ambiguity about the existence of organizations and job roles. Finally, within each case, there was a need for inter-domain collaboration in order to survive as organization. Case selection and participants
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inter-domain collaboration. Subsequently, the clients contacted the participating organizations or professionals. In this way, the selection of the respondents may be biased due to an increased chance of selecting participants who have a positive opinion regarding the change project. The main advantage is that it ensures that the participants who are chosen are fully aware and better informed of the case.
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TABLE 1
Demographics of participants
Respondent Gender Domain Function
Case 1: External consultant (1-C) F Consultancy Sr. External consultant Case 1: Boundary spanner (1-BS1) M Government Sr. policy advisor Case 1: Boundary spanner (1-BS2) M Community work Community worker Case 1: Boundary spanner (1-BS3) F Community work Community worker
Case 1: Boundary spanner (1-BS4) F Healthcare CEO
Case 1: Boundary spanner (1-BS5) F Healthcare Sr. Policy advisor Case 2: External consultant (2-C) M Consultancy Sr. External consultant
Case 2: Boundary spanner (2-BS1) F Staff CEO
Case 2: Boundary spanner (2-BS2) M Staff Manager of regional teams
Case 2: Boundary spanner (2-BS3) F Staff Program leader
Case 2: Boundary spanner (2-BS4) F Social care Social worker Case 2: Boundary spanner (2-BS5) M Community work Community worker
Case 1: Inter-domain collaboration between organizations
The first case in this paper concerned a change project within a municipality. They had to radically change the policy of their healthcare domain due to the decentralizations of healthcare tasks from the Dutch government to municipalities. The aim of the policy change of the municipality was to organize care more effectively with less budget from the Dutch government. Various organizations, ranging from specialized care to community work, have to collaborate with one another in order to realize this goal. Consequently, these organizations will also have to shift to a more market-oriented perspective. They have to think how their services add value in this new system and rethink what their raison d’être is. Specialized care organizations will have a smaller role in the future. So they have to rethink how they can fit within this new system. On the contrary, community organizations will play a larger role in this new system, since their task will be to prevent clients ending up in specialized care. Organizations in the region will have to collaborate, discuss what role they will play, and what tasks they have within this new system. They have to provide services and support for the clients while having a reduced budget.
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consultant was hired to facilitate the process of establishing collaboration between the associated organizations.
Furthermore, this project was in a pre-implementation phase when the interviews were conducted. The organizations were in a phase where they came to an agreement on the target group which they collectively wanted to serve.
Six interviews were conducted to analyze this case. Five boundary spanners were interviewed: one from the municipality, two from community work, one from home care one from psychiatric care. Finally, one external consultant from the consultancy firm was interviewed.
Case 2: Inter-domain collaboration between professions
The second case concerned a change project within a social organization. This organization provides social and community work for clients and work for several municipalities in the region. They had to radically change the way they provided services to clients, due to the decentralizations by Dutch government to the municipalities. One of the goals was to prevent overlap in services, which should result in a more cost-efficient way of working. This goal was realized by grouping professionals from different domains into regional teams. Their goal was to collaborate and provide integrated services for the clients. Social workers who were accustomed to individual work and reporting currently need to work together with community workers whom are accustomed to group work, and do not report as often. Professionals who have different ways of different domain thinking and working will have to collaborate with each other to provide services that are more effective and cost-efficient for clients. An external consultant was hired to facilitate the process of this project.
Furthermore, this project was in a pre-implementation phase when the interviews were conducted. Some aspects of this project were in the implementation phase.
Six interviews were conducted to analyze this case. The following boundary spanners were interviewed: a program leader, a manager of regional teams, the CEO, a community worker and a social worker. One external consultant from the consultancy firm was also interviewed.
Data collection
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The interview protocol (Appendix I) was split up into four sections. The first section employed general questions like: ‘’Could you briefly explain what the main goal of this project was?’’ By employing factual questions before asking the opinions of the respondents, memories are retrieved, which results in an increased reliability of the answers (Boyce & Neale, 2006).
After the general questions were posed, in-depth questions were asked. The in-depth questions aimed to obtain information about the extent in which the boundary spanners had diverged perspectives and interests, how boundary objects and boundary subjects brought these together, and how effective this was. The interview protocol was structured according to the syntactic, semantic and pragmatic frameworks of understanding. The syntactic approaches revolved around the extent to which the boundary spanners recognized the same phenomenon. The semantic perspective was based on interpretation and shared meaning, whereas the pragmatic perspective revolves around interests and trade-offs. Furthermore, questions were asked about how the boundary object and boundary subject facilitated to align meanings and interests. In the last section of the interview the questions were focused on shared frameworks of understanding.
Data analysis
The interviews generated approximately 50.000 words of raw data. An initial task was to extract the answers of the respondents in such a way that a respondents’ text phrase would represent a specific matter of concern (Van Offenbeek & Vos, 2016). Subsequently, by use of inductive coding (Thomas, 2006), the text phrases resulted into 30 categories.In this research, data analysis is partially determined by the research objectives (deductive) but primarily by multiple readings and interpretations of the raw data (inductive) (Thomas, 2006). Deductive codes were utilized in the data analysis, since the literature review already provided some directions for possible interpretations. This was followed by writing out the change stories (Appendix II & III) and subsequently a complementary round of coding.
The coding process involved an analysis of large amounts of data. Open coding was used to quote and label the codes (Appendix IV & V). The following step was to classify the codes into specific categories. The findings were mostly extracted directly from the data and were therefore inductive codes.
17 RESULTS
In this section the material from the cases will be presented. First, the extent to which the frameworks of understanding are shared will be described. Frameworks of understanding will be differentiated into syntactic frameworks of understanding, semantic frameworks of understanding and pragmatic frameworks of understandings. Next, the boundary objects and boundary subjects, together with their corresponding mechanisms will be discussed. Finally, a cross-case analysis will explain the similarities and differences between the cases.
Case 1: Towards inter-domain collaboration between organizations
First, what immediately became clear in this case was the amount of distrust and frustrations between the municipality and healthcare providers. At the start of this case, the domains had misaligned meanings, understanding of each other’s domain, and philosophies (Appendix II). In order to work towards shared frameworks of understanding two boundary objects were used along with one boundary subject. The boundary objects were the client and the research report. The boundary subject was an external consultant. Table 2 summarizes the findings of case 1.
Frameworks of understanding
Due to the decentralizations, the municipality had a strong interest to stay within the healthcare budget. In the steering group meetings, they focused the discussions on topics like budget reduction. This proved to be ineffective, since healthcare providers voiced their resistance in the following way: ‘’Are we talking about finances or about people?’’ (Policy advisor of a healthcare provider, 1-BS5). The external consultant noticed that all boundary spanners share the interest that they want all the best for their clients. The external consultant proposed the notion to revolve discussions about the clients. When discussions revolved around the client, boundary spanners were more able to recognize the actual needs of the client. This is underlined by the policy advisor of the municipality (1-BS1), who said: ‘’If it revolves around the client, then we only have to bring our operations together. If the client is central point of reference in the discussions, then it does not revolve around topics like de-budgeting and removing boundaries.’’ From this point of view, the boundary spanners had a shared syntactic understanding about the client and its needs.
Much of the distrust between the municipality and healthcare providers originated from misaligned meanings, understanding of each other’s domain, and philosophies. For instance:
‘’Healthcare providers couldn’t see any role for themselves in the prevention field, whilst the municipality clearly saw a role for them. This created a lot of confusion between the municipality and the healthcare providers. Healthcare providers thought it was the role of ‘other’ providers to provide services in the prevention field. While the municipality viewed it in a sense that the healthcare providers could transform services towards prevention and perhaps could support other providers.’’ (Policy advisor of the
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The external consultant investigated the status quo in the region. The external consultant mapped the facilities, the frequency of their use, and possible improvements to the cost-efficiency. The findings of the research report fired up many discussions that created an iterative process of meaning clarification. Meanings were clarified around issues like what methods were used, how the analyses were interpreted, the implications of the findings, and how the findings would be translated into practice. Besides the research report, the external consultant also played a role in the construction of shared meanings. The external consultant also stimulated boundary spanners to reflect on their role, tasks, and philosophies of how they can add value within this new system. Furthermore, the external consultant helped to reformulate goals, added information about best-practices in other regions, provided a structure for discussions, and provoked boundary spanners to clarify their conveyed meanings and come to new perspectives. According to the policy advisor of the municipality (1-BS1): ‘’Nowadays, healthcare providers are more open, vulnerable and propose increasingly more optional solutions.’’ They increasingly explored each other’s goals, approaches, interests, and started to acknowledge their strengths and weaknesses. They are starting to understand each other better. In this view, it can be stated that boundary spanners are working towards shared semantic understandings.
Finally, what comes forward in the case is that boundary spanners are working towards shared pragmatic understandings. Boundary spanners have a sincere interest to help clients. Moreover, it is their organization’s raison d’être. According to the healthcare providers the relational aspect of the collaboration is important.
‘’A lot of synergy was felt between the healthcare providers. This probably had to with the fact that they already had meetings with each other before the decentralizations. However, at first, healthcare providers did not know each other that well. Yet, they started to listen to each other, heard what target groups they serve, how they do that, with what method, where they stand for, what their vision is, what their mission is. Because of getting to know each other, they learned that they are not so different from each other after all.’’ (Policy advisor of a healthcare provider, 1-BS5)
From the healthcare provider’s perspective, it is important to first get to know one another. This builds trust between the boundary spanners. Then they will take the risk to acknowledge what they are good at, what they are not good at, and accept that perhaps another organizations is more suited for the job. Based on this notion, the policy advisor of the healthcare provider (1-BS5) notifies that trade-offs are starting to take place: ‘’Perhaps we should be part of a larger construct, because another provider has a better connection to that part of society.’’
Boundary objects and subjects
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neutral perspective towards each other. As one community worker (1-BS2) said: ‘’The external consultant has no organizational interest, is temporarily in the picture, and can boost the situation without ruining long-term relationships.’’
The first activity conducted by the external consultant was to research and map out the status quo within the region, then to present it, and finally to discuss it. The external consultant mapped out which services are delivered, how frequently those services are used by clients, and whether it can be cheaper or more cost-efficient. The external consultant also spoke separately with all boundary spanners and heard their perspectives on where the collaboration process went wrong, what their frustrations were, and also heard what their ideas and solutions were. Based on the findings, the external consultant re-interpreted this information with an independent view and came up with proposals for the stakeholders in the community. The conclusions of the research report were presented to each stakeholder (thus also clients and community centers) in the region by means of a presentation. The healthcare providers voiced a lot of resistance to those conclusions. The first point of resistance was that healthcare providers made the assumption that conclusions should only be presented to the steering and project group, but clients and community centers were also invited to this presentation. The policy advisor of a healthcare provider (1-BS5) stated: ‘’We could not speak freely in front of the clients, because we: did not agree with some of the analysis; assumed some of the findings were incorrect, and; questioned logic was behind the interpretations. We did not feel to disagree in a room of 100 people, because we were the ones who delivered the data.’’ This increased frustration among the healthcare providers. The second point of resistance was that healthcare providers had the perception that this research report would automatically be the policy of the municipality, whereas the municipality itself viewed the research report as starting point for discussion. The research report provides transparency about information to the stakeholders and can be used as a guideline. On the positive side, the research report stimulated the discussion between the municipality and healthcare providers, provided clarity about definitions and showed the actual status quo within the community. According to the external consultant (1-C), a few providers responded with: ‘’Now, we finally knew what it’s all about.’’
Second, the external consultant provided insight for boundary spanners to revolve their discussions about the client. According to the policy advisor of the municipality (1-BS1) this was an important eye-opener, who mentioned: ‘’If it revolves around the client, then we only have to bring our operations together. If the client is central point of reference in the discussions, then it does not revolve around topics like de-budgeting and removing boundaries.’’ All the boundary spanners share the interest that they want the best for their clients. Although differences may still exist in terms of how to serve the client, but they understand who the client is and what the client needs. The client exists in the domains of the municipality, healthcare provider and community work.
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reflection, providing new perspectives and knowledge, clarifying conveyed meanings and assumptions, structuring discussions, and removing boundaries between them. The external consultant posed questions that stimulated reflection on what the healthcare providers could do in the prevention field. The roles, tasks and associated philosophies that healthcare providers could take in the prevention field were addressed. The focus was predominantly on language and content. An important eye-opener to the policy advisor of the municipality (1-BS1) was:
‘
’If it revolves around the client, then we only have to bring our operations together. If the client is central point of reference in the discussions, then it does not revolve around topics like de-budgeting and removing boundaries.’’ Second, it helped to reformulate goals of the steering group. Third, the external consultant provoked healthcare providers by confronting them with the clients. After confrontation, the external consultant posed questions like ‘What are we talking about?’ or ‘What does society need?’ According to the policy advisor of the municipality (1-BS1), such questions helped to construct a collective view across the boundary spanners. Fourth, the external consultant structured the meetings. Agreements were made by which partners of the steering group could be held accountable for. Furthermore, meetings were structured with a project management basis. Meetings were structured in such a way that the steering group would work towards a goal, topics could be completed, a timeline was added, and the necessary resources to achieve goals became clear. Fifth, the external consultant added knowledge aimed at how the healthcare providers could add value to clients in this new system. This was done by providing examples of best-practices, flyers, reports, movies. Finally, the external consultant aimed to remove barriers between the different perspectives of the healthcare providers. This was done by posing arguments like ‘’You don’t need to enforce specialized psychiatric care on someone who occasionally feels depressed. A nice talk with the neighbor or peer help also may do the job’’ (1-C).21 TABLE 2 Case 1 results
Syntactic layer Semantic layer Pragmatic layer
Initial situation
Divided perspectives of the problem
Implicit assumptions about other domains
Divided interpretations about domains, philosophies about solution, and objects
Uncertainty about business Distrust
Boundary object
Client Community research report
Boundary subject activities
Propose notion of shared problem/ raison d’être
Active mediation between domains
Active mediation between domains
Closing situation
Shared recognition of problem
Shared raison d’être
Clarified assumptions about domains
Shared philosophies about solution
Integration of expertise Trade-offs for solution
Case 2: Towards inter-domain collaboration between professionals Frameworks of understanding
Due to the organizational change, social workers and community workers had to collaborate in regional teams and in so-called learning circles – that could be either a team aimed to develop coach projects, a team at developing new services, or a team measuring the effects of services. However, social workers and community workers provide services to clients using a different approach, philosophy, and work ethic. By focusing the discussions on the needs of the clients, professionals can easily relate to each other. One of the community workers (2-BS5) underlines this, by saying: ‘’Nowadays, we discuss what we can do for one another and what is most effective for our clients. It was surprising how easy it was to collaborate with others.’’ Each professional has a sincere interest in wanting the best for their client. From this perspective, the professionals have a shared syntactic understanding.
Before the organizational change, there was a strict boundary between care and community work. The professionals from these domains knew that they existed, but did not understand what services they delivered and how they added value for the client. By placing them into regional teams and letting them collectively work on assignments, the professionals started to understand each other. For instance, the regional teams had to conduct a region analysis. By analyzing the same community, the professionals came to the same interpretation of that community. Another example was to collaborate in the Learning Circles. According to the manager of regional teams (2-BS2), the learning circles method was successful in creating shared interpretations and interests.
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weaknesses, where they could complement each other, share success stories, to bind other professionals – because they want to be part of the success. This created shared interpretations and interests among the social and community workers.’’ (Manager of regional teams, 2-BS2).
Finally, boundary spanners are working towards shared pragmatic understandings. Nowadays, boundary spanners are more focused on collective knowledge creation. The external consultant noticed that today’s discussions between boundary spanners are no longer about the corresponding domains, but rather what someone can do for the citizen based on their expertise. They integrate their domain-knowledge in order to come to more enriched services. One of the community workers (2-BS5) underlines this: ‘’Nowadays, you understand one another’s role. It’s more about collective analyzing and identifying the organizational services. It’s about how to organize to services. Colleagues share and talk more about each other’s expertise. You could say that there is a more intense form of collaboration.’’ However, according to the external consultant this rather a spin-off than it has been a conscious choice.
Boundary objects and subjects
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boundary spanners by narrating in such a way that their immediate response was ‘Well, I am good at this!’ Another example is saying ‘Why won’t you just do it?’ Because of the external consultant’s role of an outsider, he could force boundary spanners to reflect on their role, their contribution, their strengths, and their proactivity while not ruining any relationships.
Furthermore, the external consultant and program leader cooperated to develop a change method – named the learning circles – that was based on the principle of learning and developing. The basic notion of it is that people change by learning new things and come to new insights, while at the same time applying those insights into their own practices and learn from that again. This method consisted of three themes: developing, results and measuring effects. The idea was to reflect on your work and what you are good at, and not imposing the method top-down. The external consultant explained the method to the boundary spanners by saying they had to formulate their own assignment. What they want to achieve, formulate how they want to do it, and in what way.
‘’Professionals were free to set up their own projects and develop services that aligned with the needs of clients. The acquired insights were constantly shared with other professionals. Professionals had jump back and forth into a trusted and less-trusted environment (thus sharing their insights with other learning circles), they got involved in multiple projects, reflect on it, and subsequently came to new insights. While professionals had to collaborate within this method, they analyzed the same phenomenon and came to shared interpretations of that particular theme.’’ (External Consultant, 2-C)
The external consultant also structured discussions for the professionals. At the start of the change method, boundary spanners missed a starting point for discussions. The external consultant structured the discussions by adding a time limit. By adding a time limit, the external consultants were faced with a deadline to present the progress of their projects. Consequently, this sped up the trajectory of the organizational change. Finally, when boundary got bogged down in meetings, the external consultant posed alternative perspectives to interpret the situation.
24 TABLE 3 Case 2 results
Syntactic layer Semantic layer Pragmatic layer
Circumstance Divided perspectives of the
problem
Divided approaches to serve clients
Implicit assumptions about other domains
Opposed work styles
Job uncertainty
Boundary object Client Collaborative development
of community research Collaborative development of services Collaborative development of community research Collaborative development of services Boundary subject activities
Propose notion of shared problem/ raison d’être
Active mediation between domains
Active mediation between domains
End-state Shared recognition of
problem
Shared raison d’être
Clarified assumptions and interests about other domains
Integration of expertise Trade-offs for solution
Cross-case analysis
Frameworks of understanding
The within-cases discussed the importance of shared problem recognition and/or shared raison d’être (see Table 2 and 3). Although the cases had different change goals, a commonality between these cases can be identified: all boundary spanners described the sincere interest of wanting the best for their clients. Regardless of the domains, each boundary spanner’s raison d’être is to serve the client and solve its problems. The client exists in all domains and is recognized by each boundary spanner. Following this line of reasoning, the findings suggest that the boundary spanners from these cases have a shared syntactic understanding.
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second case, the analysis also was a means to obtain an understanding of each other’s domain and get the opportunity to compare each other’s understandings. Accordingly, this also created trust and willingness to collaborate. Collaborative development of boundary objects therefore seem to be more effective in constructing shared semantic understandings, as opposed to only applying a boundary object.
Finally, the findings suggest that in both cases trade-offs between boundary spanners occur more frequently. These trade-offs are aimed on complementing each other. Based on their expertise, boundary spanners discuss how they can complement each other and integrate their knowledge and expertise to serve clients effectively and cost-efficiently. An important factor in these trade-offs is to direct it towards the needs of clients. These findings suggest that in both cases the boundary spanners are working deliberately towards shared pragmatic understandings.
Boundary objects
Various boundary objects can be identified from the within-cases. Comparing these cases leads to several distinctive insights.
It may sound strange, the first identified boundary object is the client (see Table 2 and 3). The client exists in all domains and is recognized by each boundary spanner. Regardless of the domains, each boundary spanner’s raison d’être is to serve the client and solve its problems. It is about finding a commonality (i.e. syntax) between boundary spanners, such as a shared problem or a shared raison d’être. In both cases, boundary spanners’ raison d’être was to serve clients. Additionally, in the case of Inter-Domain Collaboration between Organizations the project was targeted at solving a societal problem, namely loneliness among elderly.
Secondly, the findings suggest that collaborative development of a boundary object may be more effective in creating common meanings and interests than theapplication of a boundary object. In the case of Inter-Domain Collaboration between Organizations the external consultant conducted research that was used as a boundary object. Initially, the presentation of this boundary object led to resistance, because boundary spanners questioned the methodology of the analysis, the findings itself, and the logic behind the findings. The resistance to the findings proved to be valuable input for discussions that, consequently, clarified meanings between boundary spanners. However, accompanied with resistance, there were increased frustrations within the steering group. In the case of Inter-Domain Collaboration between Professionals the boundary spanners collaboratively conducted research and developed projects and services that were used as boundary objects.
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and subsequently attach the same meanings to it. In comparison to the first case, it is more valuable to collaboratively develop boundary objects rather than to apply them (see Table 2 and 3).
Boundary subject
In both cases, the external consultants actively mediated between domains (see Table 2 and 3). Both external consultants aimed to create shared understandings between boundary spanners. They posed questions to boundary spanners in order for them to reflect and clarify their meanings. By posing such questions, boundary spanners explained what they were good at, what they could do for the clients, and where they can assist each other. Additionally, both external consultants provoked boundary spanners to come to new insights. For instance, by confronting them with the relevant stakeholders in the community or boldly stating that they are not good at their task (while they are good at it). Both external consultants aimed to create shared understandings between boundary spanners. Furthermore, in both cases the external consultants took the role of outsider. Because of their role, they could speed up the process, provoke or induce reflection of the boundary spanners without ruining long-term relationships. Finally, the external consultants also structured discussions. In the case of Inter-Domain Collaboration between Organizations this was related to steering discussions towards a project management structure. In the second case, this was related to the starting of discussions in the right direction.
27 DISCUSSION
In this section of the paper particular attention is paid to discussing the research. First, the contributions to this paper are presented. This section proposes a process model of how shared frameworks of understandings are constructed (Figure 1). Then, the practical implications of this research are discussed. It is aimed at the user of the process model and how it should be used properly. Finally, the limitations and future research opportunities are discussed.
Discussion of findings
Syntactic framework of understanding
The evidence found in this research suggests that boundary spanners progress through layers of understanding (Figure 1). First, according to this study’s literature review, boundary spanners should establish a shared syntactic framework of understanding, which understanding supports effective communication (Galbraith, 1979) and provides a shared action focus for boundary spanners (Kanter et al., 1993). The findings of this research support the previous statements. Boundary spanners perceived collaboration as an easy task when they had a shared action focus. This study contributes to the literature by exploring how boundary spanners can establish shared syntactic frameworks of understanding. Also, the findings suggest that boundary spanners can establish shared syntactic frameworks of understanding through the identification of a shared problem and/or raison d’être. Within this study, boundary spanners revolved discussions around clients to establish a shared action focus. The boundary subject facilitated the identification of this shared problem and raison d’être.
Furthermore, this study found that the client is present within each domain of the healthcare sector. Each boundary spanner has a sincere interest of wanting the best for the client. This finding is consistent with Star & Griesemer’s (1989) definition on boundary objects. In the context of this research, clients cannot be interpreted as boundary subjects. The clients in this research do not actively mediate between boundary spanners, nor do they take part in the discussions. Therefore, clients are not in line with Huzzard et al.’s (2010) definition on boundary subjects. This study advances the literature by interpreting the client as a boundary object. Therefore, in comparison to Carlile (2002; 2004), who identified boundary objects in the manufacturing sector, this study contributes to the literature by providing a boundary object and associated mechanisms for the healthcare sector.
Semantic framework of understanding
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enhance task-related processes, motivational states and performance (DeChurch & Mesmer-Magnus, 2010; McComb & Simpson, 2013). However, prior research remains abstract on how to learn and translate domain-specific knowledge across domains.
This research contributes to the literature (mentioned above) by explaining how boundary spanners clarify their implicit meanings to one another. The findings of this research suggest that boundary spanners clarify and learn about each other’s domain through a collaborative development of boundary objects, for instance a research report or an integrated service. In this research, boundary spanners collaboratively analyzed the same phenomenon and attached meaning to it by working together. In doing so, they compared each other’s assumptions, philosophies, and interests. Furthermore, they also learned each other’s goals, work styles, strengths and weaknesses. On the other hand, boundary subjects of this research posed questions aimed on the clarification of implicit meanings of boundary spanners. These questions induced reflection of the boundary spanners on their goals, strengths, and weaknesses. As a result, boundary spanners got a clear understanding of one another’s domain. Pragmatic framework of understanding
According to the literature review, boundary spanners integrate their resources, skills, and knowledge on the pragmatic layer. Furthermore, politics and interests are important aspects on this layer. The findings suggest that boundary spanners integrate their resources, skills and knowledge by making trade-offs. Furthermore, the interviews revealed that trust is an important boundary condition for collaboration. This is in line with one of the findings of Tsasis (2009). The within-cases showed that boundary spanners may be uncertain about the future of their organization or job, and therefore may intentionally hinder collaboration. This can be explained due to the fact that boundary spanners may find it hard to envision expectations (Ariño & Ring, 2004), project outcomes, or the partnerships relationships (Jap & Ganesan, 2000; Jap, 2001). The findings suggest that boundary spanners speak out their interests to participating members in the collaborative relationship.
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collaboration process. A major difference between this paper and the work of Huzzard et al.’s (2010) is that external consultants are hired based on their expertise and potential added value. In Huzzard et al.’s (2010) work, boundary spanners were suspicious about the added value of action researchers.
Theoretical implications
30
FIGURE 1. Process model for the construction of shared frameworks of understandings
Shared action focus Shared problem Shared raison d’être Clarified domains Clarified assumptions Clarified philosophies Clarified workstyles Clarified Interests Clarified Strengths Clarified Weaknesses Clarified Goals Integration Trade-offs Syntactic frameworks of understanding
31 Practical implications
Policy makers, managers and external consultants concerned with societal problems should keep in mind that integration with other domains is particularly important to deliver effective services. Applying the process model should provide a way to integrate resources, skills and knowledge. It may contribute to solving the societal problems that policy makers, managers, and external consultants face today. Policy makers, managers, and external consultants should identify a shared problem and/or raison d’être in order to create a shared action focus and foster more constructive discussions. Hence, it may also prevent miscommunication about terminologies and priorities. Secondly, they should clarify and learn from each other’s domain in order share and access resources, skills, and knowledge, therefore, enhancing collaboration. Finally, boundary spanners should revolve trade-offs about the end-solutions (thus in this research ‘the clients’) and speak out their interests. Consequently, boundary spanners may preserve their focus during inter-domain collaboration. Altogether, applying the process model may speed up the total process of an inter-domain collaboration project.
However, it should be noted that the process model is particularly relevant for long-term projects. It requires time and effort to come to shared syntactic, semantic, and pragmatic frameworks of understanding. Therefore, it may not be worthwhile for short-term projects to invest in these analyses, discussions and negotiations. Moreover, the process model should be applied in a phase of project preparation and a phase of the project blueprint development. It may help to create shared frameworks of understanding for effective realization of collaboration projects.
Limitations and future research opportunities
32
33 CONCLUSION
This study examined extreme cases of inter-domain collaboration in which multiple boundary spanners from heterogeneous domains had to collaborate in order to tackle complex societal and organizational issues. It not only sheds light on the complexity that exists within heterogeneous domains, but moreover is conducted within the healthcare sector. Additionally, adding more complexity to this research.
It contributed to the understanding of how shared frameworks of understanding between heterogeneous domains are created. Frameworks of understanding can be divided into three distinctive layers of understanding. Each layer has its significance in inter-domain collaboration. The syntactic layer provides action focus for boundary spanners. The semantic layer clarifies each other’s domain. Based on the first two layers, boundary spanners can integrate their resources, skills and knowledge on the pragmatic layer. Aligning frameworks of understanding not only synthesizes integrated solutions to complex problems, but moreover it allows to speed up the collaboration process due to effective communication.
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