Thesis Innovations and people go hand in hand: A study how the introduction of innovations in healthcare is influenced by nurses

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Innovations and people go hand in hand: A

study how the introduction of innovations in

healthcare is influenced by nurses

Thesis

Author: D. Hoekstra

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Innovations and people go hand in hand: A

study how the introduction of innovations in

healthcare is influenced by nurses

Thesis

Author: D. Hoekstra, Student Supply Chain Management, Rijksuniversiteit

Groningen

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Preface

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Abstract

Innovation is one of the most critical subjects for healthcare providers in the last couple of years. However, very few healthcare providers are successful in adopting new innovations. A lot of different stakeholders are involved in the innovation process within healthcare providers One of the important stakeholders in the adoption process are head nurses, since they are capable of directly influencing the innovation process.

This study shows the most important criteria that are taken into consideration by head nurses in the UMCG, when deciding if new innovative medical products should be adopted. These listings of important criteria results in a better understanding of the adoption of new innovative products by head nurses, so this information can be used to provide a better facilitation in the adoption process of new medical products.

A list of innovation adoption criteria is identified based on extensive search in literature. Interviews with head nurses were conducted to determine their role in the innovation adoption process, refine and check the innovation adoption criteria as found in literature, in order to create a proper list of potentially important innovation adoption criteria. These innovation adoption criteria were used in a questionnaire among head nurses. Based on a questionnaire, the importance of these criteria among head nurses were surveyed. A second survey was sent in order to rank the 8 most important

innovation adoption criteria based on the AHP method. The Analytic Hierarchy Process (AHP) was used to prioritize a list of the 8 innovation adoption criteria as found in the first survey. Results were compared with other groups of stakeholders in earlier findings of similar studies.

Based on the results of the survey, it was concluded that head nurses and assistants are most interested in easy-to-use devices which are fully supported (training/manuals) by the supplier in order to provide complete and proper care for the patient. Compared to the other stakeholders, they were unique in this. Therefore, purchasing should consider easy-to-use devices that are supported first. The supplier should get more involved to satisfy the need for training and manuals. Lastly, head nurses and assistants are autonomous in choosing and using medical devices to a certain level. Also, they are currently focused on working on an operational level, thus not involved on a higher level concerning the management of choosing new products. Head nurses and assistants should be involved in work groups to provide their opinion about the need for fully supported and easy-to-use medical devices.

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1. Introduction

Why is there a need to innovate in healthcare organizations among professionals? As far as history goes, there is evidence of attempts at improving the standards of healthcare (Kumar, 2008). Currently, innovation is still seen as a critical need in an healthcare organization in order to create sustainability and stay competitive (Janssen & Moors, 2012; Tabak, 2000; Länsisalmi, 2006) which leads to an effective and efficient delivery of healthcare (Rosenberg-Yunger, 2008). Kamann (2007) suggested that healthcare providers have to show product leadership with a focus on an innovation strategy of products and processes.

A focus on product leadership can be elaborated in the application of new, innovative medical products. The high degree of research & development within the health care sector (Parthasarthy & Hammond, 2002) leads to new innovative medical devices. At this moment, a lot of healthcare organizations are starting to innovate in medical products, since the total costs spent on

“technological innovation” is increasing by 20-50% (Price & John, 2013) over the last few years, along with the always expanding requested innovation approval processes and relevant medical patents that are registered (Gold et al. 2009). These medical devices are usually products with new features which enhance the quality and diversity of care delivered (Curfman & Redberg, 2011) or/and are cheaper.

1.1 Complications when innovating

However, it has also been suggested that health care organizations slowly drift away from their strategic plans to innovate (Harris et al., 2009). There is a strong belief that new innovative ideas “fail to result in sustained impact” (Essén & Lindblad, 2012). Also, due to an increased complexity of medical devices, new innovative devices might not be used as intended and thus fail to be adopted (Kohn, 2000; Price & John, 2013). Furthermore, medical devices might simply not get adopted due to failure of innovative projects (van der Panne, 2003; Asplund & Sandin, 1999).

Reasons for failure of innovative projects include the fact that there is simply no complete

understanding of the demands of all stakeholders regarding the most important criteria of medical devices. Therefore, a complete picture of the demands of all stakeholders is missing. Having a complete picture could reduce or eliminate the failure of innovative projects within the healthcare organization.

In addition to the failure of adoption, Bax (2013) found adoption of medical innovations as a ‘far more slowly’ process than required. Schwartz (2004) links slow adoption to the “paradox of choice”. Because there is simply too much choice of new innovative products, this results in a slow decision or choice which new innovative products will be adopted.

1.2 Triggers for this research

All these authors indicate that healthcare innovation is important and is starting to grow, but there is a lack of well-completed adaptation of innovations within the healthcare organization which has been the initial trigger for this research.

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8 Various stakeholders are influencing and involving in an adoption process for innovative medical products: 1. Medical staff such as physicians and head nurses, who are using generally-used medical items with a desire to provide high-quality medical care (Begat et al., 2005), 2. Suppliers, who are increasing their influence to create successful products in order to reduce failed market launches (van der Panne, 2003), 3. Patients, who are increasingly demanding higher quality care (Elaine, 2012), etc. All these stakeholders have different goals, which can be translated in different ‘criteria’ that they find important in adaptation innovations.

As described before, there is a lack of well-completed adoption of innovations in healthcare. This drives the need to get a better understanding of criteria that influence the decisions that are made by medical staff when adopting innovative medical devices. An understanding of criteria leads to the choice of the right products, which will lead to an acceptation of innovative medical devices.

One of the stakeholders that hasn’t been researched before, is the head nurse. Head nurses are generally high educated employees. Part of their job is treating patients which requires a relative high level of skill and education (Schnell & Kuntz, 2013). Like a physician, head nurses are actual users of (partly sophisticated) medical products. Therefore, they form an interesting stakeholder to study in an exploratory setting.

1.3 Formulating the research question

As will be shown in the theoretical background chapter, the choice for head nurses is based on the fact that this is an important, highly influencing stakeholder in the adoption decision that hasn’t been researched before. Previous studies investigated relevant stakeholders but lacked the investigation of head nurses. This gives the opportunity to add value to previous research. Since relevant

stakeholders has been researched before, this also gives the opportunity to compare results of the opinions of head nurses with those of the other studies. This helps creating a complete map of the most important criteria as found by all stakeholders in an healthcare organization.

This study focuses on academic hospitals, since the main strategy of academic hospitals is innovation, focusing on a research & development function. Normal (peripheral) hospitals do not have this focus. Furthermore, a recent study showed that academic hospitals find innovation to be one of the most important topics overall (Arsath Ro’is & Dekker, 2010). Therefore, it makes academic hospitals a suitable stakeholder to investigate.

In this case, the UMCG will be investigated. The UMCG (University Medical Center Groningen) is an academic hospital based in the city of Groningen, the Netherlands. It is one of the largest academic hospitals in the Netherlands, providing advanced health care for patients and conducting scientific research. The UMCG includes 1.339 beds, 2.449 academic staff members, 3.445 medical students and 1.965 scientific publications.

Therefore, the research question is set as follows: “What are the most important criteria that are

taken into consideration by head nurses in the UMCG, when deciding which new innovative medical products should be adopted?”.

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1.4 Importance of this study

The combination of the problems of medical innovations with the importance of innovation in healthcare has not been researched before. Furthermore, this study contributes theoretically by giving insight in the opinions of head nurses regarding innovation criteria in an university hospital. This has not been researched before, providing a base for further research.

By using the contributions of this research, practical lessons can be learned about the specific criteria that are found important by head nurses. These lessons result in a better understanding of the adoption of new innovative products. Since the opinions regarding criteria of different, but relevant stakeholders have been studied before, this study contributes in a practical way by giving an complete overview of all stakeholders.

This overview leads to a better facilitation for all stakeholders when deciding which medical devices will be used and how they should look like according to all relevant stakeholders. Since the head nurse is the actual user of a new medical device, the opinion about the most important criteria should be taken into account by everyone who is involved in the introduction of new medical devices. Basically, this includes head nurses, purchasing department and the supplier of the medical device. As stated before, without introducing the right medical device, the adoption of new

innovative medical devices will most likely come to an end.

Chapter two will present the theoretical background. Chapter three will describe the used

methodology for this study. Chapter four will list the interviews that are conducted for this research. Chapter five will describe the details of the used survey among head nurses. Chapter six provides the results and discussion . Chapter seven will give the final conclusions limitations. Chapter 8 will provide recommendations. Finally, chapter 9 will give the limitations and notes for further research.

2. Theoretical background

This chapter covers the theoretical background of this study. First, types of innovation and the innovation diffusion process is described according to general literature. Second, relevant

organization stakeholders are described. Third, the adoption-decision of innovation which is part of the innovation diffusion process is described based on literature. Fourth, innovation criteria that influence the innovation diffusion process are described as found in literature. Fifth, the influence of head nurses on innovation diffusion decision is described. Lastly, a short summary is given which concludes the most important points of the theoretical background.

2.1 Innovation diffusion process and types

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10 Since these are all broad definitions, a more specific focus on healthcare is practical. Therefore, for the purpose of this study, innovation is defined as those changes in medical devices “that help healthcare practitioners focus on the patient by helping healthcare professionals work smarter, faster, better and more cost effectively” (Thakur et al., 2011). Ultimately, outcomes of innovation results in two parts: the production innovation which focus on what is produced and process innovation which focus on how it is produced (Huang & Rice, 2012).

In addition to the ‘what’ and ‘how’ of innovations, there are several relevant innovation types that can be used in describing innovations. Innovation can be split up in various types, including product and technological innovations of medical products (Talke et al., 2009; Verganti, 2008, Spanjol et al., 2012), discontinuous or continuous innovations (Senior & Swalies, 2010) and incremental/radical innovations (Cawsey et al., 2012; Huang & Rice, 2012; Rogers, 2003) in the approach of adopting new medical products. The diffusion of innovations (Quatraro, 2009) and the adoption of innovation (Rogers, 2003) include the actual implementation and usage of these types of innovations.

If new products are developed by external or internal suppliers, they are ought to be used in the organization. This is called the diffusion process (Rogers, 2003; Motohashi et al., 2011). Rogers (2003) described certain steps that are involved in the process of starting the diffusion process of adopting new innovations: 1. Knowledge, 2. Persuasion, 3. Decision, 4. Implementation and 5. Confirmation. The actual decision whether an innovation should be adopted is made in the decision phase, which can result in a continuation of an adoption, a later adoption or discontinuance or rejection of an adoption.

Logically, an innovation can already be rejected in the first stage of the process, if for example a lack of awareness of the innovation is recognized among stakeholders. However, the decision phase is described as the phase where stakeholders decide whether an innovation should be adopted or not. An overview of the innovation adoption process can be found below:

Figure 1 – Innovation adoption process, adapted from Rogers (2003)

2.2 Stakeholders in innovation adoptions

Until now, there has been a description of the innovation adoption among individuals. However, it is expected that the organization and related internal or external stakeholders itself is closely related to the innovation process, which results in different stakeholders that are part in the innovation

adoption process.

Service innovation literature describes various factors that are expected to influence the innovation adoption-decision on an organizational level. In healthcare, the firm-specific stakeholders are important due to a vast amount of stakeholders that are involved.

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11 A previous study of Bax (2013) already showed results of a comparison of different opinions

regarding importance of innovation adoption criteria among physicians, suppliers and financial managers from the medical department of an academic hospital. Like the head nurse, physicians are educated members of the staff and users of a specific set (high education needed) of medical devices which are needed to treat patients. The suppliers and financial managers are not actual users of medical devices.

Results from head nurses that are gathered from this study will be compared with the results from the study of Bax to give a complete insight, giving the ability to compare results with the physicians who are actual users of medical products as well, giving insight in the (possible) deviation of

perspective on the usage of medical devices. This insight is needed to fully understand the complete picture of every opinion of every stakeholder who is possibly involved in the innovation adoption decision process. An proper introduced innovation is most likely to be accepted by stakeholders, therefore reducing the chance to cause a rejection of a new innovation.

An overview of the innovation adoption process linked to the organizational stakeholders can be found below:

Figure 2 – Organizational (internal and external) stakeholders in the innovation adoption process, adapted from Rogers (2003) and Walshe & Smith (2011)

2.3 Adoption-decision

The actual adoption-decision is based on the decision of individuals (of all different channels) or organizations who are ultimately using the new innovation (Rogers, 2003). In order to adopt a new innovation, a positively employees’ attitude is required in order to have an increase in usage intention (Vankatesh & Davis, 1996). In this context of creating a positive attitude to adopt

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12 However, ultimately, the organization itself does not decide whether an innovation is adopted or not (Frambach & Schillewaert, 2002). An accepted adoption is determined by “the adoption of the innovation at the individual adopter level within the organization” (Bax, 2013). Rogers (2003)

concluded that, mostly, just a few individuals are accountable for the decision of an innovation, while different individuals are involved whether the innovations are implemented or not.

Therefore, Rogers distinguishes four types of innovation-decisions: 1. Optional decision (individually), 2. Collective decision (among members of the decision making unit), 3. Authority (few individuals with power), and 4. Contingent (individual decision after organization decision).

In the end, innovations should be adopted in order to improve healthcare for patients (patient-view) and efficiency and effectiveness for the healthcare organization (Thakur et al., 2011).

2.4 Criteria of innovation adoption-decision

A literature search on innovation adoption criteria resulted in a vast number of different criteria, referring to criteria characteristics that are found to be important characteristics of the innovation itself. A previous study of Bax (2013) shows a compilation of different criteria: Rogers (2003) listed five organizational innovation characteristics:

- Relative advantage: Degree an innovation is perceived as better than the idea it supersedes - Compatibility: Degree an innovation is perceived as consistent with existing values,

past experiences and needs of potential adopters

- Complexity: Degree an innovation is perceived as relatively difficult to understand and to use - Triability: Degree an innovation may be experimented with on a limited basis

- Observability: Degree to which the results of an innovation are visible to others The research of Rogers is expanded with previous research of Meyer and Goes (1998), who researched 300 potential adoptions of medical innovations in 25 healthcare providers during a six-year period. Narrowing this research down, they listed 15 unique innovation criteria based on environmental set, organizational set, leadership set and innovation decision set. These 15 unique innovation criteria explained around 40% of the variance in the degree of process of an innovation through the innovation process.

Furthermore, Fleuren et al. (2004 & 2010) listed 49 innovation criteria which were focused on the health care sector, giving more information about factors that influence the introduction of innovations within an healthcare organization. The 49 innovation criteria were based on socio-political context, organization, adopting by a person (user) and innovation.

Lastly, Greenhalgh et al. (2004) conducted a literature study and studied around 1000 relevant service papers on the diffusion of innovations within the service sector. As a result of this literature study, the authors listed 53 relevant service innovation criteria within a base of 9 groups of factors (innovation, adopter, assimilations, communication including influence, system antecedents, system readiness for innovations, outer context, implementation plus routinization and linkage among components).

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13 Furthermore, a Swedish study by Carlfjord et al. (2010) identified and confirmed Rogers’ criteria to be relevant. A case study within Swedish health care providers showed that adoption was positively influenced by compatible, perceived advantages and positive expectations of an innovation.

In the light of innovation in a technical setting, Roback et al. (2007) identified the expected value of the new device to be the most important factor, described as a calculated balance between benefit for the patient (positive factor) on one hand, and risks (negative factors) on the other hand.

Furthermore, the author identified two other factors (Information/learning and innovativeness of the adopting unit).

Putzer (2010) identified seven criteria that influenced the decision of smartphone adoption among nurses in hospitals (based on the basics of user’s attitude and behavioral intention). The authors based their study on the findings and criteria of previous (technology based) surveys. They found the separation of internal environment with the external environment an important step to ensure a coverage of relevant criteria for surveying.

One of the older papers is the study of Barras (1986). Since it gives criteria that should be used as a basis for innovation studies, this one is included. The author identified three criteria of the

innovation adoption among technical devices. These criteria were used in a study of general service environment (based on price and technical performance, risk or uncertainty and market structure). Rye & Kimberley (2007) identified four new categories of innovation correlation criteria (innovation characteristics, environmental influences, connectedness and organizational attributes). Based on these four categories, the authors found large variations between the categories where innovation characteristics had the most influence on the innovation adoption decision.

Furthermore, Becker (1970) already identified a difference on both an organizational and individual level among groups of health care professionals, such as prestige value and involvement among doctors and other employees with high autonomy. Therefore, the innovation adoption decision is found to be influenced by the level of prestige among health care professionals. This influences the opinion and the willingness to use a new medical device among health nurses as well.

Ghodeswar et al. (2007) identified several organizational variables to be highly influencing, which predicts whether an organization will adopt an innovation or not. The authors included innovations that were introduced by purchasing on an organization-level, as well as the individual health professional level.

Maat et al. (2010) identified relevant critical success factors to speed up healthcare innovation along with 14 groups of criteria, where Cain & Mittman (2002) identified ten innovation diffusion criteria (called the ‘ten critical dynamics of innovation diffusion’). Based on the study of Cain & Mittman, Maat added two additional dimensions as summarizing criteria.

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14 Furthermore, Frambach (1993) identified five criteria of influence on innovation that came from both the supplier- and the adopter-side of innovation (characteristics of the adopter, characteristics of the innovation, availability of information, information processing characteristics of the adopter and the competitive environment of both the adopter and the supplier).

Lastly, Frambach (2002) identified the adoption decision of innovation in organizations (individual adopter level and organizational level), based on the influence of criteria at organizational level (perceived innovation characteristics and adopter characteristics) individual level (personal

characteristics, attitude toward the innovation, organizational facilitators, personal innovativeness and social influences).

The criteria of Putzer (2010) , Becker (1970) & Barras (1996) were combined with the other listings as already written by Bax (2013), in order to create a vast list of criteria that important in the innovation adoption process. All innovation criteria are combined in one table, as shown in appendix A.

2.5 Specific Influence of nurses on the adoption innovation decision

Innovations requires a need for change. A need for change is often associated with the resistance to change (Senior & Swalies, 2010). Since old work procedures and habits are bound to be broken through the introduction of new innovations, certain individuals in the organization might resist the innovation. There are a few main causes for this resistance: 1. Innovation seems not relevant and clear, 2. Employees experience a perceived risk of the innovation, 3. Fear for changes, 4. Complexity of a new innovation.

Furthermore, Tamayo-Torres et al. (2010) suggested that healthcare practitioners such as nurses will be likely to accept an innovation if they are familiar with the technology, in which the nurse assumes that they will find the new technology “more useful and easier to use reducing their fear and

uncertainty in using the technology”.

As described before, the decision to implement is ultimately made by just a few individuals. In an healthcare organization, most clinical decisions on what medical products to use are made by medical staff, such as nurses. Through this decision-making power, nurses heavily influence the decision whether an innovation should be implemented or not. A study of Cooper (1998) showed that head nurses have high autonomy, high clinical authority and have prerogatives on range of services in their work environment. If there is no acceptance of innovations, the adoption and implementation of innovations will come to a complete stop (Frambach & Schillewaert, 2002). Therefore, the role of nurses as an stakeholder in the adoption of innovation is expected to be highly influencing.

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2.6 Summary

Literature search found an innovation adoption process as stated by Rogers (2003), including the decision phase as the phase where the decision is made whether innovations are adopted or not. Specific firms as an health care organization includes a lot of stakeholders, which includes providers as an important stakeholder. A previous study of Bax (2013) already showed results of a comparison of different opinions regarding importance of innovation adoption criteria among physicians, suppliers and financial managers from the medical department of an academic hospital. The head nurse is expected to be an important stakeholder since they are assumed to be autonomous and is ultimately the user of innovative new products, but has not been researched before. Therefore, questions arise if and how head nurses are influencing the decision making process and what criteria they find important when adopting new innovative medical products. The next methodology chapter will describe how to perform research on head nurses.

3. Methodology

This chapter covers the methodology that is used to answer the research question. The goal of this research is to gain insight in innovation adoption criteria that are found important by head nurses through an exploratory study. This is done by using a previous study of Bax (2013), further expanding this through interviews and surveys. As described in the theoretical background, the group of

innovation criteria influence the innovation adoption decision made by nurses. Based on the search in literature for innovation adoption criteria, a list of 27 was created of the most important criteria. These 27 criteria are validated by conducting interviews with head nurses. Furthermore, the role and opinion of the influence of an individual nurse on the innovation adoption decision making process is questioned. A final set of innovation adoption criteria was created after these interviews, which were used to create questionnaires to survey head nurses. Results of this questionnaire is a list of the most important criteria as found by head nurse, where a criteria on place 1 is the most important and a place larger than 1 is relatively less important one. Results were compared with stakeholders of earlier findings of a similar study of Bax (2013).

3.1 Literature

The paper of Bax (2013) was used to gain insight in a lot of different prioritized innovation adoption criteria. To maintain the ability to compare results, his list of criteria was used as a base for this study. In order to expand the list of criteria with potentially more suitable criteria with a better focus on the role of the nurse, a literature search was conducted.

Relevant articles in both the Dutch and English language were found using the Business Source Premier and Thomson Reuters’ Web of Knowledge search engine to conduct forward and backward searches on articles used by Bax (2013). Furthermore, using keywords such as ‘innovation’,

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3.2 Data collection and methods

The unit of observation for this survey is the head nurse, along with the individual head nurse as a unit of analysis for the interviews, since they are the relevant stakeholder in the adoption decision to find out what they found important criteria in innovations for the innovation adoption process. For the purpose of comparing results with the previous study of Bax (2013) to generalize the findings, the University Medical Center Groningen has been selected as a population, which is the same academic hospital as Bax used. The total population of the UMCG includes 10.949 employees. The head nurses of all 27 different departments within the UMC will be used as a sample.

Actual data collection of the interviews is performed by planning interviews with head nurses. As described in the theoretical background, it is expected that head nurses have high autonomy and highly influence the innovation adoption process. In order to check if and how the head nurse is influencing the adoption decision making process, the head nurse is asked to check whether they feel involved and to what degree they are and feel autonomous. This will be done by interviewing four head nurses and staff advisor of purchasing (previous head nurse). Standardized questions that will be asked are included in appendix B. Furthermore, questions will be asked if they agree with the list of innovation criteria, asking them what they find important or if they have anything to add in order to create a list of relevant innovation criteria.

After collecting the data of the interviews, the final list of innovation criteria is created. This list of innovation criteria is used as an input for sending questionnaires to head nurses in order to create a final list of the 10 most important criteria. These questionnaires are created by a tool named SurveyMonkey, which allows head nurses to answer the questionnaires using the internet.

All questionnaires are sent to head nurses via Bax in order to increase the number of respondents since he is an well-known employee of the organization UMCG. It was expected that head nurses will be more likely to accept and finish a questionnaire if it is sent by Bax. If wanted, participants can refuse to reply on the questionnaire or simply opt out.

Actual data collection of the questionnaire is performed in two steps:

First step

The first step is to create a questionnaire to question the head nurses to select the (maximum of 10) most important criteria from the list of 27 criteria. These maximum of 10 most important criteria are an input for the second survey.

Only the criteria that are indicated by more than 50% of the respondents are included in the second questionnaire. This results in a short list of at most 10 important criteria as found by head nurses.

Second step

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17 The AHP tool requires input of a comparison between the importance of different criteria. Therefore, the second questionnaire is used to ask head nurses whether they find criteria X less, equal or more important than the rest of the criteria. A validity check will be performed to make sure the

prioritizing is consistent. If a respondent scored a validity number above 0,10, the answers of this particular respondent will be deleted. A complete description of the AHP steps are included in appendix G.

Results of this survey are compared with the previous study of Bax (2013) to generalize the findings in order to answer the research question which criteria are most important as answered by head nurses. The main steps of the methodology can be seen in the figure below:

Figure 3 – Methodology steps to answer research question

4. Interviews

This chapter covers the conducted interviews of head nurses. The goal of the interviews was to gain insight in the role of the head nurse. As explained in the theoretical section, head nurses are

expected to have high autonomy and have a high influence on the innovation adoption process. The interview is used to get more details about the work that head nurses are performing and whether they have high autonomy and influence or not. The list of criteria as set in the theoretical background and methodology will be checked. A number of head nurses of the UMCG were interviewed.

Based on these interviews, a clear view on the role of the head nurse could be given. During the interviews, it became clear that the focus on head nurses could be more nuanced, as will be explained further in this chapter. Individual answers can be found in appendix I.

4.1 Interviewing head nurse

The following employees were interviewed:

Basically, head nurses are managers. Consequently they are experienced, older members of the staff. The head nurse is in charge of the nurses on their particular department, while supported by

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18 management of their department, leading to a financial involvement and having a lot of

communication with the purchasing department when it comes to introducing new innovations. Considering the hieratical scheme of the UMCG, the head nurse can be found directly under the lead of the care manager, as seen in the following figure:

Figure 4 – Organizational structure with head nurse involved

4.1.1 Influence of head nurse

Every introduction of a new innovative medical device starts with a certain trigger. The two triggers that influence the influence of the head nurse the most are from the purchasing department or from the head nurses’ department. This could be based on patient’s complaints about a device or other nurses who directly report to him e.g., leading to the need of a different device.

The purchasing department mainly focuses on new products that are needed for the whole hospital, named department transcending medical products. An individual head nurse can (until a certain extent) choose and order new products for their own department in collaboration with the purchasing department. The choice to give head nurses the responsibility to order products (in collaboration with purchasing) is based on a lot of factors such as the amount needed and value of the new device.

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19 Figure 5 – Responsibilities of choosing a new medical device

Officially, every new medical product need to follow certain steps before being implemented on the department. These steps are divided into three phases:

1. Orientation – Purchasing department or head nurse looks for new innovative devices available on the market or internal at UMCG

2. Analysis – Criteria that are important in new medical devices, relevant stakeholders, build conceptual model, test it (approval from risk perspective, quality of care, guidelines) 3. Implement once the product has a GO

Department specific

Since the definition of innovation is very broad, almost every new product can be included in this definition. Therefore, if for example a new cover for an iPad is needed which differs from the one that is used now, it can simply be bought in a store.

This is possible since the value is low and is a relatively unique and specific item for the department. The head nurse will then decide to buy this product by him- or herself, without following all three phases of purchasing. In this sense, the head nurse is autonomous and highly influencing his own adoption decision process.

Department transcending

In the other case, the purchasing department is planning on introducing a new medical product. As shown in the three steps, purchasing will look for relevant stakeholders and thus contact relevant departments who will be using the new product to test it. This testing is done by collaborating with the care manager to find an opportunity to test the new device.

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Stakeholders

In both the department specific as the department transcending case, medical devices are delivered by the supplier to the ultimate user (customer), which is the head nurse or other staff within the department. The supplier of a medical device should deliver a new device according to the demands of the customer (head nurse) and the specifications of the purchasing department. Therefore, the purchasing department facilitates in this process: approving and helping for the choice of the right product and supplier.

This leads to the following three involved stakeholders. The arrows indicate the communication between the stakeholders, which takes place between stakeholders depending on the situation (department transcending/specific):

Figure 6 – Stakeholders when buying new products by head nurses, or introduced by purchasing The head nurse is ultimately making the adoption decision as an individual. However, every one of these three stakeholders should be taken into account when deciding which product should be used. For example, a head nurse could opt for a different supplier if a specific product is wanted. However, through collaboration with the purchasing department, a better solution might come up. As long as the demands of every stakeholder is clear, purchasing can facilitate the best products for the head nurse, decreasing or eliminating the chance that an adoption might fail.

4.1.2 Summary of experiences

Since most head nurses are already working for quite a few years in the UMCG, they have been involved in many different situations where new products were wanted. As they are highly influential on their own department-specific adoption decision, this is an interesting process to look at.

Most head nurses find themselves looking on the internet and talking with suppliers to find the best product that is suitable for their department (department specific products). In their experience, direct communication with the supplier gives good results. Furthermore, the autonomous feeling is important for head nurses. In collaboration with purchasing, head nurses hardly ever had any problem when it comes to ordering new products except for a few exceptions.

Most exceptions were based on the fact that a deal was made with a supplier for delivering a certain product (such as measuring devices, monitors, etc.) while the head nurse definitely wants a different product for dozens of reasons. These issues can be frustrating for head nurses, in the end leading to a product that might not be wanted at first, but needed to be implemented due to contracts of the purchasing department.

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21 On the other hand, sometimes head nurses are ordering products that are used in the whole

hospital, but are different than the ones ordered because it would fit better on their department. Examples are certain fabric gloves, giving the head nurse the ability and power to order these products and even influence the adoption decision afterwards.

4.1.3 Nuanced view on head nurses’ role

An interesting finding during the interview was the fact that the UMCG employs head nurses’ assistants (called ‘regieverpleegkundigen’ in Dutch). These assistants are basically managing the department (just like the head nurse), therefore having a similar function as the head nurse. This creates an overlap with the job of the head nurse.

In some of the cases, a head nurse was obliged to lead multiple departments, therefore lacking the time to find department specific situations or give an opinion about department transcending innovation pilots themselves. In these cases, the responsibility to influence the adoption decision was sometimes delegated from the head nurse to assistant of the head nurses, therefore making the assistants do the same job as the head nurse.

Furthermore, the assistant head nurses’ is always involved when new discussing which new innovations are needed. This collaboration is done through e-mail or meetings in order to finally decide which new product is the best. Therefore, the assistant of head nurses is highly influential as well, giving the potential to include the assistant in the survey as well.

In order to check whether the assistant of the head nurses find their role the same as described by the head nurses, interviews with the head nurse assistants are conducted. These are described in the next paragraph. In order to expand the interviews to the assistant head nurses’, the interview questions were expanded as can be seen in appendix C.

4.2 Interviewing head nurse assistants

To give a view on the role of the head nurse assistants and check whether they are indeed having a similar job function as the head nurse when it comes to the adoption of new innovative medical devices, two interviews were conducted with the following head nurse assistants:

The head nurse assistant is, like the head nurse, an experienced member of the staff. However, they tend to be younger than the head nurse. Basically, the head nurse assistant is a manager as well. They lead the department in co-operation with the head nurse. Furthermore, they are providing advanced (requiring a high level of education) care for patients as well, based on the education level, department and position as a head nurse assistant.

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4.2.1 Influence of head nurse assistant

During the interviews with the head nurse assistants, it became clear that every department has its own way of handling the process of adopting new innovative medical devices. For example, the child intensive care could compare their department with a few closely related (co-operatively leaded) departments and they found out that the assistants are closely related to the head nurses. Therefore, they are both deciding what new medical product should be chosen and if it is adopted.

When compared to other departments, they found that other departments are (in most cases) delegating this task from the head nurses to the head nurse assistants, therefore having a different innovation adoption process. However, sometimes the head nurse is still involved for financially more expensive products or more complicated new innovations or even simple products, since the head nurse stays interested in cases.

Every department has a more operational function for nurses (the nurses), while a more leader-oriented function is both for head nurses as well as head nurse assistants with slight differences. Therefore, the function of head nurse and head nurse assistant is very similar. Like the head nurse, the head nurse assistant is involved autonomously in the decision making process, especially in the choice of new department specific medical products.

Note: the head nurse or assistant is still involved operational, but with different tasks when compared to the regular nurse. This includes treating a patient which requires different, higher educated skills than the regular nurse has.

This leads to the following figure of organization within a department:

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4.2.2 Summary of experiences

Since head nurse assistants are closely cooperating with head nurses, they have a broad experience regarding new medical products together. Head nurse assistants are having the same or similar experiences as the head nurses (except for age difference). In case of bigger projects, such as the introduction of new beds for the whole hospital, they were closely cooperating with the head nurse. Therefore, knowledge and opinions were shared and head nurses were involved.

On the other hand, sometimes the process of buying new innovative products are simply delegated from the head nurse to the head nurse assistants. In some cases, the head nurse was still involved in the final stage of the process of deciding whether to adopt the new innovation or not. Therefore, the head nurse still had an influence. On the other hand, there were a few occasions where the head nurse was simply not involved when deciding if the innovation should be adopted or not. The opinion, knowledge or other insight from the head nurse was thus not applied.

Overall, the head nurse assistants felt influential (special demands were often accepted by the purchasing department) on the adoption decision process. Therefore, they are an important stakeholder. Occasionally, they encountered the same problems as the head nurses pointed out, such as contract limitations.

4.3 Important extra factors

During the interview of the head nurses and head nurse assistants, they came up with their own innovation criteria which they find to be very important. These criteria are new and do no match the current list of innovation criteria as submitted during the interviews. However, these criteria are mostly personal and not a criteria of an innovation itself. Also, some characteristics were already overlapping. Nonetheless, head nurses found the following criteria important as well:

1. Nurses who are using the new medical products should definitely be trained by the supplier, or at least given a proper manual (found important by every interviewed nurse)

2. Since older staff is not completely familiar with state-of-the-art technology, suppliers should make their innovation as easy as possible so it can be used without hesitation by older employees (found important by every interviewed nurse)

3. Before even deciding which innovation should be used, specify the innovation on an abstract level

4. Prospective analysis: Trade-off between low/high risk and frequency of incidents. Could be possible that low risk medical devices with a high frequency will be adopted, some head nurses will only focus on lowest risk with low frequency.

5. People who are rejecting an innovation once it is implemented, but were not interested in the phase where these innovations where tested, thus neglecting the opportunity to give an opinion. Commitment and involvement is required

4.4 Summary

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5. Survey

This chapter covers the final design of the survey in order to answer the research question, giving insight in the innovation criteria that influence the adoption decision among head nurses and assistants of head nurses. The final design of the survey is based on the used methodology as described before. In order to collect the data, the broad list of innovation criteria is used as a basis for the survey.

The survey is divided into two parts: the first part was to create a list of the 10 most important criteria as found by head nurses and their assistants. After creating this list, another survey was sent to the participants in order to create a final top 10 of the most important criteria, which can be compared to previous results of the surveys as described by Bax (2013).

5.1 Part one: preparing the survey

As described in the theoretical background section, literature was used to find new relevant criteria that would influence the innovation adoption decision. These new criteria were added to the current list of Bax (2013) in order to compare results of the survey with previous results of Bax (2013). Since many authors base their innovation criteria on previous articles and slightly change it, only two new criteria were added. Furthermore, some authors add new criteria which might be relevant, but are already covered by a broader criteria as stated by other authors.

This results in a huge overlap in criteria. For example, Putzer (2010) mostly used criteria that were already described by Rogers and other authors, such as compatibility. On the other hand, this is a good indication that the overlapping criteria are important. Therefore, the total list of criteria as summarized in appendix A was narrowed down in order to get rid of overlap in criteria.

Non-suitable criteria such as non-relevant or overlapping criteria were deleted. In the end, this resulted in a list of 27 criteria, of which the first 25 criteria are adopted from the study of Bax (2013), as shown in appendix D. These 27 criteria were used as input for the survey. Based on these 27 criteria, questions were phrased in order to see which criteria were found to be the most important when considering to use a new and innovative medical device by head nurses and assistants of head nurses. This resulted in 28 questions, as shown in appendix E. The following figure shows the main steps that are taken to come up with a final set of questions as used in the survey:

Figure 8 – Steps to create final survey

The 27 questions were used and entered in SurveyMonkey. After completion, the survey was sent to the head nurses and assistants of head nurses via e-mail. Within a day, about 10 people complained about the English questions regarding the innovation criteria. Therefore, the response rate was partly low because respondents would drop out of the survey when they encountered the 27 questions in English.

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5.1.1 Part one: survey results

In total, 102 out of 249 (41% response rate) head nurses and head nurse assistants responded on the first survey. However, only 67 out of 249 head nurses and head nurse assistants fully completed the survey. This is a final response rate of 27%. The statistics about the respondents are shown in the following table:

Head nurse Head nurse assistant

20 head nurses (30%) 47 assistant head nurses (70%)

70% female, 30% male 74% female, 26% male

45% 41-50 years old 34% 41-50 years old, 32% 51-60 years old 85% responsible for deciding to use medical

device or not (together with others)

75% responsible for deciding to use medical device or not (together with others)

Table 1 – Statistics of the sample of the first survey

In order to use the AHP method of the second survey, only the criteria which has more than 50% response rate are included. Analyzing the results came with the following top 8 in which the response rate was more than 50%:

Number Criteria Response rate

8 Risk reduction for the patient 91,04 %

15 The device is user friendly to operate 82,09 %

24 Offers benefits to the patient 79,10 %

1 Offers advantages in clinical performance 65,67 %

10 The device is supported 62,69 %

22 The degree of improvement is high 55,22 %

21 The knowledge to operate the device is easily obtained 53,73 %

18 The usage frequency is high 50,75%

Table 2 – The eight most selected criteria

5.2 Part two: preparing the survey

As described in the theoretical background section, this second part of the survey is meant to prioritize the most important criteria as found by the answers of head nurses and assistants of the first survey. The eight most selected criteria were selected as an input for the second AHP survey (see appendix G).

Based on the formula of AHP, a total of 28 comparisons were compiled in a questionnaire.

Respondents could indicate whether they found criteria X compared to the remaining criteria: less important, equally important or more important. This list of comparisons was sent as an

questionnaire in SurveyMonkey.

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26 Like the first questionnaire, the demands of the participants to include the Dutch translation of the English criteria were added.

The following figure shows the main steps that are taken to come up with the results of the second survey:

Figure 9 – Steps to create final second survey

5.2.1 Part two: survey results

Some of the 249 respondents used the option to opt-out of the survey, therefore expressing the wish to stop receiving any more surveys. Also, a few respondents notified me to exclude them from the survey, because they weren’t a head nurse or head nurse assistant anymore. These two factors resulted in the reduction of 249 respondents to 215 respondents.

In total, 38 out of 215 (181% response rate) head nurses and head nurse assistants responded on the first survey. However, only 33 out of 249 head nurses and head nurse assistants fully completed the survey. This is a final response rate of 13%. The statistics about the respondents are shown in the following table:

Head nurse Head nurse assistant

8 head nurses 25 assistant head nurses

100% female 68% female, 32% male

33% 41-50 years old, 33% 51-60 years old 42% 41-50 years old, 31% 51-60 years old

Table 3 – Statistics of the sample of the first survey

The answers of the survey gave insight in the prioritizing of the criteria. Using a consistency factor, the respondents who didn’t fill in the survey correctly (not setting the right importance rate for the criteria, therefore conflicting the importance of criteria) were deleted from the survey. This resulted in a total of 23 usable answers from the respondents, which is a rate of 11%.

Analyzing the results using AHP came with the following top 8 in which the recipients found this (on average) the most important criteria:

Number Criteria Priority vector

10 The device is supported 0,15

21 The knowledge to operate the device is easily obtained 0,14

18 The usage frequency is high 0,13

22 The degree of improvement is high 0,12

1 Offers advantages in clinical performance 0,10

8 Risk reduction for the patient 0,10

24 Offers benefits to the patient 0,09

15 The device is user friendly to operate 0,09

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27 A fully detailed version of the results of the AHP technique as used can be found in appendix H. This appendix will give the scores per respondent, the mean, the standard deviation and the overall mean with the consistency ratio added.

5.3 Summary

In order to find out what head nurses and assistants find the prioritized most important criteria in the adoption of new innovative medical devices, two surveys were sent. The first survey was used to narrow the list of 28 criteria down to 8 criteria. Subsequently, the second survey was used to prioritize the 8 criteria using the AHP technique.

Compared to the results of the first survey, the second survey gave a different top 8. The next chapter will give a discussion about the differences between the results of the first and the second survey. Furthermore, a comparison will be made between the results of this survey and the results of previous surveys.

6. Discussion and comparison

This chapter covers the discussion of the results of the survey as described in the previous chapter. Furthermore, a comparison of the current study will be made between the results of the survey and the results of previous surveys as completed by Bax (2013), including physicians, business managers and supplier account managers. This will give insight in the difference between the prioritized important criteria between head nurses and other stakeholders. These differences can then be used to give an overview how the choice for new products can be facilitated for all stakeholders.

6.1 Discussion

After applying the AHP technique in the second survey, there was a shift in the order in which the criteria were set when compared to the results of the first survey. Therefore, the second survey gave a different top 8, as can be seen below:

First survey (List) 8, Risk 15, User-friendl y 24, Benefi ts 1, Advantages 10, Support 22, Improvement 21, Knowle dge 18, Usage Second survey (AHP) 21, Knowl edge 10, Suppo rt 18, Usage 22, Improveme nt 8, Risk 15, User-friendly 24, Benefit s 1, Advan tages

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28 Consequently, head nurses find ‘support of the device’ relatively the most important criteria, closely followed by ‘easy to obtain knowledge to operate the device’ and ‘high usage frequency’, as can be seen in the table below:

10 The device is supported 0,14

21 The knowledge to operate the device is easily obtained 0,14

8 Risk reduction for the patient 0,11

Table 5 - Eight most important criteria as responded by head nurses and assistants

As shown in these results, the opinion about innovation criteria of the head nurses and assistants shifted relatively from ‘patient first’ to ‘easy-to-use devices first’. Both the patient advantages and the easy-to-use devices criteria are found important, but changed in the second survey. A reason for this could be that ‘risk reduction for patient’ and ‘benefits for patient’ is a cultural and socially accepted reason that every head nurse and assistant should consider first. Note: the priority vectors are hardly deviating, therefore the criteria are relatively different, but not significantly different. Since the first survey only asked to click the most important characteristics, the ‘patient-first’ opinion came first. However, when asked for priorities in the second survey, the results changed. Literally, this means that head nurses and assistant find the patient ‘relatively’ less important, but in fact they are looking for easy-to-use devices which can benefit the patient.

To further expand the discussion, the results are both discussed in the light of results of interviews and theoretical background:

Comparison with interviews

As already mentioned in the chapter regarding interviews, all head nurses and assistants came up with the remark that nurses should ‘definitely be trained by the supplier, or at least given a proper manual’, along with ‘suppliers should make their innovation as easy as possible so it can be used without hesitation by older employees’. The second survey shows us that support of the device is the most important criteria, therefore complying with the remarks of the head nurses and assistants during the interviews.

It is most likely that head nurses and assistants are involved in the usage of the medical devices. As depicted in the interviews, the head nurse and head nurse assistant are more involved in

management activities than pure operational activities which involves treating a patient. However, this doesn’t mean that a head nurse or assistant is not involved in treating patients. Head nurses and assistants are still involved in treating a patient (operational level), but they are doing different activities, such as treatment which requires a higher level of education.

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Comparison with literature

As depicted by Rogers (2003), new product innovations that are ought to be used within the organization are involved in certain process steps. The ‘decision’ step decided whether to adapt an innovation or not and is partly based on the optional decision (individual decision), therefore based on the opinion of the user as influenced by the innovation criteria. Head nurses and assistants seem to be thinking a step forward, since they find an easy-to-use device very important.

An easy-to-use device might be an innovation characteristic, this affects the implementation and confirmation phase of Rogers’ process steps as well. As shown in the results of the second survey, head nurses and assistant find ‘high frequency of use’ of the innovation very important as well. Summarizing the results, head nurses and assistants want an easy-to-use device that is most likely to be implemented on their department, because they had good training and can make use of good manuals to fully understand and use the new medical device to benefit the patient.

This is in line with the initial trigger for this research, because a lot of innovations that are introduced in the healthcare organization often fail due to failure in the adoption process as depicted by van der Panne and Asplund & Sandin. This includes the non-usage of new medical devices because head nurses and assistant are possibly not trained enough or simply cannot train themselves because a manual is missing, therefore lowering the usage frequency of the new medical devices and causing failure of adoption.

Furthermore, head nurses and assistants were believed to have a high autonomous function regarding the adoption of new innovations within their department. Therefore, they claim their position as in important stakeholder in the list of Walshe & Smith. This is further confirmed by the interviews. They stated that they have the ability to search/choose and accept new department specific innovations themselves, but have an influencing opinion regarding the introduction of hospital-wide (department transcending) innovations as well.

Consequently, head nurses and assistants need to see advantages of a new innovation for both the patient and themselves (easy-to-use devices), otherwise they would most likely not accept it. This will cause the new introduction of the medical device to fail.

6.2 Comparison

In order to make a good comparison between this study and the previous study of Bax (2013), the same style of results (priority vectors) of the AHP technique were used. Bax studied three more stakeholders: physicians, business managers and supplier account managers. However, the supplier account managers were asked to give their opinion what criteria THEY thought were found to be important by physicians. Therefore, the results of the supplier account managers are combined with those of the physician.

The comparison with the physician is the most important one, since physicians are (just like the head nurse) actual users of medical devices as well. The comparison with the managers gives a short overview of the opinion from a managerial perspective, indicating the differences between stakeholders.

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6.2.1 Comparison with physicians (actual users)

As shown in figure 13 below, 5 out of 8 criteria were overlapping. The head nurse is less interested in the use of cost reduction, involvement in the development and the usability in existing clinical procedures. Instead, the head nurse is, just like the physician, more interested in the benefits for the patient (risk reduction, clinical performance, improvement and general benefits). A physician find user friendly devices important as well, but not relatively as important as the head nurse and assistant.

Moreover, risk reduction, benefits for the patient and advantages in clinical performance are the top 3 criteria for the physician (where risk reduction is significantly more important when compared to the rest), but do not see the top 3 of the head nurse. The ‘patient-first’ opinion of the physician is very recognizable. In comparison with a physician, the head nurse is more interested in easy to use devices which are actually very good for the patient, but seem less interested in side issues such as cost reduction.

Therefore, the physician seems that have a broader scope since they included cost reduction, involvement in development and usage in existing clinical procedures as well. This might influence their autonomous role positively since they are more involved on a managerial level when compared to the head nurse, which decides about the introduction of new innovative medical devices.

Regarding the supplier account managers, they thought that physicians places the patient first. This confirms the patient perspective of a physician, wanting the best for the patient. However, they thought that physicians were also interested in good easy-to use products for patients, just like the head nurse. Cost reduction was found important as well. The remaining criteria did not match. These differences in opinions can be used to facilitate a good choice for new medical products.

8 Reduces risk to the patient 0,21

2 Making use of results in cost reduction 0,11

7 The physician is involved in the development 0,08

3 The device can be used in existing clinical procedures 0,08 Table 6 - Eight most important criteria as responded by physicians, source: Bax (2013)

9 Financial resources to support application are available 0,09 16 Staff to coordinate and support implementation are available 0,08

12 The advantages, as indicated by the supplier, are solid 0,08 14 The hospital’s management board supports the introduction of

the new medical device

0,08

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6.2.2 Comparison with business managers (managerial)

As shown in figure 14 below, 5 out of 8 criteria were overlapping. The head nurse is less interested in the financial resources to support, the usage of results in cost reduction and the usage in existing clinical procedures. Instead, the head nurse is, just like the business manager, more interested in the benefits for the patient. Just like the physician, side issues such as financial resources and cost reduction are found important by business managers, but not by head nurses and assistants. Generally, the criteria of business managers are almost equally important (priority vector hardly deviates). However, the top 3 of business managers comes closer to the top 3 of the head nurses than the physicians. While the advantages in clinical performance is found the most important factor by business managers, the head nurse and assistant find this relatively less important. On the other hand, the related criteria ‘offers benefits to the patient’ scores relatively low for business managers. On the other hand, the usage frequency is found equally important by the head nurse and the business manager. Since the business manager does not have to deal with these medical devices practically, this could explain the differences in opinions.

Summarized, the business managers interested in good products for patients, just like the head nurse. However, they are also involved on a managerial level to see if a product is financially supported and costs can be reduced.

These differences in opinions can be used to facilitate the choice for new medical products as good as possible.

9 Financial resources to support application are available 0,13

3 The device can be used in existing clinical procedures 0,12

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6.3 Summary

Results of the AHP survey compared to the first survey gave different results. Head nurses and assistants found the importance of an easy-to-use and supported device RELATIVELY more important than the patient. Further analysis gave a more elaborated explanation why this happens:

- The results matched interviews, giving the wish of head nurses and assistant to involve the supplier (for manuals/training) a first priority

- The relative high importance of the perspective (first survey) on the patient might be caused by cultural pressure saying the patient is the most important factor, while during prioritizing the real answers can be divided (second survey)

- Head nurses and assistants are already thinking forward in terms of wanting an easy-to-use device so they can help patients

- If head nurses and assistants don’t understand how a device works, this might lead to non-usage thus losing the advantage of a new medical device while the old one is still working - Head nurses and assistants are autonomous, causing the ability to work with a new device or

not, therefore it’s important that they want to know how the devices work

- In fact, the head nurses and assistants don’t want too much problems or hassle when new medical devices are introduced.

While all points as listed above are mentioning the importance of an easy-to-use medical device, it should be noted that head nurses and assistant are still finding the patient important due to the low deviation of priority vectors in the second survey. In order to serve the patients as best as possible, they would like to make use of new innovative medical devices.

However, if these new medical devices are not fully usable by the head nurses and assistants, this could lead to devices which are not optimal for the patient. Therefore, IF a new medical device is introduced or head nurses and assistants are ought to use it, they would like to receive as much training as possible so they can fully operate the device.

Lastly, when comparing head nurses and assistants to the physicians and business managers, it is clear that physicians and business managers are having a similar opinion about the high importance of the patient, along with easy-to-use devices. However, head nurses and assistants are less

interested in the financial or management part.

Consequently, it appears that they are focused on a more operational level. A wish for an easy-to-use device which will treat the patient as good as possible is a good wish. However, this wish has to be translated in steps that need be taken to ensure the opinion of the head nurse is fully incorporated in the decision which new medical device should be introduced.

Thesis Innovations and people go hand in hand: A study how the introduction of innovations in healthcare is influenced by nurses

Innovations and people go hand in hand: A

study how the introduction of innovations in

healthcare is influenced by nurses

Thesis

Author: D. Hoekstra

Innovations and people go hand in hand: A

study how the introduction of innovations in

healthcare is influenced by nurses

Thesis

Author: D. Hoekstra, Student Supply Chain Management, Rijksuniversiteit

Groningen

Preface

Abstract

Contents

1. Introduction

1.1 Complications when innovating

1.2 Triggers for this research

1.3 Formulating the research question

1.4 Importance of this study

2. Theoretical background

2.1 Innovation diffusion process and types

2.2 Stakeholders in innovation adoptions

2.3 Adoption-decision

2.4 Criteria of innovation adoption-decision

2.5 Specific Influence of nurses on the adoption innovation decision

2.6 Summary

3. Methodology

3.1 Literature

3.2 Data collection and methods

4. Interviews

4.1 Interviewing head nurse

4.1.1 Influence of head nurse

4.1.2 Summary of experiences

4.1.3 Nuanced view on head nurses’ role

4.2 Interviewing head nurse assistants

4.2.1 Influence of head nurse assistant

4.2.2 Summary of experiences

4.3 Important extra factors

4.4 Summary

5. Survey

5.1 Part one: preparing the survey

5.1.1 Part one: survey results

5.2 Part two: preparing the survey

5.2.1 Part two: survey results

5.3 Summary

6. Discussion and comparison

6.1 Discussion

6.2 Comparison

6.2.1 Comparison with physicians (actual users)

6.2.2 Comparison with business managers (managerial)

6.3 Summary