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Master Thesis
The role of change interventions and their influence on e-health acceptance
among practitioners
MSc BA Change Management
University of Groningen, Faculty of Economics & Business
March 06, 2014 Marte Smit Student number: s1777971 Idastraat 32 9716 HD Groningen Tel.: +31 (0)627327608 E-mail: smit.marte@gmail.com Supervisor:
Dr. M.A.G. Van Offenbeek
Word count excluding references and appendices:
12.824
Acknowledgements
I would like to thank Dr. M.A.G van Offenbeek for her advice, motivation and extensive feedback during the process of writing this thesis. Second, I want to thank my fellow master student Mark Damink who joined me in a similar research at the same organization and with whom I was able to exchange ideas and share experiences. Most importantly, I want to thank the e-health department of the organization where this research was conducted for giving me the opportunity to learn from them.
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Abstract This research aims to refine the existing models that exist in the e-health implementation literature. To be more precise, the acceptance of practitioners is investigated by considering which change-interventions should be used during different moments of the implementation process. Thus, a combination of existing theory on implementation phases and factors influencing acceptance is being made. This thesis analyses two e-health applications that were implemented in the same organization. Interviews with practitioners and implementers were conducted to get a broad view of the implementation efforts and the experiences of the different professionals involved. The results are presented in a timeline model and suggest that an implementation process does not move from one phase to another, instead, a phase consisting out of specific interventions should be continued while a new phase starts.
The role of change interventions and their influence on
e-health acceptance among practitioners
1. Introduction
Within the 21st century many challenges have arisen in the health-care sector. Murray et al. (2011) state that an aging population, increasing prevalence of long-term conditions, improving health technologies and rising expectations of healthcare all lead to increased pressure on healthcare resources. Experts believe that the use of information and communication technology (ICT) is one of the ways of coping with this pressure; such technology is key to improving the quality and efficiency of health care (Chaudhry et al. 2006). Varying definitions of the term ‘e-health’ exist in the literature. In their systematic review, Oh, Rizo, Enkin and Jadad (2005), found that nearly all definitions include the concept of ‘health’ and most definitions explicitly refer to health-care as a process instead of merely an outcome. Most commonly cited is the definition of Eysenbach (2001) (Oh et al. (2005). Eysenbach (2001) states that e-health is an emerging field in the intersection of medical informatics, public health and business that refers to health services and information delivered or enhanced through the Internet and related technologies.
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implementing an e-health application is risky; the costs and disruption are usually much easier to demonstrate than the benefits of such an application (Boddy, King, Clark, Heany, Mair, 2009). Furthermore, Boddy et al. (2009) state that many e-health systems fail to become used as a part of everyday working practices. Murray et al. (2011) describe that there has been significant variability in the success of e-health implementations; projects face delays, budget deficits and sometimes severe negative impacts on the quality and effectiveness of care. Often, this variation in success is not caused by the new strategies or goal itself but by the way in which the e-health application is implemented (Greenhalgh, Robert, Macfarlane, Bate & Kyriakidou, 2004. Therefore, this research aims to contribute to the existing body of literature by specifically looking at implementation efforts directed at acceptance of e-health among health care practitioners. The research objective will be developed in more detail below.
1.1 Research objective
Implementation research within the healthcare sector is still a relatively young science (Eccles et al., 2009); nevertheless, a substantial body of literature already exists. A persistent implementation problem is that practitioners are often skeptical towards health while e-health can change their professional roles and affect the organization of clinical work (Mair et al., 2009). The use of clear goals, a strong vision and support from management are elements that can diminish this skepticism (Greenhalgh et al., 2004) More specifically, literature on implementing technological change in health-care environments has found that the relative advantage, the complexity, the compatibility with the organization, the opportunity to test, and the clarity of the possible results of the innovation are the significant factors that influence the phases of an e-health implementation process (Rogers, 2003). Furthermore, the characteristics of the leader or ‘implementer’ (Battilana, Gilmartin, Pache & Alexander, 2010) and the characteristics of the organization and the organizational members itself are also often found in existing literature on success of technological change (Cawsey, 2012).
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acceptance but by proposing a timeline model presenting the critical change-interventions per phase of the implementation process. In other words, a lot is known about e-health implementation, however, more detailed information should be known about the organization of the implementation process to increase acceptance among practitioners (Fleuren, 2004). The following research question is asked;
How can implementers of e-health applications make optimal use of change-interventions in order to increase the acceptance among practitioner-teams?
Looking at the managerial interest, one can use this research to improve the implementation process of an e-health application among practitioners by incorporating the interventions as indicated by this research. These practitioners are of great importance because they are the bridge between the organization and its clients. When they are not incorporating the e-health application in their daily work, the clients will never adopt the application and implementation will fail. Chauhdry (2006) emphasizes that an e-health application on its own is merely a technology, the way in which this technology is used and implemented is crucial.
The data gathering for this research will take place in a large mental health care organization located in The Netherlands. Two e-health implementation processes, one of them being a pilot and one of them in the beginning of the implementation process were investigated. The two projects are being implemented by different project-groups and have different rates of success so far. By comparing the two projects and the experiences of the practitioner-teams the main research question was answered.
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2. Theory
In this section, we will first give definitions of the most important concepts covered in this research. Secondly, a short overview of what is already known about e-health implementation and the factors influencing its success is given. Subsequently, change-intervention models are elaborated on, leading to the development of three sub-questions for this research.
2.1 E-health applications
E-health entails health informatics, health telematics, telemedicine and tele-health which together form a significant part of the information society (Hovenga, 2003). Simply said, e-health applications are e-health information technologies that support the delivery of care, however, they do not in themselves alter states of disease or health (Chaudhry, 2006). It should be noted that e-health applications always have a direct link with the delivery of care.
The term e-health can also be used to refer to a broader phenomenon, namely, a way of thinking or ‘state-of-mind’ to improve health care locally, regionally and worldwide by making use of ICT (Eysenbach, 2001). Kwankam (2004) states that e-health is essential to keeping pace with the exponential growth of health information. Furthermore, it allows for more efficient use of medical resources and a reduction of administrative costs (Kwankam, 2004). For this research a broad but simple definition is used; e-health refers to an ICT application that is introduced with the aim of improving health care provision.
2.2 Acceptance of an e-health application
Within the cases used for this research, three important stakeholder groups play a role; the project-team who is in charge of implementing the application, the practitioners who have to work with the application and the clients who are confronted with a new application. Looking at the research question, the ‘implementer’ and the ‘practitioner-teams’ are the two central stakeholder groups of interest.
The project-team initiates the change and tries to convince the practitioners to change, thus, the project-team is the ‘implementer’. According to Cawsey (2012), an ‘implementer’ or implementation-team is a stakeholder that initiates or promotes a change; in this case the implementation of an e-health application. This research will investigate both the implementer and the practitioner-teams’ opinion to gain information and it also considers the interaction between these two stakeholders.
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involves all the activities that occur between making an adoption commitment and the time that an innovation becomes part of the organizational routine (May & Finch, 2010). Cooper and Zmud (1990) portray this process for IT by suggesting a six-phase model of IT implementation, ranging from initiation to infusion, see figure 1. Within this study, the focus will lie on the first four phases as described by Cooper and Zmud (1990).
Looking at the six-phase model (figure 1), it can be observed that the first three phases are focused on making the decision to implement the application, preparing the organization for the application and installing the application. In the fourth phase ‘acceptance’, organizational members truly have to change and commit to the application; the application is employed in organizational work (Cooper & Zmud, 1990). After the acceptance phase, the application will become even more integrated in the organization in the routinization phase and after that increased organizational effectiveness is obtained in the infusion phase. Nevertheless, acceptance is crucial and needs to be reached first. Therefore, acceptance is the phase that is central in this research.
Figure 1. Model of IT-implementation, subtracted from Cooper & Zmud (1990)
2.3 Factors influencing e-health acceptance
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that there is often an alignment issue between the technology and the organization. The technology should fit with the organizational goals and the existing skills of staff (Murray et al., 2011). Rogers (2003) adds to this that the larger the relative advantage of a technology compared to the existing technology, the higher the chance of successful implementation. This research by Rogers (2003) also describes that when an innovation is easy to use, there is the opportunity to test the innovation and there is proof of the results of the innovation, adoption will increase.
Interestingly, organizations have often looked for a ‘silver bullet’ for achieving alignment (Luftman & Kempaiah, 2007). However, such a silver bullet does not exist and successful implementation cannot be achieved by simply picking the right technology. Murray et al. (2011) for example claim that a new technology will only be used when implementers perceive a positive impact on interactions between professionals and patients and between different professional groups. Furthermore, Boddy et al. (2009) have developed a model in which the outcomes of e-health implementation depend on actions of stakeholders who have an interest in the project. These stakeholders create an implementation process that takes place in a certain internal and external context. The stakeholders interact with each other, the context, and the project; in the end this might lead to the adoption or death of the application (Boddy et al., 2009). Thus, it can be seen that e-health implementation is much broader than just considering the technology itself; the interaction between the technology and organizational features is crucial (Zammuto, Griffith, Majchrzak, Dougherty & Faraj, 2007). Besides the interaction between the technology and the organization, Greenhalgh et al. (2004) explain that the following organizational features affect implementation; the membership of a network of health institutions, an organizational culture that is open to changes, clear goals and organizational vision, and support from management.
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a positive relationship with change success. Cawsey (2012) emphasizes that change leaders need to create awareness related to the ‘need for change’. When the need for change is clear, the readiness for change rises. The readiness for change is the degree to which the need for change is perceived and accepted. Nevertheless, Cawsey (2012) also states that many factors internal to the change recipient can be of influence when implementing change, for example; lack of experience with change, negative experiences with change, a negative experience with the change leader or a lack of procedural fairness in the implementation process. Moreover, the culture of an organization can play an important role in the implementation process and acceptance of the new technology (Greenhalgh et al., 2004). Lastly, although it seems obvious, it is also critical to ensure alignment between the different steps of the implementation process and have a clear communication plan which means that the same message and same assignments need to be given throughout the implementation process (Cawsey, 2012).
Thus, successful IT implementation entails a broad range of critical factors. The application itself, both the internal as well as the external context, the fit between the technology and the organization and several characteristics of the leader and the change recipients play a role. Fleuren et al. (2002; 2004) present a quite similar finding in their study of 50 factors/determinants; they have found five different domains of determinants that influence the implementation process. These domains are as follows; the characteristics of respectively the innovation, the organization, the innovation strategy, the adopting users and the social political environment (Fleuren, 2004). The determinants were later presented to 46 professionals to get an insight into the intensity and direction of influence of the different factors.
2.4 Change-interventions
9 Figure 2. 8-step model of change, Kotter (1996)
When all eight steps of the change-intervention model are included and used appropriately for that specific change, the change is most likely to be successful. The 8-step model of Kotter (1996) falls into the planned change category. This study will make use of a planned change perspective because it will look at the different phases and steps of the change implementation process and finally present results that include how to plan which change interventions.
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organizational culture is a slow process. In case of introducing a new IT application, the change does not directly affect the organizational culture. However, as the application might change the complete way of working, for example online contact instead of face to face, organizational culture might have to change as well. Schein (1992) believes there are several mechanisms like role-modelling and teaching, and the allocation of rewards and status that managers can make use of to change organizational culture. (Schein, 1992).
This research will investigate which change-interventions from each of the four categories (Beitler, 2005) should be used in each of the phases of the IT-implementation model (Cooper & Zmud, 1990) that was presented earlier. In addition, the theory of Knowles and Linn (2004) will be used to provide an even clearer perspective on how to persuade practitioners to accept e-health applications. The theory of Knowles and Linn (2004) entails an approach-avoidance model of persuasion. The approach-avoidance model states that persuasion can take place by increasing the approach forces (Alpha strategies) or by decreasing the avoidance forces (Omega strategies). Simply said there are two options; increasing the motivation to move towards the goal or reducing the motivation to move away from the goal. An Alpha strategy would be a strategy in which the positive sides of the new goal are central and the strategy aims to convince someone of the benefits of the goal. An Omega strategy on the other hand will address the avoidance forces or resistance that might exist. Thus, without addressing the resistance and decreasing it, the benefits of a new goal might be very convincing but the persons involved in the change will still have their own reasons to resist.
Dollard and Miller (1950) explain how the ‘approach cues’ or positive reasons to move to the new goal are stronger when far away from the goal. Closer to the goal, the ‘avoidance’ cues or reasons to avoid the new goal become stronger and therefore, there is a crossover point where one will be ‘frozen’ (Dollard and Miller, 1950). Therefore, the right combination of omega and alpha strategies will have to be used. Looking at first four phases of Cooper and Zmud (1990), one could say that the organizational members need to be convinced of the new goal in the first two phases of initiation and adoption. In the adaption and after that the acceptance phase the focus needs to be on strategies that acknowledge the reason for resistance that the organizational members might have.
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of practitioners in e-health and how these interventions should be used. Furthermore, we will also use the theory of Knowles and Linn (2004) to investigate when the approach or avoidance strategy is most useful in gaining acceptance. The following sub-questions will be answered;
Sub question 1: Which change-interventions seem to be valued by the practitioner-teams and,
in that sense contribute to achieving e-health acceptance among practitioner-teams?
Sub question 2: How should the change-interventions be planned in order to contribute to the
acceptance of practitioner-teams?
Sub question 3: When should an implementer of e-health pick an alpha and when an omega
strategy to persuade practitioner-teams to change?
The first sub-question aims to investigate which change interventions are valued and which important interventions were missed by the practitioner-teams. The second sub-question adds to the first sub-question by exploring how the interventions can be planned and how the change process is timed in general. Thirdly, the final sub-question looks at which strategy is most successful in persuading the practitioner-teams to change and thereby it specifies the choice for certain change-interventions even further.
By answering the sub-questions, a guideline or ‘manual’ for e-health implementation can be developed. This manual will state which change interventions are critical, what the best order of using these interventions is and how the interventions can be combined. This will answer the main research question; ‘How can implementers of e-health applications make
optimal use of change-interventions in order to increase the acceptance among practitioner-teams?’
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practitioner-team. By using the interventions in the right context and with the right timing a higher acceptance level among practitioners can be realized.
Figure 3. Research framework; E-health implementation process, modified from Cooper and Zmud (1990)
3. Methods
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3.1 Case Description
The data collection for the two case studies used in this research was conducted at a large mental health care institution with several locations in The Netherlands. This research analyzes the implementation process of two e-health applications at this organization, namely, online (hybrid) treatment and an online client portal. Both of these applications fall into the e-health category because they support the e-health care delivery and make use of ICT (Chauhdry, 2006; Eysenbach, 2001). For each of the two e-health applications, two practitioner-teams that work with the application were selected. From each team, practitioners with different functions were interviewed. Based on the project-plans and introductory interviews with the project-leaders, a short overview of each of the cases is given below.
1) Project 1 is a portal for clients. Clients can log in, check their upcoming appointments, read their patient file and comment on it, and check their personal data as are known with the organization. Furthermore, clients can choose to use text alerts that they receive on their mobile phone to remind them of their appointments. The practitioners themselves will not use the client portal, but they do need to know how the system works and stimulate their patients to make use of the application. The practitioners will work in their own online patient file application. In this application, they will read the comments that they receive from their patients via the client portal and through this application they will also be able to respond. This means that both systems are linked, yet the practitioners can still choose to keep some entries in the file to themselves. Nevertheless, it is a new way of working and the patient will be constantly looking over the practitioners shoulder since they can check their file. The pilot phase of project 1 has recently reached its end. Currently; a go/no go decision needs to be taken about this project.
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patient has finished the treatment, the practitioner can give feedback. The online treatment will consist of questionnaires and exercises that the patients will do. The practitioners can adjust the online treatment sessions to the specific patient. There are pre-developed protocols, but practitioners can make changes in the order, skip sessions, or integrate a sessions from different protocols. It is the practitioners that need to decide which patients can and should make use of online treatment, which online treatment and to what extent. The sessions will need to be put in the online account of the patient and the patient needs to understand how it works. Thus, the practitioners need to be very familiar with the application and its use and effects themselves. Therefore, a training program is offered to the practitioners. One by one, different departments are starting to work with such online treatment. Online treatment is not a free choice for the organization. They will have to start making use of such treatment because it is demanded by the insurance organizations to cut costs. Nevertheless, there are only a four teams currently working with online treatment, and it is still operating in a project format.
3.2 Data collection
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The interviews took place at the mental healthcare organization and lasted about an hour each. The protocol that was used during these interviews can be found in Appendix 2. The interview questions were structured around the different elements of an implementation process; testing, communication, preparation/training & evaluation. A semi-structured approach was used to make sure all the elements were present in each interview but to also give interviewees the opportunity to add information themselves. The interviewees were selected based on their function, that way; several professional levels within the project were represented. This variety in roles and levels improves the reliability of the study (Van Aken, Berends & Van der Bij, 2007). Furthermore, people with both positive and negative views on the projects were interviewed, this also enhances respondent reliability. All the interviewees received a guarantee that the interview would remain confidential and anonymous. In table 1 and 2, an overview of the interviewees and other sources used for this research is given.
Client portal (project 1) Hybrid treatment (project 2)
Source #
Interview Project-leader 1 Interview Project team-leader 2 Interview Practitioners 5 Observation evaluation meeting 1 Project documentation 2
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Table 1 and 2, overview of sources.
Van Aken et al. (2007) describe the instrument as a potential source of bias in the research. By making sure the interview protocol contains multiple questions on each of the implementation phases or elements, this study tries to limit the instrument bias. Furthermore, by making use of multiple research instruments, this research also tries to diminish the instrument bias even further. Besides the use of interviews, an evaluation meeting of project 1 and an introduction presentation of project 2 were observed in which practitioners also gave their opinion about the application and shared their experiences. In addition, documentation about the two e-health implementation processes was analyzed. By doing so, a better understanding of the projects was developed and certain focus points were identified. Document analysis is an indirect observation method. This means that reliability is a large problem when making use of such analysis. In this study, the document analysis consisted out
Source #
Interview Project-manager 1 Interview Project-(team)leader 2
Interview Practitioners 4
Observation of introduction presentation 1
Project documentation 2
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of project-plans and evaluation reports. This documentation was used to analyze the project and organization policies. Thus, the processes and policy and the preparation and negotiation about these policies can be analyzed. However, document analysis cannot tell us how effective the policies or implementation processes have been. The interviews were used to provide an answer to the effectiveness question.
3.3 Data analysis
After conducting the interviews and gathering the project documentation, the data analyzing process started. All of the interviews were recorded with the consent of the interviewees and afterwards completely transcribed. These transcriptions were then codified to enhance the retrieval of data. Coding is a technique that entails linking fragments of text to particular categories that are either previously developed or created ad hoc (Bauer & Gaskell, 2000). This research has made use of axial coding (Boeije, 2005) which is a combination of inductive and deductive approaches. Firstly, the interview texts were divided into large parts based on the different elements like communication or evaluation that were included in the interviews. With this technique, a preliminary list of codes was developed. With this list in mind, the axial coding process was started. Axial coding zooms in on a smaller area or category and collects all the relevant data around this category (Boeije, 2005). This coding process has led to a list of codes that are described in appendix 3. It is important to notice that axial coding is still largely inductive and thus there is not a completely pre-fabricated list of codes. Miles and Huberman (1994) explain that inductive coding ensures a more open minded and context-sensitive researcher. This is necessary while the researcher is a fourth potential source of bias (Van Aken et al. 2007). Furthermore, it is of great importance to achieve a certain level of ‘intersubjectivity’ in qualitative research (Baarda, De Goede & Teunissen, 2005). In other words; two or more individuals share the same meaning or definition of a subjective state. To reach intersubjectivity, a number of interviews was conducted by two different researchers and therefore also coded by two different researchers; the coding was compared and discussed and an agreement level of 90% was reached.
4. Results
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4.1 Results Project 1 (Client portal)
First of all, it should be noted that all the interviewees are positive about the concept of the client portal. They feel that it is important for clients to have the opportunity to enter their personal file and believe that the client portal can truly offer an added value. As one practitioner states; ‘I am in favor of the client portal while the patient file belongs to the
patient instead of it being a closed file that belongs to the practitioner’. Nevertheless, it seems
that not a lot of clients feel the need or desire to make use of the client portal; less than 40 % of the clients made use of the portal. Also, less than 50 % of the practitioners made use of the portal at least one time. In one of the teams considered for this study, only three practitioners were active. Thus, we could say that not a lot of practitioners have committed to the application and acceptance is low (Cooper and Zmud, 1990).
Below, the results for project1 will be presented based on the three sub-questions that were asked in this research. Quotes will be given to illustrate the feelings of the employees. In appendix 3, a table presenting an overview of the illustrative quotes can be found.
SQ 1: Which change-interventions seem to be valued by the practitioner-teams and, in that sense, contribute to achieving e-health acceptance among practitioner-teams?
For Project 1, it can be seen that the employees have not participated in the initiation or adoption phase as presented by Cooper and Zmud (1990). Most interviewees state that there was no opportunity to discuss or test the application before going live. As one of the project team-leaders describes; ‘When I entered the project, the decision to implement the application
was not made yet, however, the decision to run the pilot was clear.’ The project-teamleaders
did have the opportunity to test the system and experience what the client would see in the system. For other practitioners, there was no opportunity to test the system before going live. However, some of the practitioners mention that Project 1 is a pilot, and therefore, the complete implementation can be considered to be a test phase. This could also be the reason that the practitioners did not feel the urge to test the system although some of them were given the opportunity.
Secondly, communication before and after the project went live was addressed in the interviews, these can be considered to be part of the adoption and adaption phases. Most interviewees stress that the communication about the adoption of project 1 was sufficient. ‘As
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prepared for working with the application; ‘It is a pretty easy system to work with as long as
you know how to put things online’. In addition, most of the practitioners have valued the
preparatory presentation that was given by the project-leader; ‘There was a theme-meeting
with explanation, also about how it works technically, the project-leader was here once or twice, there was enough attention for the technical part.’ Nevertheless, some practitioners do
mention that they feel that a short training session instead of merely a PowerPoint and hand-out with instructions would have been good; ‘For me personally it was sufficient, however, I
do think that some colleagues feel that the system is very confusing, but they can always go to the project-teamleader.’ Another practitioner adds; ‘I can look up how it works technically, but it was never addressed how to write our reports….it would have been good to have a training in which those aspects are included, because you do worry about how your words can be interpreted .’ In addition it does seem that some of the practitioners are not completely
familiar with the functions of the system. They sometimes are not able to describe all the possibilities within the system, especially not from the client perspective. However, the practitioners feel that it was easy to ask questions or get extra information from the project-teamleaders. ‘The project-teamleader will just explain it to me again, it is very easy to ask him
something or get extra information.’ It should be noted that the project-teamleaders are
especially of added value for the practitioners that have already shown some acceptance and try to work with the application. The project-teamleaders were not very active in the adoption or adaption phases of the implementation.
To conclude this section about adoption and adaption, several practitioners describe how there was no sense of urgency or direction surrounding the project. One practitioner expresses this feeling as follows; ‘It (the project) has always felt a little vague…as if the
initiators said ‘well we are going to try this but we are not sure whether it will work’ it is a feeling like that; that is not going to work.’
The last phase that was included in the interviews was the evaluation phase. All the practitioners and project-teamleaders describe how there was an official evaluation at the end of the pilot. The practitioners all have the idea that they had the opportunity to give their feedback and criticism to the project-group. No evaluation-meetings have taken place within the practitioner teams. One of the practitioners states; ‘The evaluation took place in the
project-group, it is a pilot, so I think it is fine that the project-group did this evaluation, it is not necessary to include the teams more.’ However, some other practitioners do believe it
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It can be stated that the practitioner-teams have valued a lot of the elements of the implementation process. Especially the presence of the project-teamleader and the moments in which the project-leader addressed the team were a positive experience for the practitioners. Nevertheless, the practitioners also indicate a lot of change-interventions which they would have desired but did not take place. Especially in the communication after the project went live, which is the adaption phase or third phase according to Cooper & Zmud (1990), they see a lot of improvement possibilities. In the next section it will be described how the change interventions should be planned to achieve acceptance among more of the practitioners.
SQ 2: How should the change-interventions be planned in order to contribute to the acceptance of practitioner-teams?
In general, the pre-live phases and especially after the adoption decision was made were experienced very positively by the practitioners. The information was clear and they also felt up to date during the time of delay. Interestingly, the project-leader and the project team-leaders feel that the time between the decision to implement and truly going live were too long; ‘There was a long time gap, I showed them the application but the system did not go
online at that time. We should have kept giving information to the practitioners about the status of the project.’ None of the practitioners elaborate on this problem; they feel that they
have been informed quite well about the application before it went live. Nevertheless, both project-teamleaders and practitioners mention that the project or product should have been finished when they received the explanation, this would have created a better starting point for the project. Secondly, many of the respondents also indicate a bigger problem in the timing of the project; they feel that the teams were overwhelmed by the amount of changes in the same period. One of the project-teamleaders says; ‘My main lesson is how we underestimated what
it would mean for a team to go through this many changes’.
On average the communication after going live was not experienced very positive by the practitioner-teams; the general feeling seems to be that there was not a lot of attention for the project within the teams. One of the practitioner states ‘With something new
like this I think you should keep asking attention for it within the team….also to exchange experiences, which is not something we did.’ Another practitioner says; ‘It would have been good to talk to each other about it after some time, to know how they do it, because we really do not talk about it a lot.’ After the preparation presentations, there were no planned moments
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However, this lack of updates or meetings is partly compensated by the presence of the project-teamleaders who were always willing to answer questions as was described earlier. Thus, overall it looks like the practitioners have mainly missed regular moments in which they talk to each other about the application and how the application influences their work. The project-teamleaders also acknowledge that this part of the implementation should have gotten more attention; ‘Well I think I could have done more. Maybe put it on the agenda once
every three weeks. To give an update. It could have been more formal’.
An interesting fact is that both project-teamleaders have felt really informed and kept up to date by the project-leader, they have had bi-weekly meetings with the project-group and this was more than sufficient. ‘Yes I thought we got enough support and motivation etcetera
coming from the project-group. The project was kept alive it was good to have this many meetings.’ In other words, the project-teamleaders did get a constant flow of information and reminders about the projects, but it seems that this was not always taken into the teams. Also, as can be observed from the coding scheme in Appendix 4, evaluation moments were not created within the teams. Practitioners felt they could always ask questions or give feedback via the project-teamleader; however, they would have also appreciated some special meetings to share with one another. Not only did the practitioners not share experiences with each other, they also were not aware of important steps that were taken within the project-group. For example, at the timeline in appendix 1, one can see that all clients received a letter to inform them about the project, several of the practitioners did not know that their clients had received this letter.
To summarize this section, the change-interventions were not planned on a regular basis or in a formal setting. After the project went live, the project-group became quieter and there was not enough attention for the application. This means that more interventions should have been planned from the adoption phase onwards. Moments to share experiences and ideas within the team were not planned by the project-group. Also, the timing of introducing the project in general was not experienced very positive by the practitioners.
SQ 3: When should an implementer of e-health pick an alpha and when an omega strategy to persuade practitioner-teams to change?
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wellbeing of the clients. They feel that project 1 can be of added value for their clients, and therefore, they want to start working with the application. A simple conclusion that can be drawn from this is the fact that practitioners will be more motivated to work with the application when they become more convinced of the added value for the client. In addition, the application might need more benefits to convince the practitioners. The practitioners mention that their motivation would most probably grow if the functionalities of the application grow; ‘Expand the application. Offer something more. Now it is just a treatment
plan and a report, it is not interactive enough’. The practitioners would like to have the
opportunity to place different types of reports on which the client can respond; also functionalities like a diary were often mentioned.
Another ‘pull-factor’ towards working with the application is the ease of use. ‘I mainly
see improvement opportunities in the technical area. And also, that the system reminds you to put things online, otherwise there is no point’. By improving the functionalities and the ease
of the system, the application will become more attractive for the practitioners and they will be more likely to accept the application. This would mean that an alpha strategy of persuasion will have to be used to convince more practitioners in the future. One could think that in order to convince the practitioners, management or directors should make use of their power to influence the practitioners. However, the practitioners do seem to value the project-teamleader who is part of their own team very highly. Nevertheless, they sometimes miss the involvement of the higher levels within the organization. The practitioners and project-teamleaders do feel that the project-group can bring this extra force; ‘You can see that people
ask a different type of questions when the project-leader is here. It is different when it comes from the project-group; it is a little bit more from ‘above’’. The project-leader himself sees a
larger role for the general management and directors to enact their power and persuade the practitioners. The project-leader feels that he has no power over the practitioner teams while he is merely a project-leader and not their boss.
Maybe more importantly, the results also show a prominent reason to make more use of omega strategies. During the evaluation meeting that was attended by the researcher, several practitioners indicated that they are worried about ‘the reading along’ of the client. One of the project-teamleaders states that he knows that at least one practitioner did not enter the project for this reason. One of the practitioners explains very clearly where the fear of ‘reading along’ comes from; ‘That is always a danger, also with email-contact, that things do
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Another reason for resistance, as mentioned in the evaluation meeting, is the extra work that the project brings; ‘The client found all kind of little mistakes in his file, this gives a
huge amount of extra work. The application should be focused on the treatment’. Also, the
practitioners are very straight forward about the amount of steps that need to be taken to put a client online, this process is very straining and multiple practitioners state that this is one of their largest problems with the application. The extra work and steps obviously mean that the practitioners avoid moving towards the desired goal.
This section can be summarized as follows. Most practitioners seem to have a clear understanding of the benefits; nevertheless, they seem to feel that these benefits can be enlarged when the functionalities of the application are enlarged. In addition, the practitioners feel that the project-group including the ‘higher’ members of this group could be more involved and actively convince them of the new goal. Another finding of this section is the importance of the omega strategies, several significant reasons for resistance exist and these need to be addressed in order to persuade the practitioners.
4.2 Results Project 2 (Hybrid treatment)
Similar to project 1, the practitioners perceive the system as a great added-value for their client. The system makes the treatment more intense and provides recognition for the clients. The application has been in use for about a year in the two teams that first started the project. Thus far, the project has been quite successful, only two practitioners do not work with the application and 260 clients have already received blended treatment.
SQ 1: Which change-interventions seem to be valued by the practitioner-teams and, in that sense, contribute to achieving e-health acceptance among practitioner-teams?
Project 2 started out small in one team. Several members of this team had already indicated that they were interested in online treatment and it was something that they had spoken to each other about. One of the practitioners became project-leader and some of the practitioners from the first team have also been involved in the adoption phase of the project; ‘I have also
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going live, another team from the same department was asked to join the project. These two teams can be considered to be the pilot of the project.
The practitioners from both teams have valued the efforts that were made in the adaption phase, after the project went live. As the project-leader explains, some of the practitioners got lost in the large amount of modules that the system contains and not all practitioners were equally enthusiastic. Therefore, the project-leader decided that the practitioners needed to present modules to each other. This was very much valued by the practitioners; ‘We had information meetings and exchanges about the project. Not many, but
we did talk about how to make use of the application, how do others use it? It gave me new ideas and direction.’
Another intervention that was valued by the practitioners was the buddy-system that they had to work with. Unfortunately, the presentations and meetings as well as the buddy system were something that moved to the background pretty quick; ‘In the beginning we had
to find buddies to work together. I did it for a while but we could not find the time for it, it degenerated very soon’. The training that all practitioners received before starting to work
with the application took two days and was very extensive. Therefore, all of the practitioners were very satisfied with the training they did. The training consisted of discussing the system and after that a very practical in depth explanation followed. The practitioners had the opportunity to play with the application and could also see what the clients would go through on their end. In the words of Cooper and Zmud (1990), this means that an important step was taken in the adaption phase; organizational members were trained and organizational procedures are revised.
As for the evaluation, the practitioner-teams seem to be satisfied as well. The project-leader involved all of the practitioners and ask them to give their opinions about the system; ‘We had the opportunity to share where we think the system works and where it does not
work’.These evaluations were done with the team as a whole, and moreover, the practitioners were supposed to share their experiences with each other in different ways as was explained above. Not all of these exchange moments stayed on the agenda, and therefore, looking at evaluation, more team evaluations could have been present. Another issue related to evaluation is the missing feedback about what is being done with the evaluation. The practitioners would like to know what steps are taken with their criticism and ideas; ‘We had
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To summarize this section, one can state that the practitioner teams have appreciated many of the change interventions. Yet, a large amount of these interventions were not followed through or followed up which leaves room for improvement. In the next section, this will be reflected on in more depth.
SQ 2: How should the change-interventions be planned in order to contribute to the acceptance of practitioner-teams?
As was mentioned in the previous section, some of the planned change interventions degenerated relatively quickly. This degeneration of planned interventions seems to be related to the issue of timing. The project-leader describes this as follows; ‘We did not pay attention
to it for a while because we are a department in which there is a lot of commotion and change going on.’ One of the practitioners adds to this; ‘I think the actions that were planned were very good but they will only work in a calm environment. For us, it did not work.’ On the
other hand, another practitioner does in fact believe that while they are a new department, they are more comfortable with changes, and therefore, many of the practitioners were enthusiastic about the project. However, most practitioners as well as the project-leader agree that the introduction of such a project would be better off in a stable department.
Although the bad timing of introducing the project in a new department is the biggest timing issue, the general idea of planning more interventions is an important conclusion of this section. The practitioners recognize that they know the system, but they do not know all of its content and are not completely familiar with the whole system. One of the practitioners explains; ‘If for some reason you are not that enthusiastic about the project, if you feel some
resistance, than this training (the training they received) is too superficial.’
SQ 3: When should an implementer of e-health pick an alpha and when an omega strategy to persuade practitioner-teams to change?
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Similar to project 1, there are indications do make more use of omega strategies to implement project 2 even stronger. A main reason for practitioners to be hesitant towards the system is the idea that their complete way of working is being ‘replaced’ by e-health. One of the practitioners describes how he has already changed her way of integrating the system into his working routine; ‘At first I approached the system as something that could replace part of
my face to face moments with a client, now I look at the system as something that adds to my face to face treatment’. Although most of the practitioners realize that the project will exist
next to the face to face treatment and therefore it called ‘blended treatment’, some uncomfortable feelings about the system still seem to present within the practitioner teams. Thus, the hesitation needs to be addressed upon and the practitioners need to be assured that they can still make use of their ‘traditional’ way of working.
Another possible cause of resistance is mentioned by only one of the practitioners, but it seems to be a valid cause nonetheless. The practitioner explains; ‘I do not want to speak for
the whole department, but I think the department has felt a huge pressure from the production rates. The production had to be high and the project did not help with that.’ Strangely
enough, the project should make the treatment of a client more efficient and thus faster. An easy conclusion would be that project 2 will make production rates higher. However, production rates are being calculated based on the amount of time spend with a client. The particular practitioner who is very much involved in the project explains that making use of the system is therefore not always a logical choice. While the department is still new and not a lot of new clients are waiting, the practitioners could be better off by treating their existing clients for a longer period of time. This issue that one of the practitioners addresses could be an underlying reason for resistance towards using the system. An omega strategy can be used to overcome this.
Overall, it seems that the practitioners are very motivated to be part of the project and not many persuasion strategies will have to be introduced in the future. However, there should always be a clear explanation of the goal of the project to make sure that practitioners do not fear that their current way of working is being attacked while this would be avoidance feeding.
4.3 Cross case analysis
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compares the projects as follows; ‘Project 2 was just a lot more ‘dressed up’. There was
extensive training, there were a lot of meetings in the beginning, there was a lot more to it. The management was very involved, the director was present. It was a lot more comprehensive than project 1. I did not see the management with project 1, you get some newsletters, but it was a lot more hesitant. Just less dressed up.’
When looking at the previous two sections, the differences between the two projects can be described more extensively. First of all, the practitioners seem to have been more involved in the pre-live phases with project 2. Although the respondents for project 1 state that they felt informed in the pre-live phase, they do not indicate feeling involved with or enthusiastic about the project. Furthermore, the respondents from project 2 describe more meetings, updates and exchanges with other practitioners than the respondents from project 1. To give an overview of the differences between the two projects, table 3 summarizes the main results for sub-question 1 according to the first four phases of Cooper & Zmud (1990).
Phase of IT implementation (Cooper & Zmud, 1990)
Project 1, Client portal Project 2, Hybrid treatment Phase 1, Initiation Practitioners were not
involved; application is initiated by higher members of project-group.
Department identified
opportunity for the application. Some practitioners were involved and were asked to discuss options.
Phase 2, Adoption Practitioners are not involved in decision or testing of the system. Information about decisions is provided. Project-teamleaders become involved.
Some team-members are involved. Practitioner-teams are informed by project-leader.
Phase 3, Adaption Explanation in the form of a presentation and hand-out. Further information via project-teamleader. Process of
adaption is evaluated in the project-group.
Extensive training and after this meetings to exchange
experiences. Temporarily, the use of a ‘buddy-system’ and presenting modules to each other.
Phase 4, Acceptance Low level of acceptance, only a hand-full of practitioners is committed to the application.
Relatively high level of acceptance. Practitioners use the application on a daily basis. Table 3. Comparison of project 1 and 2; change-interventions valued by the practitioner-teams.
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project 2 when project 1 went live. Looking at the planning or timing of interventions, project 2 seems to have been more structured and the practitioners were able to recall the different steps more clearly. From this, it can be concluded that the practitioner teams were more part of the project from the beginning with project 2. The intensity in which change-interventions were used in each phase, thus in other words, the extent to which practitioners were involved is depicted in the graph in figure 5 below.
Figure 5. Intensity of change-interventions in each phase.
The intensity is based on the amount of planned interventions that the practitioners remember from each phase. Also, the practitioners have experienced some interventions as more intense than others, thus, the graph does not only depict the amount of interventions but also the intensity of the interventions taken together. As can be observed from the graph, the highest intensity of change-interventions were experienced in phase 3. Nevertheless, for both projects, even more change-interventions would have been preferred by the practitioners in the adaption phase. Especially team-related interventions are mentioned by the practitioners. For project 2, several of these interventions have been introduced but not thoroughly enough, the spike that the graph shows for project 2 is indeed a spike and most interventions described in table 3 were not continued for more than a few weeks.
Looking at sub-question 3, the use of both Alpha and Omega strategies was found in each of the projects; table 4 for presents an overview. Consistent with the findings of Dollard and Miller (1950), we can observe that approach interventions were used in the first phases of
Phase 1 Phase 2 Phase 3 Phase 4
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the implementation. Closer to the new goal, in this case in the adaption phase (phase 3), the avoidance cues become stronger, and therefore more use of Omega strategies is necessary in these phases. Although both projects did use some avoidance interventions or Omega strategies, the practitioners from both projects indicate that they would like to give even more attention to the possible negative aspects of the application. For example, the practitioners worry about changes in their contact with clients, they are unsure what the client experiences when using the application or they do not know all the functionalities of the application. All of these problems need to be addressed explicitly by the implementer. Looking at table 4, it should be noted that some of the interventions mentioned could be an approach intervention as well as an avoidance intervention. For example, a team-meeting could be focused on providing reasons to move towards the new goal but it could also be aimed at sharing reasons for resistance and finding a solution. Based on the interviews, an indication on whether an intervention was mainly Alpha or mainly Omega focused was made.
Table 4. Approach and avoidance interventions used in each project.
A major difference between the projects is the amount of functionalities and the accessibility of the system. One could say that the system used in project 2 is more developed and therefore there are less barriers and more motivation to be join project 2. This means that for project 1 a lot of technical improvement have to be made and the practitioners than need to be convinced of the application with alpha strategies of persuasion. Very important when using these alpha strategies is the presence of management, directors and other ‘higher levels’ within the organization. Although in both projects, the person that was the direct contact for the practitioners (project-teamleader, project-leader) was appreciated very much because this person was easy accessible, the practitioners do indicate how the presence or support of a manager can make the difference. In response to this result, the director of the e-health department states that they never deliberately supported project 2 more than project 1. Approach/strategy Project 1, Client Portal Project 2, Hybrid Treatment
Approach interventions (Alpha)
• Fase 1,2 & 3
-E-mails and newsletter updates about application.
-Presentation about application. -Project-teamleader answers questions and tries to stimulate team-members.
-Updates in team-meeting by project-leader & and via e-mail.
-Training program and practice sessions
-Small presentations in team -Buddy-system with colleague
Avoidance
interventions (Omega)
• Fase 3 & 4
-Bi-weekly project-group meeting -Project-group evaluation with practitioners present
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However, the presence of the director at a training of project 2 was experienced as very positive by the practitioners and can also be considered to be a change-intervention.
Overall, the experiences with project 2 were more positive than those of project 1, this is consistent with the acceptance of the projects thus far. Project 2 is currently being used more actively and practitioners are committed to the application. In the next section, this will be discussed in more detail.
5. Discussion
This section concludes this research by summarizing the results and answering the main research question. After that, the theoretical and practical implications coming from this study are presented. Thirdly, the limitations of this study are reflected on. Finally, the study is concluded by presenting the main contributions.
5.1 Timeline model
How can implementers of e-health applications make optimal use of change-interventions in order to increase the acceptance among practitioner-teams?
According to Cooper and Zmud (1990), acceptance is a phase in which organizational members are induced to commit to an IT application. Before the acceptance phase, the phases of initiation, adoption and adaption are ran through.
The initiation phase in which the organizational problems or opportunities are identified and a push/pull for an IT solution is found is mainly outside of the scope of this research. Nevertheless, for project 2 there was more involvement in this phase and some practitioners have created an extra pull for the application. Looking at phase two (adoption), testing and communication pre-live can be considered to be most central in this phase. In this phase, the application is not yet developed completely and the application is being negotiated. In addition, support for the application is generated and the decision to invest resources is being made in this phase. Again, the practitioner-teams of project 2 were more active in this phase than the teams in project 1. After presenting these results (see figure 4) to the project-leaders and directors, they indeed confirm that the involvement in the first phases was higher for project 2. In addition they also see the ‘danger’ of losing the attention from practitioners after the training took place.
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three; adaption. According to Cooper & Zmud (1990), this phase entails the installation and maintaining of the application, training is provided to organizational members and organizational procedures are revised. For project 1, there was no formal training but the project-teamleaders played an important role in explaining and maintaining the application. For project 2, formal training was provided and this was very much valued by the organizational members. When using the phases as developed by Cooper & Zmud (1990), it can be observed that the different phases leading towards acceptance were more present in project 2. This can explain why project 2 is currently more ‘accepted’ by the practitioner teams. Still, for both projects changes in the type of interventions and the planning of these interventions in the different phases could be improved. A suggestion on how to make optimal use of interventions is now presented in the form of a model (Figure 5) and answers the main research question.
Figure 5. Timeline model, change-interventions that lead to acceptance
Each of the four arrows in figure 5 is considered to point towards acceptance of practitioner-teams. After the fourth phase of ‘evaluation’, acceptance will normally follow. Also, the beginning of phase 5, routinization, is established. As can be seen in figure 5, there are two levels on which different change-interventions should be included. First, there is the level in which the implementer including the project-group and project-leaders are most central. The implementers need to convince the practitioners of the application by using approach strategies (Knowles & Linn, 2004). Examples of this are explaining the added-value and goals
Initiation & adoption
-Sharing of reasonbehind the project and goals with the
practitioners. - Involve practitioners in testing and discussing the application. -Provide updates to the practitioners on progress of project. -Support from higher (management) levels.
Training (Adaption)
-Formal team training, practice with the application. -Experience client perspective. -Continuous training to learn more options and changes.
-Time to train each other.
Sharing (Adaption)
-Team meetings to discuss problems and successes.
-Regular updates on progress within team. -Remind each other (buddy system practitioners). -Talk about reasons for resistance /fears.
Evaluation
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of the new application and the management and directors need to show their support for the application. After this, indicated by the change of color in the model, the practitioner-teams become most central in the implementation process and to successfully go through the adaption phase the avoidance forces will need to be decreased. Sharing experiences and giving resistance explicit attention are examples of omega strategies to decrease avoidance. It should be noted that although the practitioners are central in these phases, the implementer still plays an important role in organizing the process and stimulating the practitioner-teams to take over.
5.2 Theoretical Contributions
The results of this study are largely consistent with previous research on change interventions. For example, when reconsidering the planned intervention model of Kotter (1996) that was presented in figure 3, we can see that most of these steps have a clear overlap with the outcomes of this research as presented in figure 5. Second, factors like ease of use, the opportunity to test (Rogers, 2003) and the fit between the technology and existing skills of staff (Murray et al., 2011) that were presented in section 2.3 were also mentioned by the interviewees of this research. However, the technology and its features were mainly outside the scope of this research; the focus was on how the change is implemented and how this process can make a difference.
What this research adds to existing theory is the demand for specific change interventions and the timing of these interventions. This research explains how to make optimal use of particular change-interventions in a planned change approach. A main finding of this research is the fact that the change interventions do not follow each other in steps or stages, but they need to be given attention during the whole process in a consistent way (see figure 5). Knowles and Linn (2004) also provide a theory in which there are not specific steps but merely two strategies to persuade organizational members to change. This research is consistent with their findings that both alpha and omega need to be included to persuade organizational members. In addition, the findings of this research suggest that an alpha strategy is most important in the initiation and adoption phases of implementation as is indicated by the blue arrow in figure 5. The omega strategies are added in the adaption phase and need to be continued until the application is truly institutionalized.
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importance of team-building and team rewards. However, this research claims that including the practitioners as a team in every phase is important. The blue arrow in figure 5 emphasizes the implementer or, in this research the project-group, pulling the practitioner-teams towards the new application. In the purple phase (see figure 5) after the initiation and adoption phases, the change implementation and therefore the interventions are more and more transferred to the practitioner-teams.
5.2 Practical implications
As can be seen in figure 5, this study proposes a timeline model that can be used as a guideline by change implementers. When making use of this model and not trying to move from one phase to the next, higher e-health acceptance among practitioner teams can be reached. In addition, this research also explains when to use these interventions and in what way the intensity of the interventions should be divided along the process. This study emphasizes the importance of communicating and informing practitioners right from the start of the process and it warns not to quit using planned interventions too soon. In the first two phases of implementation the implementer should make sure to inform the practitioners and try to involve them in the decision making. After this, the implementer should mainly play a facilitating role and motivate the teams to take the implementation to the next phases of adaption and acceptance. This research states that the practitioners value the contact with a team-leader or manager on an individual basis, but they also feel the need to discuss and share things within their teams. This suggests that group interventions are important and these interventions need to be continued all the way through the implementation process. Especially in the adaption phase, the practitioner-teams need to have the opportunity to share experiences by for example working in couples or teaching each other. Also, a certain amount of pressure and presence from the higher levels within the organization can increase acceptance among the practitioners. This means that e-health applications need to be introduced in a convincing and clear way while at the same time respecting the autonomy of the practitioner-team.
5.3 Limitations and further research
