Creating Willingness to Change among Medical Specialists:

Master Thesis, MscBA, specialization Change Management

A.M. Ruepert Studentnumber: 1544268

Dirk Huizingastraat 14a 9713 GM Groningen, The Netherlands

Phone: +31 6 39793294 E-mail: aruepert@hotmail.com 27 April 2011 Supervisor/ university Dr. C. Reezigt Co-supervisor/ university Dr. J. Rupert

Supervisors/ field of study M. van Gent & C.B.M. Kaagman MBA

Contents

1

Introduction

1

1.1

Management problem at the UMCG

1

1.2

Goal

2

2

Theory

3

2.1

Organizational change in general

3

2.1.1

Importance of organizational change

3

2.1.2

Two approaches to organizational change

3

2.1.3

The focus of this study

5

2.2

Willingness to change

5

2.2.1

Individual behavior central in organizational change

5

2.2.2

Overcoming resistance to change vs. creating willingness to

change

7

2.2.3

Creating willingness to change

9

2.3

Organizational change in healthcare context

15

2.3.1

Importance of organizational change in healthcare context

15

2.3.2

Characteristics of healthcare organizations

16

2.3.3

The focus of this study

18

2.4

Sub-questions and conceptual model

18

2.4.1

Sub-questions

18

2.4.2

Conceptual Model

19

2.4.3

Definitions

19

3

Methodology

21

3.1

Research design

21

3.2

Data collection

21

3.3

Measures

24

3.3.1

Willingness to change

24

3.3.2

Level of Principal support

24

3.3.3

Level of personal valence

25

3.3.4

Validity and reliability from literature

25

3.3.5

Validity and reliability in this study

26

3.4

Data analysis

26

3.4.1

Testing for extreme values

27

3.4.2

The analysis

27

4

Results

30

4.1

Descriptive statistics

30

4.2

Correlation analysis

30

5

Conclusion

37

5.1

Answering the sub-questions

37

5.2

Answering the research question

39

6

Discussion

40

6.1

Theoretical contributions

40

6.2

Practical implications

41

6.3

Limitations and further research

42

7

References

43

Appendix 1

Questionnaire

47

Appendix 2

Validity Analysis

51

Appendix 3

Reliability Analysis

53

Appendix 4

Testing for Extreme Values

56

Appendix 5

Model Assumptions

57

Appendix 6

Descriptive Statistics

58

Appendix 7

Correlation Analysis

59

Appendix 8

Regression Analysis

60

8.1

Simple regression

60

8.2

Multiple regression

62

8.3

Mediation

63

Appendix 9

Testing for Moderation

65

9.1

Regression analysis to test for moderation

65

1

Introduction

1.1

Management problem at the UMCG

In December 2009 the then Minister of Health in the Netherlands stated that the emergency care must be improved at short notice. Mr. Klink based his statement on an investigation of 27 departments of emergency healthcare in the Netherlands, which showed that none of the departments complied with the existing norms1. The University Medical Centre Groningen (UMCG) recognizes the problem and aims at improving its emergency care.

As a trauma centre holding hospital, the UMCG coordinates the emergency care network North Netherlands, which involves the three Northern provinces: Friesland, Groningen and Drenthe. This emergency care network focuses on different areas of attention, but, with Mr. Klink’s statement in mind, it is one of these areas that is of particular interest: the knowledge centre. The knowledge centre is especially concerned with and responsible for knowledge development and the promotion of professionalism.

Emergency healthcare implies that a chain of professions cooperate in their collective responsibility for the care offered to the patient. The subject of this study is a change project at the UMCG, concerning regional meetings with all the different professions in the emergency healthcare. Three years ago the UMCG took the initiative to introduce the so-called “Chaincasemeeting”, in Dutch a “Ketencasusbespreking” (KCB), during which particular cases selected from the practice of the emergency healthcare are being elucidated and discussed. The ultimate goal of these meetings is to bring about an improvement in the quality of the emergency healthcare. The first step on the way to this ultimate goal is to raise the level of knowledge among all the employees in the emergency care chain, by means of mutual learning. These so called KCB’s thus aim at knowledge sharing and learning from each other by means of case studies. According to the management of the trauma centre the problem is that these meetings are not as effective as they are supposed to be, due to low numbers of medical specialist participants.

1

1.2

Goal

In this study a research will be done on the factors influencing the willingness to change among members involved in the change initiative. In the literature on healthcare organizations, the importance of leadership is emphasized again and again. The main argument, that can be identified, is a clash of interests between clinical and managerial decision makers. A second point of interest is the importance of commitment and personal valence. The latter is still considered to be of minor importance among medical specialists. The reasoning behind this is that they would rather value their work intrinsically and recognize their duty to patients and the community as a whole. All this makes the two factors principal support and personal valence interesting and subject of the diagnosis that will be conducted. The research question of this study is:

Research question:

2

Theory

In this section I will build on the academic foundations for this study. The first part of this chapter consists of an elaboration on the literature about organizational change in general. The second part will focus on the literature about the willingness to change and the variables influencing change willingness. In the third part the focus will be on the literature specifically concerned with the context of this study: change in the healthcare organization. Based on this literature study, sub questions will be formulated and these will be presented in the fourth part of this chapter together with an overview of the relation between the variables in the conceptual model.

2.1

Organizational change in general

2.1.1

Importance of organizational change

For society at large, and organizations in particular, the magnitude, speed, impact, and particularly the unpredictability of change, are greater than ever before (Burnes, 2009: 1). Much has been written about the subject of organizational change, and the multiple approaches and responses to it (Gilley, Godek and Gilley, 2009). In general, most authors would argue that organizations exist in the context of a dynamic, rapidly changing environment. Although some argue that change is nothing new, others suggest that it occurs at an increasingly rapid rate. Continuous rapid change significantly affects the way in which organizations function (Gilley et al., 2009). As Beer, Eisenstat, and Spector (1990: p.1) have stated, faced with changing markets and tougher competition, more and more companies realize that in order to compete effectively they must transform. But Beer et al. (1990: p.6) also argue that while senior managers understand the necessity of change, they often misunderstand what it takes to bring it about. Beer and Nohria (2000) state that it is a fact that about 70% of all change initiatives fails. A sound understanding of the subject of organizational change will form the basis of making the right decisions.

2.1.2

Two approaches to organizational change

categorizing them, scholars of OD would agree on the division of two dominant ones; the planned and emergent approaches (e.g. Burnes, 2009; Cummings and Worley, 2001; Kanter et al., 1992, Stace and Dunphy, 2001*). Planned change is the term coined by Kurt Lewin in the 1940s to distinguish change that was consciously embarked upon and planned by the organization. This, as opposed to unplanned or emergent types of change that might come about by accident or by impulse or that might be forced on an organization (Burnes, 2009: 600). I will now look closer at the planned approach of change, because the change initiative under research can be classified as such. The organization has identified an area for which it believes change is required and takes the initiative to evaluate and bring about the change.

Lewin’s three step model: Planned change, which originated with Kurt Lewin, embraces

four elements: field theory, group dynamics, action research, and the three-step model. Within the framework of this study I will focus on the last element. Lewin (1951) argued that a successful change project implied the following three steps: unfreezing, moving, and refreezing. The first step, “unfreezing”, refers to conditioning individuals and organizations for change, examining individuals’ readiness for change, and establishing ownership. This step is seen as necessary, because Lewin believes that the stability of human behavior is based on a quasi-stationary equilibrium supported by a complex field of driving and restraining forces. He argues that this equilibrium needs to be de-established (unfrozen) before new behavior can be adopted. Momentum builds when employees align to introduce the change and plan its implementation. Unfreezing creates motivation to change. The second step, “moving”, occurs when individuals engage in a change initiative. Lewin makes clear that it is a process of considering all the forces at work to identify and evaluate all the available options. In the final step, “refreezing”, individuals incorporate the change into their daily routine; new behaviors are solidified and ultimately determine the norm (Lewin, 1951). Refreezing seeks to stabilize the group at a new equilibrium in order to ensure that the new behaviors will not wane (Burnes, 2004).

1999). This work has dominated the theory and practice of change management for over 50 years. Building on the early models, researchers have developed more extensive, multi-step frameworks that incorporate leadership, employee involvement and commitment, monitoring, rewards, and more. Well-known examples are Gilley’s 7-step model (Gilley, 2005: p.19), Ulrich’s 7-step model (Ulrich, 1998), and Kotter’s 8-step model (Kotter, 1996: p.33 and further).

In the past 20 years, Lewin’s approach to change, and particularly the three-step model, has attracted major criticism. Hendry (1996) notes: “Scratch any account of creating and managing change and the idea that change is a three-stage process which necessarily begins with a process of unfreezing will not be far below the surface.” Furthermore Burnes sums up some key criticisms at the work of Lewin: it assumed organizations to operate in a stable state and thus as too simplistic; it was only suitable for small-scale change projects; it ignored organizational power and politics; and it was top-down and management driven. (Burnes, 2004a) In spite of these criticisms there is a fairly high degree of consensus on the three main phases of change. Hendry (1996) states that it is indeed true that the whole theory of change is reducible to the one idea of Kurt Lewin.

2.1.3

The focus of this study

This study focuses on a change planned by the management of the organization in response to changes in regulations. Specifically, the first step of Lewin’s three-step model, unfreezing, is important in this management problem. Although we speak about three phases, Armenakis and Bedeian (1999) also stress the overlap of these phases and the continuousness of the whole process.

2.2

Willingness to change

2.2.1

Individual behavior central in organizational change

change process. But, understanding human behavior, in all its complexity, is a rather difficult task. To come to an understanding of individual behavior, I will look at a prominent theory on this subject that has been applied in various fields; the theory of planned behavior.

Ajzen’s theory of planned behavior: The theory of planned behavior suggests that the

decision to engage in a particular behavior is the result of a rational process. This process is based on a number of behavioral options, the evaluation of consequences or outcomes, and the decision to act or not. The next step is that this decision is translated into behavioral intentions, which strongly influence behavior. Three motivational factors underlie a person’s behavioral intention:

the person’s attitude toward the new behavior, the subjective norm toward the new behavior and

the person’s perceived behavior control (locus of control).

The central factor in the theory of planned behavior is the individual’s intention to perform a given behavior (Figure 1). As a general rule, the stronger the intention to engage in a behavior, the more likely should be its performance (Ajzen, 1991).

Attitude Subjective norm Perceived behavioral control Behavioral Intentions Behavior Source: Ajzen (1991) FIGURE 1

The premise that follows this model is that the willingness to change forms a positive behavioral intention, whereas resistance forms a negative behavioral intention. With this in mind, I will now move on to one of the most important factors involved in employees’ initial support for change initiatives: willingness to change (Armenakis, Harris and Mossholder, 1993; Armenakis and Harris, 2002; Holt, Armenakis, Field and Harris, 2007). According to Armenakis and Bedeian (1999) many factors contribute to the effectiveness of the implementation of organizational change. One of these factors is the willingness to change. As stated before, the willingness to change is especially important in the first phase of the three in which organizational change is thought of to unfold according to Lewin (1951). As was also stated before, during this phase organizational members are being prepared for the change and ideally become its supporters.

2.2.2

Overcoming resistance to change vs. creating willingness to change

In the existing literature the concept of willingness to change is extensively discussed. Within the context of this topic different terms are used, such as “readiness” or “willingness to change”; the term “resistance” is used to refer to a lack of willingness to change. Basically two groups of literature can be separated. The first group focuses on strategies to overcome resistance. The second group is focused on creating readiness / willingness.

The first group concentrates on a rather negative approach. Examples of this approach can be found in the works of Coch and French (1948), Lawrence (1954), Watson (1991), and Rumelt (1995), in which strategies to overcome resistance are emphasized. In the article by Metselaar and Cozijnsen (1997), which reviews the works of authors mentioned above, they conclude that the focus in these works is on resistance as an irrational, unavoidable behavioral response to change (Metselaar and Cozijnsen, 1997).

much seen as a barrier to change but rather as resources that will support change if certain conditions are fulfilled. Furthermore, Ford, Ford and D’Amelio (2008) have stated that the prevailing views of resistance to change, as described above, only tell a one-sided story that favors change agents. They argue that, on the one hand, these change agents contribute to resistance through their own actions and inactions, but, on the other hand resistance can also be a resource for change.

As a summary, Table 1 which is based on the work of Metselaar and Cozijnsen (1997) can be presented.

TABLE 1

Elements of ‘negative’ and ‘positive’ models on resistance to change

‘Negative’ models on resistance ‘Positive’ models on resistance Insert header

Labeling resistance as: Unavoidable reaction to organizational change. Undesired response.

Unhealthy, harmful reaction to change efforts.

Expression of disapproval.

Avoidable reaction to organizational change.

Legitimate response.

Healthy, beneficial reaction to change efforts.

Expression of concern.

Focus on: Fighting and minimizing

resistance.

Working against resistance.

Understanding and

responding to resistance. Working with resistance.

View organizational change as:

A collective systems change. Changing structures.

A collective behavioral change.

Changing people. Source: Metselaar and Cozijnsen (1997)

2.2.3

Creating willingness to change

To create a clear and workable picture of the willingness to change, I will further investigate the literature available on this principle.

Vroom’s VIE model: According to Vroom’s Expectancy Theory (Vroom, 1964), the

willingness to change is a cognitive process, which is presented in Vroom’s VIE model (Figure 2). This theory suggests that there are three cognitive processes that underlie motivation. For the first cognitive process, Vroom uses the term: expectancy beliefs. This is a person’s belief whether a particular outcome is possible. For the second cognitive process, he uses the term: instrumentality. The outcome of this process is an anticipation that this outcome will lead to other outcomes. For the third cognitive process, he uses the term: valence. Valence is the affective orientation the person holds with regard to outcomes. The concept of “valence” consists of various aspects ranging from financial aspects to personal relations, status etc. “Valence” is different for each individual.

This theory states that the willingness to change is a cognitive process and that one of the important aspects of this process is valence. This is one of the concepts that I will investigate further in this study. For this I use Vroom’s Expectancy Theory as a foundation.

Metselaar’s DINAMO model: Building on Ajzen’s theory of planned behavior, Metselaar and

Cozijnsen (1997) put forward a framework for the construction of a measurement instrument of the willingness to change; DINAMO (Diagnostics Inventory for the

Expectancy:

Perceived probability that effort will lead to good performance

Instrumentality:

Perceived

probability that good performance will lead to desired outcomes Valence: Value of expected outcomes to the individual

Effort Performance Outcome Motivation

Source: Vroom (1964)

Assessment of the willingness to change among Management in Organizations). By applying the Azjen’s theory of planned behavior to a change scenario, Metselaar and Cozijnsen (1997) have hypothesized that three motivational factors will determine a person’s behavioral intention (Figure 3).

This theory, by Metselaar and Cozijnsen, gives an extensive description of the concept of willingness to change and its attributes. In this study I will use the DINAMO model and its description to provide a workable definition of willingness to change and to construct the list of items used to measure the willingness to change.

Armenakis et al.’s five change message domains: Armenakis and Harris (2002) state that the

change message is crucial in creating willingness to change. As was described before, organizational change is thought of as unfolding in three phases. Armenakis and Harris

Work related outcomes Outcomes for the organization Affective response Co-worker attitudes External control factors Self-control factors Change related behavior Willingness to change Contentment with process rate Complexity of the change Attitude Subjective norm Perceived behavioral control

Source: Metselaar en Cozijnsen (1997)

FIGURE 3

(2002) see these three phases of change as overlapping and as a continuous process. They argue that the change message and its communication can serve to coordinate the three change phases by providing the organizing framework for creating readiness and the motivation to adopt and institutionalize the change. The change message is responsible for both conveying the contents of the change and for creating the sentiments regarding the change. They argue that most of the failures in organizational change are caused by leaders’ misunderstanding of the importance of communicating a consistent and sound change message.

Armenakis et al. (1993) have clarified this statement by specifying five domains that a change message must address to. The five key change message components identified are discrepancy, appropriateness, efficacy, principal support and personal valence.2 _{The model of Armenakis and Harris (2002) can be found in figure 4.}

The first component is discrepancy and refers to the sentiments experienced by the people involved, whether the change is needed. It is the perceived discrepancy between an organization’s current performance and the desired end-state of the change. Recognizing that a discrepancy is present is not sufficient. Apart from the discrepancy it is also important to recognize that the desired end-state is the most appropriate solution for the discrepancy. The second component is the appropriateness of the change. Armenakis and Harris (2002) recognize that the presence of a discrepancy is not sufficient. It is also important to recognize that the desired end-state is the most appropriate solution for the discrepancy. The component appropriateness refers to this statement. The third component is

efficacy and refers to beliefs regarding one’s ability to succeed. The employees people

concerned must be confidence that they have the capacity to successfully implement the change and correct the discrepancy

The fourth component is principal support. Armenakis and Harris (2002) make clear that change, which includes of the whole process from starting the change until ultimately reaching the point of institutionalization, requires resources and commitment. They stress that employees have already experienced many failures in relation to change efforts, due to a lack of principal support, and that these employees have become skeptical and unwilling to support actively a new change. This might only be brought about by a clear demonstration of principal support. This statement is based on a study of 91

1

hospitals, by Nutt (1986). He found that the most successful change initiatives were the ones in which the people concerned experienced early and continuing management support. Principal support refers to the extent to which one feels that the organization’s leadership and management are or are not committed to and support or do not support implementation of the prospective change (Holt et al. 2007)

This key change message component shows similarities with the second factor of readiness as presented by Metselaar and Cozijnsen (1997): co-worker attitude or subjective norm. In a change situation, gaining insight into the perceived principal support might be crucial for the willingness the change among the people concerned.

The fifth and final component is personal valence. According to Armenakis and Harris (2002), the people concerned with the change are interested in the benefits they can personally receive from the change. This means that employees involved in the organizational change will assess the positive and negative outcomes, the fairness of the change, and the manner in which individuals are treated (Cobb, Wooten and Folger, 1995). Personal valence refers to the extent to which one feels that he or she will or will not benefit from the implementation of the change (Holt et al., 2007) Thus, if an individual’s self-interest is threatened, the proposed changes will likely be resisted (Clarke, Ellett, Bateman and Rugutt, 1996).

Also Knotters en Hoogstra (2009) stress that the concept of “interests” is an important factor that needs to be considered. Schiefele (1991) has defined interests as: “a content-specific motivational characteristic composed of intrinsic feeling-related and value-related valences”. In essence, this is the same as personal valence. These interests can be based on the possible advantages that can be gained from the change initiative. Possible advantages might be found in the area of more efficient working methods or a more purposeful and effective approach. At the same time, to what amount this possible advantage is connected to one individual or a group of people, is also important. In the case of a change project alternative, with a possible advantage for more people, it is likely that this change project will receive priority over a change project alternative in which one person’s interests are served. However, small individual changes are often easier carried through, as long as the interests of the group are not disadvantaged.

individuals, for example by means of knowledge extension and/or experiences. The belief in these possibilities will influence the employees’ willingness to change. Furthermore, when an individual has a feeling of attachment to the common goal, it is more likely that this person will support the change initiative in comparison to an individual who does not support the common goal. (Knotters and Hoogstra, 2009)

All this is in line with the expectancy theory of motivation(Vroom, 1964), discussed earlier, which states that individuals will only be motivated to change to the extent that they have an affective orientation with regard to the outcomes of the change process: valence.

The theory by Armenakis et al (1993) gives a clear overview of the factors influencing the willingness to change. The sustainability of a part of this theory will be tested in this study.

2.3

Organizational change in healthcare context

2.3.1

Importance of organizational change in healthcare context

I will now focus on the literature specifically concerned with change in the healthcare organization. According to the literature, healthcare organizations are undergoing unavoidable changes. Competition, cut-backs in expenditure, efforts to improve cost-efficiency, mergers, the re-engineering of work processes and the need to be constantly up to date with the latest medical techniques are placing enormous demands on healthcare organization and their employees (Cunningham et al., 2002).

Discrepancy Willingness to Change Principal Support Efficacy Personal Valence Appropriateness

Source: Armenakis et al. (1993)

FIGURE 4

2.3.2

Characteristics of healthcare organizations

However, the characteristics of the industry make organizations inherently resistant to change. It is said that they operate in a knowledge intensive sector, they provide complex services, and are characterized by the interaction of multiple disciplines (Vassalou, 2001). It is also stated that professionals in this knowledge intensive sector tend to look at their peers to determine codes of behavior and often refuse to accept evaluations by those outside their discipline. This can easily result in inward looking systems that are resistant to change. (Quinn, Anderson and Finkelstein, 1998: 89) Furthermore, according to Hannan and Freeman (1984), reliable performance requires the organizational structure to be highly reproducible. This means that healthcare organizations often rely on routines to handle daily work, which in turn, cause practices to become rigid, resulting in a decrease in their ability to adapt to the rapidly changing healthcare environment (Cohen et al., 2004). This highly reproductive structure will thus result in a strong inertial pressure and will make implementing a change initiative difficult. Besides that, as healthcare organizations are composed of professionals with expertise in various types, professional autonomy affects the collaborating and adapting abilities of an organization (Vassalou, 2001).

The importance of leadership: One especially important characteristic of the healthcare

organization is the crucial role of leadership. Within the healthcare organization there is a clear interdependency between clinical decision making and nonclinical decision making or managerial decision making. One result of this interdependency is increased conflict among decision makers driven, in part, by different norms of rationality. (Anderson and McDaniel. 2000)

Furthermore, it is stated that healthcare organizations are seen as a clear model of a professional organization. They are unique in so far that it is not an organization in which one profession occupies all of the major professional roles, but that there are several different professions central to the success of the organization. All these important professional groups have their own values and interests, which results in a clear need to coordinate these values and interests of the diverse professional groups. (Anderson and Mc.Daniel et al. 2000)

context includes concepts such as management infrastructure, communication, and leadership style. (Cohen et al. 2004; Vassalou, 2001)

The impact of having a management function: Additional to the importance of leadership,

Metselaar and Cozijnsen (1997) note that because middle managers often have the task of implementing change in the organization, they play a key role in this change process. Their position in the organizational structure makes them a hub between the wishes and demands of managerial decision makers and the consequences of the change for the employees in their department. The willingness to change is thus even more important for medical specialists with a middle management function, because of the leadership role they have to play in changing their own department. They have to serve as an example for the employees in their department. This makes medical specialists with a middle management function a vulnerable group in organizational change processes. (Metselaar and Cozijnsen, 1997)

Metselaar and Cozijnsen (1997) outline that during this change process the difference between employees with a management function and without should be taken into account, because of their different levels of involvement. Additionally, the degree of involvement of these groups also varies during the stages of change. As stated before, this study focusses on the first step of Lewin’s three-step model. According to Metselaar and Cozijnsen (1997) this means that employees with a management function should score higher on the willingness to change during this phase. Thus, the management function has the potential to serve as a moderator variable.

The state of mind: Another characteristic of the healthcare organization to pay special

attention to is the crucial role played by the state of mind among medical specialists. The difference between working as a professional within the healthcare organization, and many other organizations, is that professionals in the healthcare have broader responsibilities to society and the profession. Medical specialists do value their work intrinsically and see it as central to their self-identity. (Frankford, Patterson and Konrad, 2000) There is the tradition that medical specialists recognize a duty to individual patients and to their community as a whole. (Herbert and Swick, 2000)

Association of American Medical Colleges (AAMC), Medical School Objectives Project (MSOP), and the American Board of Internal Medicine (ABIM). A few examples of these behaviors are: Physicians subordinate their own interest to the interest of others, Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served and Physicians demonstrate a continuing commitment to excellence. The essence of these behaviors is the importance of commitment in exercising their profession and commitment to keep improving. Organizational change in the healthcare organization requires commitment. (Herbert and Swick, 2000)

2.3.3

The focus of this study

Based on the examination of the literature concerning organizational change this study will focus on the concept of the willingness to change. Within this main subject I will study the factor principal support because of the importance of leadership within the healthcare context. Besides, attention will be paid to the difference between medical specialists with a management function and those without. Furthermore, this study will focus on the factor personal valence. As stated before, personal valence in the medical world is of less importance than in many other organizations. I would like to investigate to what extent this is so. These factors will be studied within the context of a change initiative planned by the management of the healthcare organization.

2.4

Sub-questions and conceptual model

2.4.1

Sub-questions

Based on the theory discussed above, this study will investigate the influence of the factors, principal support and personal valence on the willingness to change and the influence of the management function, within this case. The sub-questions that follow this way of reasoning are:

Sub-question 1: What is the influence of principal support on the willingness to

change (at the UMCG)?

Sub-question 2: What is the influence of personal valence on the willingness to

Sub-question 3a: To what extent does the management function influence the

relationship between principal support and the willingness to change (at the UMCG)?

Sub-question 3b: To what extent does the management function influence the

relationship between personal valence and the willingness to change (at the UMCG)?

2.4.2

Conceptual Model

The conceptual model presented in figure 5 illustrates the relationships that will be investigated.

2.4.3

Definitions

The definition of willingness to change used in this study is derived from Metselaar and Cozijnsen (1997). Willingness to change is defined as:

“A positive behavioral intention towards the implementation of modifications in an organization’s structure, or work and administrative processes, resulting in efforts from the organization member’s side to support or enhance the change process.”

The definition of principal support used in this study is derived from Armenakis and Harris (2002). Principal support is defined as:

“The clear demonstration of support from the management in the form of resources and commitment.”

The definition of personal valence used in this study is derived from Armenakis and Harris (2002). Personal valence is defined as:

“The extent to which one feels that he or she will or will not benefit from the implementation of the change.”

The definition of management function used in this study is derived from Metselaar and Cozijnsen (1997). Management function is defined as:

3

Methodology

The previous section introduced the theoretical background for this study, with special attention to the concept of the willingness to change. In this section I will focus on the research methods used in order to answer the sub-questions and ultimately the main research question. The first part of this chapter will elaborate on the research design. The second part of this chapter deals with the techniques used for data collection. In the third part the measures are investigated. The final part gives an explanation of the analyses used in this study.

3.1

Research design

To answer the sub questions, presented in section 2.4, and in order to test the relations as discussed in the conceptual model a quantitative study of an organizational change initiative was carried out. This study was conducted at the emergency healthcare division of the UMCG. Especially in the emergency healthcare the cooperation of good teamwork among all those involved is of prime importance. Nurse practitioners and medical specialists have to work together to provide the best healthcare. In this study I will concentrate on specialists only. The change initiative at the trauma center of the UMCG was started of to improve this cooperation between the different professions. The data, necessary to test the relations as discussed in the conceptual model, are gathered by a questionnaire. Conclusions have been drawn from the sample’s characteristics in an attempt to capture the population’s characteristics.

3.2

Data collection

Sample: The participants were all medical specialists working in the Emergency Care Network Northern Netherlands. A questionnaire was sent to them in order to gather data on the level of management support, the amount of personal valence and the willingness to change as perceived among the medical specialists. The sample has been randomly selected.

The questionnaires were sent to 598 medical specialists, which resulted in 55 respondents. Preliminary analyses showed that 3 participants failed to comply with the instructions. These participants were dropped from the analyses, leaving an N of 52. This corresponds to a response rate of 9%. Although, appears to be very low, it does not differ from the expected response rate. Employees within the healthcare organization, and especially medical specialists, work under high pressure and do not have much time to fill in questionnaires.

Table 2 and 3 show the sample characteristics.

TABLE 2

Sample characteristics: Function and Province

Province Total

TABLE 3

Sample characteristics: Function and Management function Management function Total

No Yes

Function Emergency physician 4 8 12

Anesthesiologist 5 3 8 Resident 6 0 6 Surgeon 2 4 6 Orthopedist 3 2 5 Vascular surgeon 1 4 5 Neurosurgeon 1 3 4 Radiologist 1 3 4 MMT doctor 0 2 2 Total 23 29 52

Questionnaire: The questionnaires consist of two parts. The first part contains 4

introductory questions in order to make the sample characteristics clear and to make a distinction between employees with a management function and without a management function. The second part contains 14 statements on willingness to change, the level of principal support, and the amount of personal valence. Respondents were asked to respond to these statements on a 5 point Likert-scale. The response choice “no opinion” was included. The 5 point Likert-scale that has been used serves as the measuring instrument for the positive or negative attitudes of the respondents.

3.3

Measures

3.3.1

Willingness to change

In order to measure the willingness to change, respondents were asked to rate to what extent they agree or not with these statements, using a 5-point scale: “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree”. These scales were derived from the article by Metselaar and Cozijnsen (1997).

“I have the intention to convince my colleagues of the benefits the change will bring”

“I have the intention to put effort into achieving the goals of the change”

“I have the intention to reduce resistance to the change among my colleagues/employees”

“I have the intention to make time to execute the change”

“I have the intention to participate when the change is executed”

3.3.2

Level of Principal support

In order to measure the level of principal support, respondents were asked to rate to what extent they agree or not with these statements, using a 5-point scale: “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree”. These scales were derived from the article by Holt et al. (2007).

“Our senior leaders have encouraged all of us to embrace this change”

“Our organization’s top decision makers have put all their support behind this change effort”

“Every senior manager has stressed the importance of this change” “This organization’s most senior leader is committed to this change”

“I think we are spending a lot of time on this change when the senior managers don’t even want it implemented”

3.3.3

Level of personal valence

In order to measure the level of personal valence, respondents were asked to rate to what extent they agree or not with these statements, using a 5-point scale: “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree”. These scales were derived from the article by Holt et al. (2007).

“This change will disrupt many of the personal relationships I have developed” “I am worried I will lose some of my status in the organization when this change is implemented”

“My future in this job will be limited because of this change”

3.3.4

Validity and reliability from literature

In their article Metselaar and Cozijnsen (1997) tested the validity of the variable willingness to change through content analysis and factor analysis. Based on these analyses poor items were either rewritten or removed from the questionnaire and replaced by new items. Holt et al. (2007) have evaluated the construct and predictive validity of the scales through a factor analysis. Content validity was tested by means of a content analysis. From this analysis it has appeared that personal valence reflected concerns about relationships, status and opportunities while the more job-related concerns loaded the factor appropriateness. This statement is in line with the discussion presented in part concerning the factors influencing the willingness to change. Holt et al. (2007) have also rewritten or removed the items that appeared poor on the basis of the validity analyses.

3.3.5

Validity and reliability in this study

To analyze the construct validity of the model, with our collected data, a factor analysis was used. A confirmatory factor analysis was conducted on all the items. The fixed number of factors was set at 3. Factors were extracted and loadings were evaluated. In this factor analysis it appeared that two items from the management support scale did not load well with the intended factor. One item intended to measure personal valence did not load well either on the intended factor. These three items were removed. The rotated component matrix can be found in Appendix 2.

In order to test the reliability of the variables, with the collected data, Cronbach’s alfa was calculated. For the dependent variable, willingness to change, Cronbach’s alfa shows an acceptable estimate of .909. The reliability analysis for the independent variables Cronbach’s alfa shows respectively values of .878 for principal support and .850 for personal valence. This means that all variables have sufficient values. Table 4 shows the outcome of the reliability analysis. The SPSS output for the reliability analysis can be found in Appendix 3.

TABLE 4

Outcome of reliability analysis

Variable Items Cronbach’s alfa

Willingness to change 5 .909

Principal Support 4 .878

Personal Valence 2 .850

3.4

Data analysis

3.4.1

Testing for extreme values

In order to be able to make valid statements the data were tested for extreme values and outliers. Extreme values and outliers may result in drawing incorrect conclusions from the results. Each variable was tested for extreme values and outliers with box plots.

The first variable, willingness to change has no outliers and no extreme values. The second variable, the independent variable principal support, has one outlier, but no extreme values. The last variable, the independent variable has no outliers and no extreme values, but does show a lack of normality. A further investigation of the normality will be given below where the assumptions for regression analysis will be tested. The box plots for the three variables can be found in Appendix 4.

3.4.2

The analysis

Descriptive statistics: The analysis in this study consists first of all of descriptive statistics,

which show the mean and the standard deviation of the variables.

Correlation analysis: Secondly, a correlation analysis was executed to provide answers to

the first and second sub-questions. Spearman’s Rang Correlation was used because this is the best instrument to test the ordinal measurement level of the data.

Regression analysis: Thirdly, regression analysis was conducted to define the explained

variance, the regression equations and mediation. Before a sound regression analysis could be executed and the correct conclusions can be drawn four assumptions have to be controlled for: independent sample, linearity, homoscedasticity, and normal distribution.

Independent sample: For the regression analysis, the first assumption is independence. Generally speaking the independence is guaranteed by taking a random sample, within the context of this research this independence has been checked in the research design.

Homoscedasticity: The third assumption is homoscedasticity. This was tested by means of the residual plots. Homoscedasticity was found with regard to the willingness to change and principal support. With respect to personal valence homoscedasticity was not clear, due to the low number of items within this variable.

Normal distribution: The fourth and final assumption is normality. This is tested by QQ-plots. No extreme values were found for the willingness to change and management support, but the personal valence scale showed a skewed distribution.

The complete residual plots and QQ-plots can be found in the Appendix 5.

Simple and multiple regression analyses were conducted. The simple regression analysis was used to investigate the causal relationships between an independent variable and the dependent variable. To be more precise: the causal relationship between principal support and the willingness to change and the causal relationship between personal valence and the willingness to change. Multiple regression analysis was used to investigate the relationship between multiple independent variables and the dependent variable. To be precise: the effect of these two independent variables on the willingness to change.

Moderation: Furthermore, regression analysis was used to investigate the possibility of a

Additionally, the Student t test was used to investigate if the correlation coefficients for the model used for employees with a management function are significantly different from the model for those without a management function. This could indicate a moderator effect (Fisher, 1924)

The results from these analyses are presented in the next section: Results. Model 1: Y = α1 + bX b must be significant

Model 2: Y = α2 + bX + cZ b and c must be significant Model 3: Y = α3 + bX + cZ + dXZ b and d must be significant, c not.

Independent variable (X) Moderator (Z) Dependent variable (Y)

Source: Baron and Kenny (1986)

FIGURE 6

4

Results

The previous section consisted of an elaboration on the research methods used in this study. In this section I will present the results. The first part of this chapter contains the descriptive statistics, which show the mean and the standard deviation of the variables. The second part of this chapter presents the results of the correlation analysis, followed by the answers to the first and second sub-questions. In the third part, the results of the regression analysis are displayed. This includes the explained variance and the regression equations for the model. Finally, the regression analysis shows the results of the investigation into a moderating variable, followed by the answers to the sub-questions 3a and 3b.

4.1

Descriptive statistics

The data from the questionnaire are based on the 5-point Likert-scale, ranging from “strongly disagree” to “strongly agree”. Table 5 shows the mean value and standard deviation of the three variables. The output from SPSS can be found in Appendix 6.

These results show that the dependent variable willingness to change and the independent variable principal support score moderately negatively. The independent variable personal valence produces a more negative score. I can conclude that the respondents are not willing to change.

TABLE 5 Descriptive statistics

Variable Mean Standard Deviation

Willingness to change 2.86 .879

Principal Support 2.22 .703

Personal Valence 1.51 .652

4.2

Correlation analysis

Correlation Analysis: To analyze the correlation Spearman’s Rang Correlation was used.

TABLE 6

Outcome of correlation analysis

Relationship Correlation coefficient P-value

Principal Support - Willingness to Change .433 .001

Personal Valence - Willingness to Change .193 .087

Personal Valence - Principal support .365 .005

The results show a significant correlation of .433 between principal support and willingness to change. There is no significant correlation between personal valence and the willingness to change, but there is a significant correlation between these variables of .193 at the .10 level. Finally, a significant and relatively high correlation of .365 between Personal Valence and Principal Support can be found. Because there is a relatively high and significant correlation between the independent variables, I will explore the possibility of a mediating relationship in the regression analysis. I will investigate the possible influence of principal support on personal valence. It is imaginable that principal support results in a positive relation with the principal, and consequently becomes part of personal valence. The influence of personal valence on principal support will not be included, because the link between these factors can hardly be considered to be a logical one.

4.3

Regression analysis

Simple Regression: The output from SPSS can be found in Appendix 8. The results are

shown in Table 7.

TABLE 7

Outcomes of simple regression analysis

Relationship Regression

coefficient

Constant Sig. R²

Principal Support - Willingness to Change .624 1.489 .000 .247

From this analysis I can draw the conclusion that there is a significant main effect between principal support and the willingness to change. The regression coefficient is .624 and the constant factor is 1.489. I can state that the regression coefficient is: Y = 1.489 + 0.624X. In addition, from the R-square, we can draw the conclusion that principal support explains 24.7% of the variance in the willingness to change.

On the basis of the analysis I can also state that the main effect between personal valence and the willingness to change is not significant. In this case the regression

coefficient is .252 and the constant factor is 2.518. The regression coefficient is: Y = 2.518 + 0 .252X. Furthermore, the explained variance is .038, which is very low. But, as was mentioned before, this relationship is not significant.

Multiple regression: The output from SPSS can be found in Appendix 8. The results are

shown in Table 8.

TABLE 8

Outcomes of multiple regression analysis

Independent Variable Dependent Variable

Willingness to Change

Constant Regression coefficient

Sig.

1.623 .000 Principal Support Regression coefficient

Sig.

.554 .002 Personal Valence Regression coefficient

Sig.

.030 .870

From this analysis I can see that only principal support has a causal relationship with the willingness to change. The significant regression coefficient is .554.

Mediation: Because the correlation analysis showed a relatively high and significant

Their argumentation is that, in order to demonstrate mediation, I have to estimate three models (Figure 7). It is important that the first three of the four conditions, mentioned behind the models, are met. Simple and multiple regression analyses are used to test the models in which I will investigate personal valence as a mediating factor.

The results of the three steps taken to test personal valence as mediator are presented in Table 9. From this analysis I can conclude that personal valence is not a mediator in the relationship between principal support and the willingness to change, because the third and fourth conditions are not met. The output from SPSS can be found in Appendix 8.

Model 1: Y = α1 + cX c must be significant Model 2: Z = α2 + aX a must be significant

Model 3: Y = α3 + c’X + bZ b must be significant and the effect of c’ must be zero Principal Support (X) Personal Valence (Z) Willingness to Change (Y)

Source: Baron and Kenny (1986)

FIGURE 7

TABLE 9

Outcomes mediation analysis personal valence

Step Model Regression

coefficiënt Constant Sig. R² 1 Y = α1 + cX .624 1.489 .000 .247 Y =1.489 + .624X 2 Z = α2 + aX .340 .757 .011 .128 Z =.757 + .340X 3 Y = α3 + c’X + bZ .554, .030 1.623 .870 .209 Y= 1.623 + .554X + .030Z

Moderation: First I will investigate the management function as a moderator variable in

the relationship between principal support and the willingness to change. Secondly, I will investigate management function as a moderator variable in the relationship between personal valence and the willingness to change. The output from SPSS can be found in Appendix 9.

TABLE 10

Outcomes moderation analysis management function in the relationship between principal support and the willingness to change

Step Model Regression

coefficiënt Constant Sig. R² 1 Y = α1 + bX .624 1.489 .000 .247 Y =1.489 + .624X 2 Z = α2 + bX + cZ .624, .484 .1.183 .000, .025 .322 Y = 1.183 + .624X + .484Z 3 Y = α3 + bX + cZ + dXZ .726, .898, -.186 .994 ..001, .208, .540 .328 Y= .994 + .726X + .898Z - .186XZ

The results of the three steps taken to test the management function as a moderator variable in the relationship between personal valence and the willingness to change are presented in Table 11. From the analysis I can conclude that the management function is not a moderator variable in the relationship between personal valence and the willingness to change, because the first condition is not met. The analysis is not continued after the first model.

TABLE 11

Outcomes moderation analysis management function in the relationship between Personal valence and willingness to change

Step Model Regression

coefficiënt

Constant Sig. R²

1 Y = α1 + bX .252 2.518 .173 .038

Y = 2.518 + .252X

not a moderator variable in this model. The output from the analysis can also be found in Appendix 9.

TABLE 12

Outcomes Student t test: moderation analysis management function in the relationship between principal support and willingness to change

Principal Support – Willingness to Change

Discrepancy Vs. B Stand.

Error B

Sb1-b2 T-statistic DoF P-value

2-tailed P-value 1-tailed Management function .539 .240 .3024 -.6184 47 .5393 .2696 No management function .726 .184 TABLE 13

Outcomes Student t test: moderation analysis management function in the relationship between Personal valence and willingness to change

Personal Valence – Willingness to Change

Discrepancy Vs. B Stand.

Error B

Sb1-b2 T-statistic DoF P-value

5

Conclusion

This study was designed to contribute to the existing literature on the willingness to change in healthcare organizations. Research has been done on the influence of principal support and personal valence on the willingness to change among medical specialists involved in a change initiative at the UMCG. Within this research the factor management function has also been investigated as a possible moderator. This section will draw conclusions based on the results presented in the previous section. Answers to the sub-questions and research question will be provided.

5.1

Answering the sub-questions

Sub-question 1: What is the influence of principal support on the willingness to change

(at the UMCG)?

The first level analysis has provided the answers to the sub-questions 1 and 2. The first question deals with the influence of principal support on the willingness to change. The results that appeared from the simple regression analysis have shown a significant positive relationship of .433 between principal support and the willingness to change. The results of the multiple regression analysis show that principal support has a causal relationship with the willingness to change. The significant regression coefficient is .554. This suggests that principal support has a significant influence on the willingness to change and that within the change initiative it is important that clear principal support is present.

Sub-question 2: What is the influence of personal valence on the willingness to change

(at the UMCG)?

importance for the willingness to change. An explanation might be that, as was stated in the theory section, commitment is more important than personal valence in the healthcare context.

Sub-question 3a: Does management function moderate the influence of principal

support on the willingness to change (at the UMCG)?

The results of the moderator analysis have shown that management function is not a significant moderator variable in this model. The answer to the sub-question 3a is negative. Management function does not moderate the influence of principal support on the willingness to change. The conclusion can be drawn that the influence of principal support on employees with a management function is not significantly different from the influence of principal support on employees without a management function and thus with a different department principals. A possible explanation could be that one out of the four questions on principal support concerns the department principals. The other three questions concern the organization’s top decision makers. Because, regardless of somebody’s place in the hierarchy of a healthcare organization, everybody has the same top decision makers, this could be the very reason why principal support is not significant different for employees in different positions

Sub-question 3b: Does management function moderate the influence of personal

valence on the willingness to change (at the UMCG)?

5.2

Answering the research question

Research question: How do principal support and personal valence influence the

willingness to change (among specialists at the UMCG)?

The second level analysis has provided the fit of the model. It is clear that this model will never provide a strong fit, because I only investigate two independent variables out of the five independent variables from the model by Armenakis and Harris (2002). The regression coefficient of principal support (Y = 1.489 + 0.624X) shows a positive linear relationship and explains 24.7% of the variance in the willingness to change. This is relatively high. On the other hand, the regression coefficient of personal valence (Y = 2.518 + 0 .252X) shows a positive linear relationship and explains 3.8% of the variance in the willingness to change. This is very low.

The results of the multiple regression analysis have shown that there is no significant causal relationship between personal valence and the willingness to change when the two independent variables are both included.

A remarkable conclusion drawn from the regression analysis is that a significant causal relationship exists between principal support and personal valence of .365. This could indicate that the influence of principal support on the willingness to change takes place by means of personal valence. But the analysis to test a possible mediating relationship has resulted in the conclusion that there is no significant evidence for the presence of a mediating relationship. Personal valence is not a mediator in the relationship between principal support and the willingness to change. A possible explanation for the significant correlation between the two independent variables might lie in another, unknown variable influencing both.

6

Discussion

6.1

Theoretical contributions

This study has added support for Armenakis et al.’s theory in which they specify five change message domains, by investigating the concepts of principal support and personal valence. From this study in a healthcare context there is additional support for the positive relationship between principal support and the willingness to change. Personal valence, on the other hand, is seen as having no significant relationship with the willingness to change. This was not unexpected, as in the theory section it was already mentioned that commitment is a more important factor in the healthcare context rather than personal interests. The results of this research support the notion that personal valence is not important in this context. This explains why, within the existing models on factors influencing the willingness to change, generalization directed to different businesses should be expressed with caution.

6.2

Practical implications

As was said by Ford et al. (2008) the willingness to change is one of the factors contributing to the effectiveness of organizational change. At the trauma centre of the UMCG the employees that filled in the questionnaire appear to be scoring moderately negative on the willingness to change scale. This indicates a need for action to improve the situation. The results of this research indicate that not so much personal valence but especially principal support may contribute to stimulating the notion of willingness to change among its employees.

In general several researchers (Metselaar and Cozijnsen, 1997; Holt et al, 2007; Armenakis and Harris, 2002) emphasize the importance of principal support for the willingness to change. Analysis of the available data on this subject, for example by De Wagt (2010), shows that principal support has both a positive correlation and a causal relationship with the willingness to change. In the healthcare context it is even said that principal support is especially important, because of the typical characteristics of this sector (Anderson and Mc.Daniel et al. 2000; Cohen et al. 2004; Vassalou, 2001). In line with this reasoning a high correlation was found between principal support and the willingness to change, at the trauma centre of the UMCG. According to this research it is particularly important that the management of the organization demonstrates support in the form of resources and commitment.

on the study by Herbert and Swick (2000) the UMCG can opt for the investigation of the variable commitment in the future.

Management function does not moderate the relationships, which suggests that there is no difference between employees with a management function and those without. Consequently there is no reason to threat employees with a management function differently from those without, but according to Metselaar and Cozijnsen (1997) middle managers play a key role in change processes. They state that for the success of a change initiative it is crucial to have a high degree of willingness to change among employees with a management function. At the trauma centre of the UMCG both the employees without a management function and the employees with a management function score moderately negative on willingness to change. This suggests that special attention should be paid to the employees with a management function, because of their key role.

6.3

Limitations and further research

This research has some limitations which have to be considered. Although all the professions are equally represented and the number of respondents is also representative enough to come to the analysis as described, there was a response rate of only 9%. This was not unexpected, but is still very low. The sample consisted of 52 respondents and represents only a small proportion of the population. The fact that the size of the sample used was relatively small makes it necessary to interpret the conclusions with caution. Another implication of the sample size of 52, is the difficulty in finding significant results of the moderator analysis. Further research should include a larger sample size to generate a higher absolute response to investigate the moderating effect of management function.