READINESS FOR CHANGE: HOW DO HEALTH CARE
PROFESSIONALS EVALUATE PATIENT VALENCE,
ORGANIZATIONAL VALENCE AND PERSONAL VALENCE?
A Delphi study among home mechanical ventilation centers
Master Thesis MSc BA – Specialization Change Management University of Groningen, Faculty of Economics and Business
March 4th , 2013 Nienke Maas Student number: 1647032 Wielingenstraat 10-1 1078 KK Amsterdam Tel: +31 (0)683207395 E-mail: njs.maas@gmail.com
Supervisor Rijksuniversiteit Groningen: Dr. M.A.G. van Offenbeek Second Assessor Rijksuniversiteit Groningen: Dr. C. Reezigt
Supervisor CTB UMC Groningen: Dr. P.J. Wijkstra/A. Hazenberg
Table of contents
1. INTRODUCTION ... 4
2. THEORY ... 7
2.1 Readiness for change ... 7
2.2 Organizational valence ... 8 2.3 Personal valence ... 8 2.4 Patient valence ... 9 2.6 Evaluation of valences ... 11 2.7 Research model ... 13 3. METHODS ... 16 3.1 Delphi technique ... 16 3.2 Data collection ... 17 3.2.1 Interviews ... 17 3.2.2 Questionnaire ... 18 3.3 Delphi panel ... 19 3.4 Data analysis ... 20
3.4.1 Delphi round one ... 20
3.4.2 Delphi round two ... 21
4. RESULTS ... 22 4.1 Criteria ... 22 4.1.1 Patient valence ... 26 4.1.2 Organizational valence ... 28 4.1.3 Personal valence ... 30 4.1.4 Prerequisites ... 31 4.1.5 Other valences ... 35 4.2 Weights ... 36 4.2.1 Patient valence ... 37 4.2.2 Organizational valence ... 38 4.2.3 Personal valence ... 40
4.2.4 Difference between benefits and disadvantages ... 42
5. DISCUSSION & CONCLUSION ... 47
5.1 Practical implications ... 49
5.2 Theoretical implications ... 50
5.3 Limitations and recommendations for further research ... 52
5.4 Conclusion ... 54
APPENDICES ... 60
Appendix 1 Interview ... 60
Appendix II Enquête ... 63
Appendix III Delphi panel ... 70
Appendix IV Overview benefits, disadvantages and prerequisites ... 71
Appendix V Ranking ... 84
Appendix VI Exact weights ... 85
Appendix VII Valences and readiness for change ... 86
Appendix VIII Correlation graphs ... 87
1. INTRODUCTION
In today’s fast moving world change becomes more and more important (Burnes, 2009). For instance in health care organizations many innovations take place ranging from the introduction of new communication and information systems to improved treatments and advanced medical devices (Narine & Persaud, 2003). These change initiatives are focused on improving efficiency and effectiveness. Furthermore, patient satisfaction and safety needs to be maintained or even enhanced (Woordward et al., 1999; Weiner, Amick & Lee, 2008; Narine & Persaud, 2003). Unfortunately, a number of innovations in the health care sector achieve only partial implementation success while a large amount of effort, time and resources has been put into these change initiatives. In order to achieve complete implementation success, both change specialists and health care professionals argue that readiness for change is a prerequisite (Weiner et al, 2008).
Much has been written about factors that influence readiness for change. Recently, Oreg, Vakola and Armenakis (2011) reviewed quantitative studies about readiness for change between 1948 and 2007 and came up with many findings that together comprise approximately 100 antecedents of readiness for change. These antecedents vary from recipient characteristics to internal context and change content factors (Oreg et al, 2011). In change literature, personal valence and organizational valence are often found to be determinants of readiness for change (Holt, Armenakis, Field & Harris, 2007; Cunningham et al., 2002; Miller & Monge, 1985; Eby, Adams, Russell & Gaby; 2000). Valence refers to the value people attribute to outcomes (Buelens, Van den Broek, Vanderheyden, Kreitner & Kinicki, 2006).
in the many implementation processes they are confronted with. Similarly, this knowledge could enhance our understanding of what actions are most effective in increasing readiness for change. Therefore, research about readiness for change in the health care sector should be extended in two ways. First, it should be explored whether the value health care professionals allot to the expected patient benefits and patient disadvantages of a change is a third kind of valence that influences health care professionals’ readiness for change. In addition, the extent to which health care professionals look at personal, organizational and patient valences in evaluating a proposed change should be investigated. Secondly, research should be extended by examining the importance health care professionals allot to these valences in approaching a change or avoiding it. This research addresses the identified gaps above. It intends to answer the main question of this research:
The main research question has an explorative character because it is an open question focusing on characteristics, relationships between these characteristics and generating presumptions instead of testing existing theories and statements. In addition, there are no restrictions beforehand and the researcher does not know what is the most important thing to look at.
In order to answer the explorative research question, the case of a proposed change at the home mechanical ventilation center of the University Medical Center Groningen (UMCG) will be investigated. This center currently performs an experiment focused on the initiation of mechanical ventilation at home. Whereas at the moment patients who need chronic ventilatory support are initiated in the hospital, it is probably more cost efficient to initiate these people outside the hospital. At the same time it is expected that initiation of patients at home will increase patients’ quality of life. If the results of the experiment are positive, the home mechanical ventilation center of the UMCG aspires national implementation of the innovation. National implementation of the innovation entails that all of the four home mechanical ventilation centers in the Netherlands need to change from initiation at the hospital to initiation at home of patients who need chronic ventilatory support. The management of the home mechanical ventilation center of the UMCG has raised the question whether health care professionals in all of the four centers are ready to change to initiation at home and how these professionals evaluate the proposed change.
The remainder of this paper is structured as follows. Section two discusses the relevant literature about readiness for change, research on personal, organizational and patient valences, and studies that
MAIN RESEARCH QUESTION
2. THEORY
This literature review is built up as follows. First of all, the concept of readiness for change is discussed. Subsequently, the factors organizational valence and personal valence are elaborated on as antecedents of readiness for change. Patient valence, a factor that is not explicitly addressed in the current health care literature, will be tentatively introduced as a factor that also influences readiness for change among health care professionals. The literature research done in order to find out whether anything has been written about the relationship between patient valence and readiness for change was conducted with PurpleSearch. This database was used because it is a combination of several other databases. PurpleSearch contains medical databases such as PubMeb as well as databases for business studies such as Business Source Premier and so a broad range of literature was searched in order to determine whether something was written about patient valence. The terms that were searched for are patient valence, client valence, customer valence, readiness for change, commitment to change, innovation in health care, innovation adoption, expected benefits, client benefits, patient benefits, customer focus, patient focus and several combinations of these terms. Results were scanned on title and abstract. When an article possibly addressed patient valence also the introduction and conclusion were read. Next to the use of PurpleSearch, cross-referencing of articles that implicitly address patient valence was done. However, this has not led to any articles that explicitly address patient valence. This literature review also focuses on how people evaluate valences and how this is related to their readiness for change. The section ends with a model that follows from this literature review.
2.1 Readiness for change
the intentional dimension regards to explicit behavior or the intention to behave in a certain way (Oreg et al, 2011).
A key determinant of whether change recipients will approach or avoid a change are the perceived benefits and/or harms of a proposed change (Oreg et al., 2011). Two seminal studies most often referred to in this context stress the importance of expected benefits and disadvantages (Armenakis & Harris, 2002; Holt et al., 2007). Both studies identify personal and organizational valence as determinants of readiness for change. With respect to the latter however, the conceptualization differs between the two studies. Armenakis and Harris (2002) find a direct relationship between organizational valence and readiness for change, whereas Holt et al. (2007) combine organizational valence and discrepancy in a factor they describe as ‘appropriateness’. In the health care sector, benefits or disadvantages of a change can occur for the organization, the health care professional or the patient. This research focuses on these valences. Since readiness for change is prerequisite to successfully implement an innovation (Armenakis et al., 1993; Kotter, 1996; O’Connor & Fiol, 2006), it is not only important to determine the valences that influence readiness for change but also how these subjective valences come about. More specifically, it is necessary to understand the extent to which health care professionals look at patient valence, organizational valence and personal valence and the criteria they apply in evaluating these valences. In addition, the weights that health care professionals allot to personal, organizational and patient valences and how this is related to their readiness for change should be investigated. In order to be able to do so, the concepts of organizational valence, personal valence and patient valence should first be elaborated on.
2.2 Organizational valence
Organizational valence can be defined as “the extent to which one feels that the organization will or will not benefit from the implementation of the prospective change” (Holt et al., 2007, p. 239). There are several ways in which a change can be beneficial for an organization: it could make the organization more productive or more efficient, improve practices or outdated practices could be replaced. In contrast, a change can be non-beneficial if valuable assets are lost when implementing the prospective change in practice (Holt et al., 2007). As mentioned before, changes in the health care sector are often aimed at improving efficiency and effectiveness (Woodward et al., 1999; Weiner et al, 2008; Narine & Persaud, 2003). Therefore, in order to establish readiness for change among health care professionals, the proposed change should at least benefit the organization in one of the ways discussed above.
2.3 Personal valence
personally (Armenakis & Harris, 2002). Clearly, personal valence focuses on people’s self-interests. A proposed change that is perceived as personally beneficial will lead to more positive reactions such as readiness for change (Oreg et al., 2011). Personal benefits are associated with expected positive outcomes of a proposed change, e.g. work that becomes more challenging and interesting, increased salary and personal development (Bartunek et al, 2006). On the contrary, when a proposed change is expected to lead to negative outcomes such as job loss, increased workload, loss of status and disturbed relationships, people are less open to accept the change (Cunningham et al., 2002; Holt et al., 2007; Oreg et al., 2011). Therefore, people’s readiness for change will be lower or even absent in such circumstances.
2.4 Patient valence
As was mentioned in the introduction, while organizational valence and personal valence are often mentioned as determinants of readiness for change, the expected benefits and/or harms for a patient from the perspective of a health care professional are not explicitly addressed. This can be concluded from the literature research that was performed in order to find out whether anything was written about the relationship between patient valence and readiness for change. The unavailability of literature that explicitly addresses patient valence is remarkable since most people who work in the health care sector are assumed to be customer focused because of the core value to help, service and benefit patients (von Nordenflycht, 2010). Therefore, it is expected that in order to get ready for change employees should not only have the feeling that the prospective change fulfills their own demands and that of the organization, but also the demands of their patients. When applying the definition of organizational valence by Holt et al. (2007) to the patient instead of the organization, patient valence can be defined as: “the extent to which one feels that one’s patients will or will not benefit from the implementation of a prospective change”.
TABLE 1
Patient valence as a part of other variables in literature
Author(s) Item(s) that contain patient valence Part of other variable Field of study Bouckenooghe et al., 2009 I think that most change will have a
negative effect on the clients we serve
Cognitive readiness for change
Readiness for change Fleuren, 2004 Extent to which the health professional
expects that the patient will be satisfied with the innovation
Relevance of the innovation for the patient: extent to which the innovation has added value
Related to the adopting person/user/health professional
Related to the innovation
Innovation
Greenhalgh et al., 2004 If the meaning attached to the innovation by individual adopters matches the meaning attached by service users [read: clients], the innovation is more likely to be assimilated
Meaning/adoption by individuals
Innovation
Holt et al., 2007 When we adopt this change, we will be better equipped to meet our customers’ needs
In many service industries the delivery of a service is a co-production between the producer and consumer which makes the customer pivotal (Dunston, Lee, Boud, Brodie & Chiarella, 2009). Consequently, we expect that within these industries readiness for change among employees is largely determined by the expected benefits and disadvantages of a change for the customer. For instance, in the hospital where the role of the client is pivotal to the provision of health care. Therefore, it is expected that patient valence is an important determinant of readiness for change among professionals in the health care sector.
2.6 Evaluation of valences
So far, the concepts of organizational and personal valence have been described and patient valence is introduced as a possible determinant of readiness for change in the health care sector. In addition to the conceptualization of organizational, personal and patient valence, this part of the literature review focuses on what is currently known about how people evaluate valences. Following from this discussion, the two sub questions of this paper are introduced.
The concept of valence stems from motivation theories. One of these theories is Vroom’s expectancy theory (Vroom, 1964) in which the principle of hedonism is embedded (Buelens et al., 2006). Hedonism refers to the maximization of pleasure and the minimization of pain. The expectancy theory was developed by Vroom to gain a better understanding of the cognitive processes underlying the motivation of people (Buelens et al, 2006). Figure 1 illustrates that according to Vroom’s expectancy model, motivation is composed of three main components: expectancy, instrumentality and valence (Buelens et al, 2006). As can be seen in the figure below, expectancy refers to the likelihood that personal effort leads to an acceptable level of performance. The relationship between achieved performance results and specific outcomes for a person is called instrumentality. Subsequently, valence refers to the extent to which a person values an outcome (Isaac, Zerbe & Pitt, 2001; Buelens, 2006). Buelens et al. (2006) argue that Vroom’s expectancy model can be applied to any situation in which a choice between alternatives must be made by an individual, e.g. the choice to approach or avoid a proposed change, i.e. one’s readiness for change.
FIGURE 1 The expectancy model
Porter and Lawler (1968) extended the expectancy model of Vroom. The most relevant extensions for this paper are twofold. First of all that satisfaction, which is a result of outcomes and the perceived equity of outcomes, influences the attributed valence. Secondly, that effort is a function of both valence and the perceived effort-outcome probability. This implies that people become motivated when valued benefits are derived from performance and outcomes and therefore, their effort will increase (Buelens, 2006).
In summary, what is currently known about the evaluation of valences is that people evaluate outcomes with regard to their own personal goals. In addition, valences are determined by satisfaction which is a result of expected outcomes and the perceived equity of outcomes. Since valence reflects personal preferences (Feather, 1995; Pecotich & Churchill, 1981), the evaluation of valences differs among people. For instance while one person places a highly positive value on monetary rewards such as bonuses and salary, another person could place more value on non-monetary rewards such as explicit recognition or extra holidays. Therefore, different people could have a different mix of positive and negative valences in the same situation (Buelens et al, 2006). Although knowledge is available about how individuals and thus also health care professionals evaluate valences in general, further research is needed about the criteria health care professionals apply in evaluating a proposed change because that reflects the extent to which these professionals look at patient valence, organizational valence and personal in the context of a proposed organizational change. Therefore, the first sub question of this research is formulated as follows:
According to Greenberg and Baron (2008) motivation requires strictly positive valences. In contrast, Buelens et al. (2006) argue that the sum of positive and negative valences needs to be positive in order to motivate people. The latter implies that despite the fact that change recipients could have a negative valence for some outcomes, motivation might still result. When the positive valences outweigh the negative valences people become motivated (Buelens et al, 2006). A possible explanation for the difference in findings between Greenberg and Baron (2008) and Buelens et al. (2006) may be that the authors are referring to different degrees of motivation. Greenberg and Baron (2008) seem to refer to motivation in a one dimensional sense, being either motivated or not motivated, while Buelens et al (2006) distinguish several degrees of motivation. The existence of different degrees of motivation for a change is confirmed by Coetsee (1999) who states that while acceptance of a change and resistance
SUB QUESTION ONE (Q1)
are often referred to as unrelated concepts, commitment and resistance are two extremes of a continuum. Whereas on one side of the continuum people behave enthusiastic towards a proposed change and will cooperate, on the other side of the continuum change recipients actively resist the change by slowing it down, by spoilage and even sabotage. In between, indifference and passive resistance can be found (Coetsee, 1999). Likewise, research done by Lapointe and Rivard (2005) about resistance to IT implementation acknowledges different degrees of resistance ranging from aggressive resistance and active resistance to passive resistance, apathy and neutrality (Lapointe and Rivard, 2005).
All taken into account, although no consensus exists about the influence of negative valences on readiness for change, in general there is a relationship between valences and readiness for change. The more change recipients value a proposed change, the more they approach the change. However, in order to increase readiness for change among health care professionals, it is not only important to know that a relationship between valences and readiness for change exists but also to investigate the relative weights health care professionals allot to personal, organizational and patient valences and how this is related to their resulting readiness for change. Therefore, the second sub question of this research that will be investigated is:
In conclusion, this literature study shows that personal and organizational valence have a direct influence on readiness for change. In addition to these two types of valences, patient valence is proposed as a potential third kind of valence that influences readiness for change among health care professionals. Furthermore, extant literature suggests that the evaluation of valences depends on the preferences of an individual. In addition, it depends on satisfaction as a result of expected outcomes and the perceived equity of these outcomes.
2.7 Research model
Based on the literature review the research model in figure 2 has been developed. This model depicts our expectation that personal valence, organizational valence and patient valence all influence readiness for change among health care professionals. Further research is needed about the extent to which health care professionals look at these valences in evaluating a proposed change. That is where the first sub question (Q1) focuses on. Because of the explorative character of this research, a dotted square with a question mark is added to the research model. This implies that during the study the
SUB QUESTION TWO (Q2)
researcher will be open to other kinds of valences influencing readiness for change among health care professionals. As can be seen in figure 2, the second sub question (Q2) focuses on the relationship between valences and readiness for change.
FIGURE 2 Research model
veto level criterion a change recipient does not want to change even if there are more positive scores than negative scores on the other criteria (Fisher & Lovell, 2006).
3. METHODS
This chapter first sets out the Delphi method used, followed by a description of the data collection. Furthermore, the composition of the Delphi panel will be elaborated on. Finally, the way in which the data were analysed will be discussed.
3.1 Delphi technique
The method used to answer the main research question and the sub questions combines the ‘Argument and Ranking Delphi’ technique. The traditional Delphi has been widely applied in the health care sector since the 1960s and aims at achieving consensus among a group of experts (Dalkey & Helmer, 1993; Mullen, 2003; Powell, 2003). However, over the years many varieties of the Delphi method were developed that do not aim at achieving consensus but at other ultimate goals such as priority setting, decision making or policy development (Mullen, 2003). The argument Delphi and ranking Delphi are two of these modifications used within the health care sector that do not aim at achieving consensus. Instead, these methods are focused on finding arguments and the ranking of, among others, arguments and priorities (Schmidt, Montgomery, Bruene, Kenney, 1997; Mullen, 2003; Lindeman, 1975). Nevertheless, these modifications also contain the main characteristics of the Delphi method that are summarized in table 2. The column on the left provides the main reasons for using a Delphi method. The what-column in the middle contains information about what the method consists of and on the right side of the table it is summarized how the Delphi method is structured.
TABLE 2
Main characteristics of the Delphi technique
Why What How
Structuring a group communication process
To deal with a complex problem
Assessment of the group judgement or view
Panel of experts
Anonymity of the experts
Feedback on information and knowledge
Opportunity to revise views
Source: adapted from Linstone & Turoff (1975) and Mullen (2003)
method is an appropriate method because an expert opinion seems to be important in answering the research questions and rich data can be obtained by this method (Okoli & Pawlowski, 2004). Since the research questions were focused on a specific sector and a case about the specific topic of home mechanical ventilation was investigated, people needed to be knowledgeable about the subject in order to be able to provide relevant information. Furthermore, rich data were needed since the main research question was an explorative ‘how’ question focused on the criteria by which health care professionals evaluate a proposed change. Rich data can be obtained as a result of the Delphi technique because of the feedback and response revision (Okoli & Pawlowski, 2004).
3.2 Data collection
The traditional Delphi method is often structured as a questionnaire of which the answers are summarized, followed by a second questionnaire that builds on the results of the first one. At least one opportunity to provide feedback on their answers will be given to the respondents (Linstone & Turoff, 1975). However, there is no blueprint for conducting research according to the Delphi technique and the design of the method is flexible (Okoli & Pawlowski, 2004). The Delphi method used for this research consisted of two rounds. While the traditional Delphi method often uses four rounds, recent research in the health care sector finds that two or three rounds are preferred (Hasson, Keeney & McKenna, 2000). This is because one round does not provide meaningful results while too many rounds leads to fatigue and may burden experts (Schmidt, 1997). Interviews formed the basis of the first round of data collection. During the second round of data collection a questionnaire was send to the interviewees of the first round.
3.2.1 Interviews
In total, 16 interviews were carried out with health care professionals who are working in one of the four home mechanical ventilation centers in the Netherlands. These interviews were conducted in August and September 2012 in each of the four home mechanical ventilation centers in the Netherlands and lasted between 30 and 70 minutes.
The results of the first round of the Delphi method were send to the interviewees in the form of an overview of the benefits, disadvantages and prerequisites mentioned during the interviews. Furthermore, an overview of the weight each of the interviewees allot to personal, organizational and patient valence was provided to the interviewees.
3.2.2 Questionnaire
After the results of the first round were provided to the interviewees, an online questionnaire was send to the participants during the second round of data collection. This questionnaire can be found in appendix II. The questionnaire was structured around the importance health care professionals allot to criteria to evaluate valences and the importance these professionals allot to certain prerequisites associated with home mechanical ventilation. Furthermore, patient valence, organizational valence, personal valence and readiness for change were measured in the online questionnaire. Since approximately 200 advantages and disadvantages and about 70 prerequisites associated with home mechanical ventilation which together represent the criteria to evaluate valences resulted from the interviews, only criteria that were mentioned by 3 or more interviewees were included in the questionnaire. For each of these criteria, the experts were asked to rank on a 7 point Likert scale the importance they allot to the criteria when making the decision to change or not to change to initiation at home (1 = very unimportant and 7 = very important).
Independent variables
Patient valence, organizational valence and personal valence were measured using a question adapted from the definition of organizational and patient valence by Holt et al (2007): “to what extent do you
have the feeling that the groups below benefit or will not benefit from the proposed change to initiate people who need chronic ventilatory support at home?” .
Dependent variable
The OCQ-C, P, R comprises 9 items that represent the emotional, cognitive and intentional dimensions of readiness for change (Bouckenooghe et al, 2009).
As a pilot, two employees of the home mechanical ventilation Groningen who did not participate in the research filled in the questionnaire and provided the researcher with feedback. This was done to test whether the questions about the independent variables were properly formulated. In addition, a pilot was conducted to test whether the instrument by Bouckenooghe et al. (2009), used to measure the dependent variable, was correctly adjusted for this specific context. As a result of the feedback, several adjustments were made.
3.3 Delphi panel
The population of home mechanical ventilation professionals in the Netherlands consists of approximately 60 people. All of these professionals are working in one of the four home mechanical ventilation centers in the Netherlands. These centers are located in Groningen, Maastricht, Rotterdam and Utrecht. In order to determine the sample for this study, the quota selection strategy offered by Goetz and Lecompte (1984) was used. This strategy first identifies the major subgroups within a population and then selects an arbitrary number of participants from each of these groups (Miles & Huberman, 1994) The major subgroups within the population of home mechanical ventilation center professionals are nurses, physicians, secretaries, technicians and ‘others’. The ‘others’ group consists of project members or people who bring and collect the measure equipment and ventilation equipment. However, health care professionals argue that nothing will change for the secretaries and ‘others group’ as a result of the proposed change. Besides that, these subgroups do not have enough substantive knowledge about home mechanical ventilation. Therefore, participants were selected within the major subgroups of nurses, physicians and technicians. In each of the four centers, one technician and one physician were selected. Furthermore, two nurses were selected in each of the centers because more than half of the home mechanical ventilation professionals is composed of nurses. For the recruitment of participants the researcher informed the department managers of the home mechanical ventilation centers in the Netherlands about the research. All of the managers were willing to contribute and so the researcher asked them to select one physician, one technician and two nurses. So in total the Delphi panel consisted of 16 experts. This is an appropriate number since literature about the Delphi method recommends the use of 10-18 experts (Okoli & Pawlowski, 2004).
patients, the average number of initiations per month by each professional is 3,78. During the second round of the Delphi method, 13 out of the 16 experts responded so during this round the Delphi panel was smaller. However, 13 is still an appropriate number according to Okoli and Pawlowski (2004). One of the experts was not longer working for the home mechanical ventilation center and therefore it was impossible to contact this person. The two other experts provided no reason for not responding.
3.4 Data analysis
3.4.1 Delphi round one
With consent of participants the interviews of the first round were voice recorded. The audio interviews were transcribed and the data were coded because “codes are efficient data-labeling and data retrieval devices. They empower and speed up analysis” (Miles & Huberman, 1994, p. 65). Coding was done with the qualitative software program ATLAS.ti 7.0. A software program was preferred over coding by hand because of the possibility to “assign meaningful phrases as codes” instead of only short labels (Miles & Huberman, p. 58). Furthermore, a program is valuable when showing the structure of the code list (Miles & Huberman, 1994). To assign codes to the data an inductive coding method was used. No start list of codes was created but codes were created during the analysis. With inductive coding “the analyst is more open minded and more context-sensitive, although, here, too, the ultimate objective is to match the observations to a theory or set of constructs” (Miles & Huberman, 1994, p. 58). The coded data in this research were then matched with the theoretical framework in section 2.
In order to ensure reliability of coding, check-coding by the researcher (intra-coding) as well as by another student (inter-coding) was done (Miles & Huberman, 1994). According to Miles and Huberman (1994) both the intra-coder agreement and the inter-coder agreement needs to be around 90%. The researcher check-coded half of the transcribed interviews a week after the first coding was done with an ultimate intra-coding agreement of 90%. Furthermore, several pages of one transcription of an interview in each center, so 4 in total, were check-coded by another student. The researcher and other student reviewed their codes together and discussed the differences in coding. As a result, at the end the inter-coding agreement was 90%. The code list was adjusted several times and some parts of the transcriptions were re-coded during the check-coding process.
researcher, the best term in ATLAS.ti to describe the link was chosen: is associated with, is part of, is cause of, contradicts, is a, noname or is property of.
3.4.2 Delphi round two
4. RESULTS
In this chapter the data that have been gathered through the interviews and questionnaire will be presented. The first part contains results associated with the first sub question about the extent to which health care professionals look at personal, organizational and patient valence in evaluating a proposed change. In order to determine this, the criteria health care professionals apply in evaluating a proposed change are investigated. Results of the second sub question about the weights health care professionals allot to personal, organizational and patient valences and how this is related to their readiness for change will be presented afterwards.
4.1 Criteria
Appendix IV provides an overview of all the criteria home mechanical ventilation center employees mentioned during the interviews to evaluate patient valence, organizational valence and personal valence. In addition, the number of interviewees per center and the total number of interviewees that reported each of these criteria are given. The criteria are structured around 7 main categories: patient benefits, patient disadvantages, organizational benefits, organizational disadvantages, personal benefits, personal disadvantages and prerequisites associated with the proposed change.
This last category, prerequisites, emerged during the interviews. Fourteen out of the 16 interviewees declared they evaluate the proposed change under certain prerequisites associated with initiation at home. As one argues: “Personally, I am a strong proponent of the change. But, and here I
am repeating myself again, that is part of the prerequisites. That is of course, if the prerequisites are good then I will give the proposed change immediately a 1. But of course only if, as I just said, the right criteria are applied. But that is difficult to realize. As I just said, defining those criteria, it needs to be redone every time. You can make a protocol but each case should be reviewed individually”.
This implies that the extent to which a proposed change meets certain prerequisites associated with initiation at home influences readiness for change. Furthermore, interviewees evaluate each of the valences based on the prerequisites he or she finds important. As can be seen in appendix IV, the prerequisites can be divided into five categories: patient prerequisites, situation prerequisites, center prerequisites, input prerequisites and process prerequisites.
the decision of changing to initiation at home. In other words, that number of respondents definitely wants to change if that benefit or prerequisite is present. The number of respondents that marked a certain disadvantage as a veto is also given. So that number of respondents does definitely not want to change if such a disadvantage is present. In order to compare the questionnaire results with the interview results, table 3 contains also the number of experts that named a criterion during the interviews in round 1.
In general, table 3 shows that, except for ‘initiation takes longer’ and ‘more time consuming for myself’, the criteria that are most often mentioned during the interviews score above a mean score of 4 on the questionnaire. Accordingly, all of those criteria vary from slightly to very important in the decision to change or not to change to initiation at home. However, there is a difference between the criteria that are most often reported during the interviews and the criteria with the highest mean score on the questionnaire. The lowest mean score for all criteria ranges from 1 to 4 and the highest score differs from 5 to 7. The range lies between 3 and 7. The number of veto/crucial for each of the criteria lies between 1 and 6. Thereby, it is remarkable that the prerequisites are more often scored as veto/crucial than benefits and disadvantages criteria.
TABLE 3
Importance of criteria in the decision to change or not
Category Criteria Round 1 N (1-16) Round 2 Mean (1-7) Lowest score Highest score Range Veto / crucial (N)
Patient benefits More pleasant at home/in the own situation 13 5,69 3 7 4 3
(Patient valence) Own bed/better sleeping 10 5,92 3 7 4 3
Own caregivers instead of new nurses 6 5,23 2 7 5 3
No hospital admission 6 5,23 1 7 6 3
Network of the patient directly involved/network
directly learns how to handle it 5 5 2 7 5 0
Reliable and representative initiation process 4 5 2 7 5 1
No confrontation with very ill patients or patients who
die 3 5,15 2 7 5 1
No unsuitable (IC) environment 3 5 2 7 5 1
Handy/convenience for the patient 3 5,23 2 7 5 1
More reliable scheduling of the initiation process 3 5,07 4 7 3 0
Average 5,25
Patient disadvantages No proximity of health care professionals to help 8 5 3 7 4 0
(Patient valence) Initiation takes longer 6 3,62 1 5 4 0
Patient feels unsafe 6 5,77 4 7 3 2
In case of failure at night there is no possibility for direct
advice 4 5 3 7 4 0
In case of failure the patient will not immediately be in
the hospital/in case of an acute situation 4 5,54 3 7 4 1
Patient feels uncertain 4 5,54 4 7 3 0
Safety of the patient is lower 3 4,85 3 7 4 1
Average 5,05
Organizational benefits Cheaper 7 4,23 1 6 5 0
(Organizational valence) Hospitalization capacity/hospital bed capacity improves 7 5,38 3 7 4 0
Less waiting lists/no waiting lists 7 5,70 4 7 3 0
Independent of availability hospital beds 6 5,77 4 7 3 2
More efficient 3 5,38 3 7 4 0
Innovation/development 3 6 4 7 3 0
Telemonitoring/telemedicine opportunities 3 6,08 4 7 3 3
Average 5,51
Organizational
disadvantages Less efficient 6 4,54 3 6 3 0
(Organizational valence) More personnel required/capacity 5 4,62 2 7 5 0
Travelling time/kilometers 5 4,31 2 7 5 0
Number of visits at patients' home increases 4 4,38 2 7 5 1
Financial structure is not warranted 4 5,08 2 7 5 0
Productivity of the center lower 4 4,69 3 7 4 0
Investment costs 3 4,91 3 7 4 0
Costs of initiation higher 3 4,85 3 7 4 1
Less possibilities to measure during the initiation
Less grip/control over the initiation process 3 4,38 2 6 4 1 Do not have the capacity/lack of personnel 3 5,15 3 7 4 0 Initiation at home is more labor intensive 3 4,92 3 7 4 0
Average 4,71
Personal benefits Innovation 5 5,85 3 7 4 2
(Personal valence) More autonomy 4 5,85 4 7 3 2
Initiation at home is more fun for myself 4 5,08 1 7 6 0
A satisfied patient 3 6,38 4 7 3 1
Initiation at home is challenging 3 5,69 4 7 3 1
Average 5,77
Personal disadvantages More time consuming for myself 6 3,92 2 6 4 0
(Personal valence) No feedback during the initiation process 4 4,46 2 7 5 1
More accessibility during the night/more often contacted
during the night 3 4,31 2 7 5 0
You do not know the patient/little or no patient contact 3 4 2 6 4 0
Average 4,17
Patient prerequisites Clinical picture/condition of the patient 7 5,92 4 7 3 2
(Prerequisites) Patient coping 5 5,85 4 7 3 1
Insight/intelligence 5 5,92 4 7 3 1
Initiation at home or in the hospital is a patients' choice 3 5,46 4 7 3 2
Age of the patient 3 5,08 4 7 3 0
Patient feels safe 3 6,15 4 7 3 2
Average 5,73
Situation prerequisites Patient needs to have a network 7 6,08 4 7 3 2
(Prerequisites) Average 6,08
Center prerequisites Legal indemnity for responsibilities 4 6,31 4 7 3 6
(Prerequisites) Average 6,31
Inputs prerequisites Measuring equipment 4 6,46 4 7 3 5
(Prerequisites) Telemedicine/taking advantage of the possibilities 4 6 4 7 3 4
Average 6,23
Process prerequisites Safety of the initiation process/patient safety 7 6,46 4 7 3 6
(Prerequisites) Monitoring of the patient 4 6,08 4 7 3 1
Discuss risks with the patient/acceptance of risks by the
patient 4 6,23 4 7 3 3
No risks for the patient/prevent complications 3 6,08 4 7 3 3 Good organization of the initiation process 3 6,15 4 7 3 3
Good/experienced nurses 3 6,38 4 7 3 3
Instruction possibility 3 6,15 4 7 3 3
Discuss expectations with the patient 3 6 4 7 3 2
4.1.1 Patient valence
Patient benefits
Table 3 shows that 10 patient benefit criteria were mentioned by 3 or more people during the interviews. The mean score on each of these criteria lies between 5 and 6. This implies that each of the 10 patient benefits are quite important in experts’ decision to change or not to initiation at home.
‘More pleasant at home/in the own situation’ was most often reported during the interviews. The questionnaire confirms the importance of this criterion since it is with a mean score of 5,69 the second most important patient benefit.
‘Own bed/better sleeping’ is the patient benefit with the highest mean score. 11 out of the 13 respondents scored higher than a 4 on this criterion. This confirms the interview results in which ‘own bed/better sleeping’ was the second most reported patient benefit criterion. The Delphi panel experts explain the importance allotted to this criterion by motivating that a better sleep leads to a better initiation process: “the deeper people sleep, the more serious is the hypoventilation and that is where
you want to focus on”.
Quotes to which a patient benefit code is assigned often contain more than one patient benefit code. Therefore, these criteria seem to be related. The links between the criteria, resulting from the co-occurring codes output and evaluation of the researcher, are displayed in figure 3.
FIGURE 3
Patient disadvantages
In general, patient disadvantages mentioned during the interviews by 3 or more persons scored between 5 and 6 on the questionnaire. It thus appears that experts are consistent in their opinion that these criteria are important for the decision whether or not to change to initiation at home.
However, the criterion ‘initiation takes longer’ shows inconsistent interview and questionnaire results. Six interviewees named this criterion while the mean score on the questionnaire was 3,63 and the highest score a 5. Thereby, disagreement exists among the experts about whether the duration of the initiation process will be longer or shorter. This can be seen in the two contrasting codes about duration resulting from the interviews: ‘initiation takes longer’ and ‘initiation takes shorter’. One of the interviewees explains why the initiation process takes longer as: “We have seen that observation is
very important and that you can immediately adjust the mechanical ventilation. When you initiate at home you can adjust only the next day and so it could take longer”.
The patient disadvantage most often mentioned during the interviews is ‘no proximity of health care professionals to help’. As one of the interviewees reports: “And the chance that you leave
patients to take care of themselves during the first night. Even though they have all kinds of instructions and so on. But we see in practice that it is in general insufficient. So in my opinion that is a drawback”. Remarkably, none of the respondents scored this criterion at a veto level.
The patient disadvantage with the highest mean score is ‘patient feels unsafe’. Two respondents score this criterion at a veto level. So if the patient feels unsafe these experts do not want to change to initiation at home. One of the respondents explains it is crucial that a patient does not feel unsafe because: “That is what determines whether the initiation process at home succeeds or not. So
that is the most important thing I think”. It is important to distinguish the criterion ‘patient feels
unsafe’ from the criterion ‘safety of the patient is lower’ because the first one focuses on a feeling while the second one is presented as a fact.
The quotes to which a patient disadvantage code is assigned often contain more than one code of this category. Possible links between patient disadvantages are presented in figure 4.
FIGURE 4
4.1.2 Organizational valence
Organizational benefits
Seven organizational benefits were named by 3 or more experts during the interviews. Remarkably, the organizational benefits most often mentioned during the interviews scored a lower mean on the questionnaire than organizational benefits that had previously been mentioned by 3 interviewees. For instance, 7 interviewees reported ‘cheaper’ while the mean score on the questionnaire for this criterion is with a 4,23 relatively low. Ninety-five out of the 63 criteria in table 3 score higher than ‘cheaper’.
The organizational benefits ‘innovation/development’ and ‘telemedicine/telemonitoring opportunities’ are with a mean score of 6 respectively 6,08 and a lowest score of 4, quite important for respondents’ decision to change or not to initiation at home.
Regarding innovation/development, one of the interviewees declared: “You want to develop.
You want to innovate. You do not want get stuck into the old patterns. So that is where I see a chance, that you start pioneering, I love that”. Another reason to apply this criterion is that it creates cohesion
among the four centers within the Netherlands: “I do not know what the results are, it is always
waiting for the results and which patients can be initiated at home. But the fact that it happens is also a benefit. Because it is something new and it directly appeals to other centers to get ourselves together. It could also be another research but the fact that something happens creates more cohesion among the home mechanical ventilation centers”. Although the cited interviewees report
innovation/development as a organizational benefit, it is also mentioned as a personal benefit.
With respect to telemedicine/telemonitoring opportunities, a reason to apply this criterion is that it could decrease or solve bed capacity problems the centers are currently facing. “There is a
shortage within the hospitals, and that is in Groningen as well as in Utrecht and Rotterdam, of beds for patients. There is a immense waiting list we cannot tackle in each of the 4 centers. That can be solved in this way”. Thus, the criteria ‘telemedicine/telemonitoring’ and ‘less waiting lists/no waiting
lists’ seem to be related. This link and other possible links resulting from the co-occurring codes output and researchers’ evaluation of the quotes are given in figure 5.
FIGURE 5
Organizational disadvantages
Organizational disadvantages is the category that comprises the most criteria. However, table 3 shows that the mean score for 10 out of the 12 criteria lies between 4 and 5. This implies that respondents find these 10 organizational disadvantages just slightly important to apply in evaluating the proposed change.
‘Less efficient’ is the organizational disadvantage that popped up most often during the interviews. This criterion consists of 3 different parts namely instruction efficiency: “In the hospital
you could, if we have 2 or 3 patients and they agree, give 1 instruction for all of them. You could not do that at home, then you should repeat that instruction so that may take more time”, logistics
efficiency and efficiency as the result of the combination of tasks. Remarkably, disagreement exists among experts about whether initiation at home results in a more or a less efficient organization. 3 interviewees stated that the organization becomes more efficient while 6 others argue that their center will become less efficient as a result of the proposed change.
The questionnaire results show that ‘do not have the capacity/lack of personnel’ has the highest mean score of all organizational disadvantages. “Because we do not have the personnel. And it
takes time to educate people. We do have personnel problems now, certainly when we are going to initiate patients everywhere within the country at home” explains one of the interviewees.
In line with results on the categories discussed in previous subsections, there seem to be links between the organizational disadvantages categories that are showed in figure 6.
FIGURE 6
4.1.3 Personal valence
Personal benefits
Although just 5 criteria were mentioned by 3 or more interviewees, all of these ones scored relatively high on the questionnaire with a mean score ranging from 5,08 for ‘initiation at home is more fun for myself’ to 6,38 for ‘a satisfied patient’. For each of the personal benefits a short motivation to apply this criterion will be given.
Home mechanical ventilation center employees apply ‘innovation’ because they love to do new things and want to develop themselves. One of the interviewees said: “Another point is that it is something
innovative, that is what I always like. For me personally, to develop myself. Furthermore, if you initiate people at home that could be also innovative for us as physicians. However you also get acquainted with other means of communication such as telemedicine for example. As a consequence, you will get a different way of working. And that is also very enjoyable.
‘More autonomy’ is especially for nurses an important criterion because one of the main
reasons why nurses want to work for the home mechanical ventilation center is that the work is more autonomous than in other parts of the hospital. As one of the interviewees argued: “If you work here
as a nurse, one tends to say that the most important benefit is the freedom. It is highly valued by everyone. We are all quite experienced and have done a variety of things. And still you have always been straitjacketed by the hospital, the shifts, the managers, the hospital rules, etcetera. And this is some sort of escape. You can nicely take your car, have your own agenda, you often get away from things. You know, there is no one pushing you around. You are the one visiting the patients and you are the one that decides: this patient will get an hour, that patient will get half an hour. You have so much freedom”.
Experts’ motivation to apply ‘initiation at home is more fun for myself’ is that job satisfaction is important for them.
‘A satisfied patient’ is applied because, according to the interviewees, patient satisfaction results in satisfaction for yourself.
‘Initiation at home is challenging’ is a criterion home mechanical ventilation center employees apply because “they like to be challenged”. “If I really get the feeling that I am doing my
work in an assembly line en there is no incentive or challenge to be found, than I am no longer a happy person. That is not a good thing either” argues one of the interviewees.
FIGURE 7
Links between personal benefits codes
Personal disadvantages
Table 3 shows that all 4 personal disadvantages that were mentioned by 3 or more interviewees score around a mean of 4. This implies that these criteria are neutral (not important and not unimportant) for the decision to change or not to initiation at home. So in comparison to the other categories, personal disadvantages are relatively unimportant.
‘No feedback during the initiation process’ scored 1 veto. Thus, one respondent does not want to change when this personal disadvantage is expected from the proposed change. Home mechanical ventilation center employees apply the feedback criterion because they want to test their skills and knowledge and “everybody has blind spots”, as one of the interviewees reports.
In contrast with the results on the previously discussed categories, there seem to be no links between the 4 personal disadvantages.
4.1.4 Prerequisites
So far, the categories that comprise benefits and disadvantages are discussed. In addition, as mentioned at the beginning of this chapter, 5 prerequisite categories emerged during the interviews. Results on these prerequisites in general will first be discussed in subsection 4.1.4, followed by the results on each of the 5 prerequisite categories separately.
Prerequisites in general
employees find it important to apply the prerequisites in table 3 in evaluating patient valence, organizational valence and personal valence. Thereby, prerequisites are more often scored as crucial than benefits and disadvantages are scored as crucial/veto. Seventeen of the 18 prerequisites that were mentioned by 3 or more interviewees scored at least one crucial level. In other words, respondents who scored a prerequisite as crucial definitely want to change if that prerequisite is associated with the proposed change.
Patient prerequisites
In general, patient prerequisites score a higher mean than benefits and disadvantages but a lower mean than the other prerequisite categories. Besides that, it is less often rated as crucial than the other prerequisites. Patient prerequisites mainly contains characteristics of the patient that should or should not be there in order to change to initiation at home.
The patient prerequisite most often mentioned during the interviews is ‘clinical picture/condition of the patient’. This criterion focuses on characteristics of a patients’ disease. However, no consensus among the experts exists about patients with what diseases can be initiated at home and patients with what diseases cannot. For instance, one interviewee argues about the disease ALS: “If it is an ALS patient with a slightly elevated CO2 I think that patient could be easily initiated
at home”. In contrast, another interviewee explains: “When someone has Duchenne obviously they already have the disease for a very long time so all is adapted to this. Someone that has ALS is continuously confronted with things happening to him. That makes it very difficult to accept a myriad of things”.
The prerequisite ‘coping of the patient’ refers to how a patient deals with problems and with stress.
With respect to ‘insight/intelligence’ experts share the opinion that a patient should possess a certain level of cognitive development to understand initiation at home and how to deal with it: “Not
every patient should be taken into consideration for initiation at home. That has to do with the patient’s level of understanding, do they understand what it is all about”.
The interview results show some disagreement about the criterion ‘initiation at home or in the hospital is a patients’ choice’. While some of the interviewees argue that it is a patients’ choice whether he or she wants to be initiated in the hospital or at home, others state that it is a health care professionals’ choice to decide where a patient needs to be initiated. However, the lowest score for this criterion on the questionnaire is a 4. This implies that as a result of additional insights gained after the first round of this research, experts share the opinion that it is the patients’ choice where to be initiated even though health care professionals could advice another place. As one of the physicians explains: “I can imagine that you provide a negative advice but that I will do it at home because the
The patient prerequisite ‘age of the patient’ focuses mainly on differences between young and old people. Thereby, disagreement exists about whether children can be initiated at home or not.
‘Patient feels safe’ is with a mean of 6,15 the most important patient prerequisite according to the questionnaire results: “People should feel safe with initiation at home, independently from the
question whether is it medically responsible”.
Situation prerequisites
One situation prerequisite is mentioned by more than 3, namely 7, interviewees. ‘Patient needs to have a network’ focuses on characteristics of the people around a patient such as a the partner, parents and family caregivers. The question is whether those people are available and able to provide the necessary assistance to the patient.
Center prerequisites
Center prerequisites also includes one prerequisite that is mentioned by more than 3 interviewees, ‘legal indemnity for responsibilities’. One of the interviewees explains: “We are questioning our legal
position. Initiating people at home, is that all covered from a legal perspective? Because that is something that should all be correctly discussed higher up in the organisation. Because when something goes wrong, that can definitely happen even though you have screened the patient as happened with Anda in the past when a patient died, you have a problem. So you should define your legal position beforehand. Because otherwise you could be hanged from the highest tree while you are not to be blamed”. 6 respondents marked this prerequisite as crucial and so these respondents
definitely want to change if there is legal indemnity for responsibilities.
Input prerequisites
Five input prerequisites popped up during the interviews. Two of these 5 were mentioned by 3 or more interviewees: ‘measuring equipment’ and ‘telemedicine/taking advantage of the possibilities’. ‘Measuring equipment’ scored together with one process prerequisite the highest mean of all criteria in table 3, a 6,46. The measuring equipment experts refer to are mainly measures of carbon and oxygen.
One of the interviewees explains what the prerequisite ‘telemedicine/taking advantage of the possibilities’ means: “that you could read out the equipment from a distance and that you could make
adjustments to the equipment from a distance. Some mechanical ventilation devices already have those functions. However, the question is to what extent safety is guaranteed. Eventually with a webcam or something like that, that you could speak to the patient”. 6 respondents scored this
Process prerequisites
All of the 8 process prerequisites reported by 3 or more interviewees scored a mean of 6 or higher and thus are quite important in home mechanical ventilation center employees’ decision to change or not to initiation at home.
With a mean of 6,46 ‘safety of the initiation process/patient safety’ scored, together with an input prerequisite, the highest mean score of all criteria in table 3. In addition, 6 out of the 16 interviewees reported that if the proposed change meets this process prerequisite they definitely want to change. Safety comprises according to one of the interviewees: “The situation should be safe. The
electric devices should be safe. There should be an alarm system.” Others argue that prerequisites
such as ‘measuring equipment’ and ‘patients needs to have a network’ need to be fulfilled to create a safe situation.
The criterion ‘monitoring of the patient’ focuses on observation of the patient. As one of the interviewees argued: “What has been shown so far with respect to the initiation process is that it is
important that we continue our efforts. And that you can make adjustments when necessary, that you can observe people about what goes well and what goes wrong and that you provide the patient with instructions. If you invest in that during the initiation phase you will benefit from it in the long run”.
‘Discuss risks with the patient/acceptance of risks by the patient’ and ‘no risks for the patient/prevent complications’ are in contrast with each other. While the first one indicates it is acceptable that there are risks for the patient although these need to be made clear to the patient and accepted by him or her, the second one implies that risks for the patient are unaccpetable, even if these risks are discussed with the patient.
The fifth process prerequisite, ‘good organization of the initiation process’ means that chaos should be avoided and that the initiation process should be tightly directed.
The sixth criterion ‘good/experienced nurses’ is important because as one of the interviewees reports: “I think you should have a lot of experience as a nurse to do this well. Because you should
take into account so many aspects. Really”. One of the physicians explains how to select good and
experienced nurses to initiate patients at home: “To depend it on both experience and the level of
education. Some of the nurses have a Master Advanced Nurse Practitioner. Those people are better educated and thereby more independent. That initiation at home is reserved for those nurses”.
‘Instruction possibility’ is with a mean score of 6,15 quite important in the decision to change or not because “A good start is half the battle” according to one of the interviewees.
A quote that represents the content of the eighth prerequisite ‘discuss expectations with the patient’ is: “It is of tremendous importance that you clearly discuss with the patient what he or she
not work like that. So if there are distorted expectations, wherever you initiate, it would not be successful”.
4.1.5 Other valences
For the most part, patient valence, organizational valence and personal valence comprise all expected benefits and expected disadvantages home mechanical ventilation center employees apply in evaluating a proposed change. However, some of the interviewees argue that expected benefits and disadvantages for family caregivers also influence their decision to change or not to initiation at home. This could be a separate variable influencing readiness for change but also an extension of patient valence or situation prerequisites. The 5 criteria to evaluate expected benefits and disadvantages for family caregivers that popped up during the interviews are discussed below. Since each of these 5 criteria are mentioned by less than 3 interviewees they were not included in the questionnaire.
Other benefits
Expected benefits for family caregivers are ‘more time available’, ‘does not have to go to the hospital’ and ‘directly learn how to deal with the devices’. The first two of these criteria are related because as family caregivers do not have to go to the hospital there is more time available for other activities. The last criterion ‘directly learns how to deal with devices’ is linked with the patient benefit ‘network of the patient directly involved/network directly learns how to handle it’. When a family caregiver directly learns how to deal with the devices and becomes able to provide the necessary help to the patient this benefits both the patient and the family caregiver.
Other disadvantages
The criteria applied to evaluate the expected disadvantages from the proposed change for family caregivers are ‘uncertainty’ and ‘responsibility’. “I can imagine that not everyone feels comfortable
with that. That family caregivers get the feeling of extra responsibilities. And maybe feel a bit insecure about that. I can imagine” explains one of the interviewees.
4.2 Weights
Section 4.2 has the same structure as section 4.1. First of all, an overview of the weights allotted to patient, organizational and personal valences will be given. Subsequently, subsection 4.2.1 elaborates on patient valence. Subsection 4.2.2 provides the results on the weights allotted to organizational benefits and disadvantages in determining readiness for change. The third subsection shows the results on personal valence. Subsection 4.2.4 provides the results on the differences between weights allotted to benefits and to disadvantages. This section ends with a subsection about the relationship between valences and the readiness for change dimensions. In all of the five subsections, interview results are first discussed and afterwards the questionnaire results are provided.
Overview of the weights allotted to patient, organizational and patient valences
Figure 8 provides the interview results on the importance health care professionals allot to personal valence, organizational valence and patient valence in determining their readiness for change. For each of these valences, a distinction is made between the importance participants allot to expected benefits and to expected disadvantages from the proposed change. The total number of interviewees could be above 16 because some of the experts rated a benefit or disadvantage for different groups of equal importance. This could be seen in appendix VI where the exact weights interviewees allot to benefits and disadvantages for patients, the organization and themselves are given. If that is the case, the groups ranked of equal importance are given both the highest ranking of the two groups. For instance, appendix VI shows that interviewee number 11 assigns 40 points to patient benefits and 30 points to organizational and personal benefits. Therefore, patient benefits are ranked as most important and organizational benefits and personal benefits are both ranked as medium important.
Figure 9 presents the questionnaire results on the second sub question. The average of all mean scores per category, that can also be found in table 3, is given. Figures 8 and 9 show that the questionnaire results and interview results differ.
FIGURE 8 FIGURE 9
Round 1: importance of valences Round 2: importance of valences
