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Transforming the assessment process of potential donor hearts from best

evidence to best practice

Research about the influence of the communication message on the willingness to change of individual professionals

Master Thesis, MscBA, Specialization Change Management University of Groningen, Faculty of Economics and Business

June, 2010 MICHEL EVERS Studentnumber: 1737155 Oude Bos 63 9641 HX Veendam (+31) 644224399 michelevers@hotmail.com Supervisors/ University Dr. C. Reezigt Drs. J.C.L. Paul Supervisors/ UMCG Drs. Aat van den Berg Drs. Christian van der Hilst

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Abstract

This thesis is focused on the willingness to change. The research question that has to be answered is to what extent communication regarding: discrepancy, self-efficacy, personal valence, organizational valence, and principle support, influences the willingness to change of individual health care professionals in the transplantation region of Groningen? The research results give new insight into the willingness to change of individual health care professionals in the field of organ donation, and how the willingness to change can be influenced. The research took place from September 2009 until April 2010 at 21 hospitals in the transplantation region of Groningen. The most important findings are that sense of urgency is insignificantly perceived, self-efficacy is significantly present, personal valence seems to be absent, or is hardly ‘observable’, organizational valence seems to be absent, and support from hospital’s board, and peers are important. Although communication about these elements, improve the willingness to change, it must be noticed that results can be different between individual health care professionals.

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1.

INTRODUCTION

1.1 From best evidence to best practice 4

1.2 Organ donation in the Netherlands 4

1.3 Change Target & Previous Research 5

1.4 Research Question 6

1.5 What’s to come? 7

2. LITERATURE REVIEW

2.1. Behavior in organizational change 8

2.1.2 Behavior and willingness to change 8

2.1.3 Formation of behavior 9

2.1.4 Theoretical relations 10

2.1.5 Behavior and perception 11

2.2 Communication 12 2.2.1 Discrepancy 12 2.2.2 Self- efficacy 13 2.2.3 Personal valence 13 2.2.4 Organizational valence 14 2.2.5 Principle Support 15

2.3 Conceptual model with causal relations 16

3. METHOD 3.1 Procedure 17 3.2 Measures 18 3.3 Population 19 3.4 Analyses 20 4. RESULTS 4.1 Descriptive Statistics 21

4.2 Accepting or rejecting hypotheses 22

5. DISCUSSION

5.1 Answering the research question 26

5.2 Reliability & Validity 32

5.4 Further research 33

REFERENCES 34

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1. Introduction

1.1 From best evidence to best practice

One of the most consistent findings in health services research is the gap between best practice (as determined by scientific evidence), on the one hand, and actual clinical care, on the other (Grol and Wensing, 2004). Health care is among the best endowed of all industries in the richness of its science base (Berwick, 2003). Major gaps in knowledge exist, but clinical science progresses, often providing a rational basis for choosing the best drugs, surgery, diagnostic strategies, and other elements of care (Berwick, 2003; Ellis et al., 1995). Failing to use available science is costly and harmful; it leads to overuse of unhelpful care, underuse of effective care, and errors in execution (Berwick, 2003).

Why is the gap between knowledge and practice so large? According to Fleuren et al. (2004) the introduction of innovations to healthcare is widely recognized as a complex process. Several factors affect, positively or negatively, the process, and sometimes changes do not occur because health professionals do not accept the innovation (Fleuren et al., 2004; Greenhalgh et al., 2004). Sometimes, the step from best evidence to best practice is simple; however, most of the time it is not, and we need various strategies targeting obstacles to change at different levels, which could even present conflicting values for individual practitioners (Grol and Wensing, 2003).

This thesis is focused on the change process. The change process refers to the steps followed during implementation (Holt et al., 2007). For this thesis, research is conducted about the implementation of changes (best practice) in the assessment process of donor hearts.

1.2 Organ donation in the Netherlands

In recent years, a lot of media attention, nationally and internationally has been paid to organ donation. Many interest groups force politicians to take organ donation very seriously. In 2008, a national working group was set up on this issue with representatives of all involved parties. The national working group handed over a report to the Ministry of Health which comprehended advices to improve the quality and the processes of organ donation in Dutch hospitals.

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figures confirm the point of view, that potential donor hearts are lost in the assessment process (Medisch Status Overzicht, 2008). Experts of the UMCG want to implement

improvements in the assessment process of donor hearts (appendix 1). Possibly, these changes will be laid down in a new clinical guideline. These changes should be implemented in all hospitals in the transplantation region of Groningen. Throughout this thesis, the term ‘implementation’ refers to the translation of any tool or technique, process, or method of doing, from knowledge to practice (Tornatzky et al., 1982).

Some studies report that guideline implementation is at times unsuccessful because there are high levels of disagreement or ambivalence over recommendations among practitioners (Moulding et al., 1999) Therefore, Moulding et al. (1999) emphasized the importance of building agreement with clinical practice guidelines through consultative processes as part of any implementation strategy. In the health care sector, professionals have the power to block change. Therefore they must be engaged in a change process for it to succeed (Ferlie et al., 2005).

During this research, professionals of all hospitals could participate in the development of improvements for the assessment process of donor hearts. However, I

emphasize that this thesis is focused on the implementation process and not on the content of change. Research outcomes are supplementary to the outcomes of the consultative processes. This thesis is focused on the implementation of the changes, which experts of the UMCG proposed during the start-up of this research (appendix 1; proposed changes).

1.3 Change Target & Previous Research

Initiator of the change process is the UMCG. The UMCG is one of the largest hospitals in the Netherlands. Since 2006, the UMCG is licensed to conduct heart

transplantations. The Netherlands are divided in four regions regarding the explantation of organs. The region of Groningen (UMCG) comprises nineteen autonomous hospitals (appendix 2; overview of region Groningen). All nineteen hospitals collaborate with the UMCG on the issue of transplantation & organ donation. According to Armenakis et al. (2001), the change target is the collection of individuals who must modify their cognitions and behavior in order to achieve the objectives of the change effort. In this thesis, the change target consist of cardiologists, intensive care practitioners, donation coordinator and

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scientific evidence and patient care we need an in-depth understanding of the barriers and incentives to achieving change in practice’’ (Grol and Wensing, 2004: p57). We need more research to gain a better insight into the important processes and elements of successful change (Grol and Grimshaw, 2003: p1229). Which strategies work for a particular type of evidence in a setting? This question implies we need to give more attention to the validation of different theories on changing professional and organizational performance (from health promotion, social sciences, organizational and management sciences, marketing, and economy) to find the crucial determinants of effective change (Grol and Grimshaw, 2003: p1229)

Two discussions about the research design of previous researches are in particular relevant for this thesis. Most knowledge to and incentives for change are not derived from well designed prospected studies (Grol and Wensing, 2004). In the absence of this knowledge, the success or failure of an implementation intervention may well be left to chance (Grol and Wensing, 2004). Furthermore, Fleuren et al. (2004) concluded that most research in health care has focused on individual doctors working independently in small practices, such as general practitioners. Less is known about the determinants of change in larger health care organizations, which may be different from those for individual health care professionals (Fleuren et al, 2004). This thesis is primary focused on answering the management question of the UMCG. However, this thesis attempt to bridge the above mentioned knowledge gaps, through conducting prospective research in larger healthcare organizations.

1.4 Research Question

The impact of organizational change has been traditionally assessed in terms of profitability, costs, and other easily accessible criteria (Armenakis et al., 2001). One wonders, however, whether these criteria alone suffice to evaluate the true psychological response toward the change. The extent to which adoption exists can be assessed in terms of commitment to the new behaviors, attitudes, and paradigms (Armenakis et al., 2001).

Nowadays, many authors state that successfully implementing changes inevitably requires encouraging individuals to enact new behaviours so that desired changes are

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Many theories can provide a starting point for changing the determinants for successful implementation (Bartholomew et al., 2001). Based on pilot research, this thesis explores the influence of communication on the willingness to change, and eventually on behavior of individual professionals. According to Buiter et al. (1995:7) ‘’an organization will only change when people change their behaviors’’. Because people are the organization. They will only change if they are really willing to change and have the ability to change. Therefore, communication is indispensable. Communication is one of the strict conditions in order to control an organizational change.’’ This thesis elaborates the change message that is being conveyed in order to implement changes in the assessment process of potential donor hearts. The research question can be formulated as:

To what extent communication regarding: discrepancy, self-efficacy, personal valence, organizational valence, and principle support, influences the willingness to change of individual health care professionals in the transplantation region of Groningen?

1.5 What’s to come?

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2 Literature review

2.1. Behavior in organizational change

Because a full review of the relation between behavior and its influence on the implementation process is beyond the scope of this thesis, this section summarizes that what is most important for this thesis. Lewin (1947) was the first to conceptualize change as

progressing through successive phases called unfreezing, moving, and freezing. The three step model of Lewin (1947) intended to change group behavior. Lewin (1947) considered the present situation as the status quo as being maintained by certain conditions or forces. Lewin (1947) believed that human behavior was based on a quasi-stationary equilibrium supported by a complex field of driving and restraining forces. To unlearn old behavior and learn new behavior, this quasi-stationary equilibrium needs to be unfrozen.

Since Lewin (1947), many authors acknowledge the role of behavior in organizational change but emphasize moreover the role of individual behavior (Armenakis & Bedeian,1999; Moulding et al, 1999; Lawrence 1969; Lundberg, 2004; Armenakis, 2001; Grol and Wensing, 2003; Holt et al, 2007). Organizational change and individual change are synonymous and complementary, and when approached together consciously, provide the potential for a

synergistic reinforcement of one another that can produce truly significant and lasting changes in the thinking, feeling, and sense-making of individuals as well as the practices, structures, processes and arrangements of organizing (Pasmore & Fagans, 1992). Organizations can only act and change through their members and even collective activities that occur in

organizations are the result of some amalgamation of the activities of individuals (Lundberg, 2004).

2.1.2 Behavior and willingness to change

Management actions leading to what we commonly label ‘change’ are usually initiated outside the work group by staff people (Lawrence, 1969). These are changes that we notice and the ones that most frequently bring on symptoms of resistance (Lawrence, 1969).

Resistance influences the implementation process negatively (Lawrence, 1969; Armenakis et al., 2001. The transtheoretical model of behaviour change, often referred to as the ‘readiness to change’ model, is a well recognised behaviour change theory with a broader

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an individual or individuals cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo. The creation of readiness is the preparation of behavior required to unfreeze an organization before change is possible (Armenakis et al., 2001). Readiness can be distinguished from resistance by considering readiness as a cognitive, emotional state and resistance as a set of resultant behaviors

(Armenakis et al., 2001). The degree of readiness a person can experience thus anticipates his or her support for the change or resistance to it. (Armenakis et al., 2001; Armenakis et al., 1993; Jaffe et al., 1994).

2.1.3 Formation of behavior

People’s behavior results from conscious choices between alternatives, and these choices are systematically related to psychological processes such as perception and the formation of beliefs and attitudes (Vroom, 1964). The Valence, Instrumentality and Expectancy model (VIE model) intends to predict a force to perform a certain act (Vroom, 1964). Valence is defined as all possible affective orientations toward outcomes as

importance, attractiveness and desirability. Instrumentality refers the degree to which a person sees the outcome in question as leading to the attainment of other outcomes. Expectancy is defined as the subjective probability of an action or effort leading to an outcome or

performance. Based on expectancy theory, Ajzen (1991) developed the theory of planned behavior. According to Ajzen (1991) behavior depends jointly on intention (motivation) and behavioural control (ability). Intentions are assumed to capture the motivational factors that influence a behavior; they are indications of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behavior (Ajtzen, 1991). Intention is determined by three variables, attitude toward the behavior, subjective norm and perceived behavioural control. Attitude toward the behavior refers to the degree to which a person has a favourable or unfavourable evaluation or appraisal of the behavior in question. Subjective norm refers to the perceived social pressure to perform or not to perform the behavior. The latter, perceived behavioral control refers to people’s perception of the ease or difficulty of performing the behavior of interest. (Ajzen, 1991). As a general rule, the more favourable the attitude and subjective norm with respect to a behavior, and the greater the perceived behavioral control, the stronger should be an individual’s intention to perform the behavior under consideration (Ajtzen, 1991).

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model, Metselaar & Cozijnsen (2002) developed a diagnostic model to measure and declare the willingness to change. Metselaar & Cozijnsen (2002) modified Atjzen’s model, elaborated it in more detail and aimed it specifically for change management practices. They modified the definition of ‘intention’ into the ‘willingness to change’, but ultimately, behavior is still target of change. Whereas Atzjen (1991) elaborate the influence of the attitude, the subjective norm and perceived behavioral control on behavior, Metselaar & Cozijnsen (2002) changed these definitions. According to them, attitude refers to a positive attitude (1) towards the change, subjective norm refers to co-workers attitudes (need to change) (2) and perceived behavioral control is defined as the ability to change (3). A positive attitude (1) towards the change is the product of the expected work-related outcomes, the expected consequences for the organization and the affective responses of employees (Metselaar & Cozijnsen, 2002). Co-workers attitudes (2) of colleagues, managers and others create pressure on the individual to perform a certain behavior (Metselaar & Cozijnsen, 2002). The ability to change (3) is extracted into the experience of an individual with previous changes, the time and means someone can use to conduct the changes, the manner how the change process is guided and the complexity of the change.

2.1.4 Theoretical relations

Table 1 presents an overview of theoretical relations between the models of Vroom (1964), Ajzen (1991), Metselaar & Cozijnsen (2002), and Armenakis et al. (2001). Holt et al. (2007) republished the model of Armenakis et al. (2001) and elaborated it extensively. The model of Armenakis et al. (2001) will be elaborated in section 2.2 and is used as theoretical foundation in this thesis.

All models in table 1 attempt to explain the formation of a certain motivation, behavior or willingness/readiness to change. Among the models, many determinants are considerably related. First of all, all models incorporate components of valence. However, Vroom’s model (1964) distinguished the determinants valence and instrumentality, and Armenakis et al. (2001) distinguished organisational and personal valence as two different determinants. Furthermore, Metselaar & Cozijnsen (2002) included organizational valence in ‘positive attitude towards the change’ and labelled it added value for the organization.

Different to the model of Armenakis et al. (2001), Metselaar & Cozijnsen (2002) included determinants about emotions and emotional involvement.

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model is interpreted by Metselaar (1997) as a person’s belief about whether a particular outcome is possible. This is similar in concept to their interpretation of perceived behavioural control which refers to the feasibility of a certain behavior (Metselaar & Cozijnsen, 2001). Therefore, expectancy relates to ability to change, perceived behavioural control, and self-efficacy.

Model: Vroom (1964) Ajzen (1991) Metselaar&

Cozijnsen (2002)

Armenakis et al. (2001)

Focus on: Motivational Force Behavioral intention Willingness to change Readiness to change Valence Instrumentality

Attitude toward the behavior

Positive attitude toward the change

Appropriateness (organizational valence)

Personal valence Co-worker attitudes Co-worker attitudes

(must change) (need for change)

Discrepancy Principle support Theoretical relations among determinants: Expectancy Perceived behavioral control

Ability to change Self-efficacy

Table 1: Theoretical relations between components of Vroom (1964), Ajzen (1991), Armenakis et al. (2001) and Metselaar & Cozijnsen (2002).

2.1.5 Behavior and perception

How can we know what we think until we see what we say? People need to act in order to discover what they face, and they need to talk in order to discover what is on their mind (Weick, 2000). Vroom (1964) already acknowledged the role of perspectives, and subjectivity in the formation of behavior. When individuals observe objects, actions and behaviors their paradigms and resultant diagnostic models shape what is ultimately perceived (Armenakis et al., 2001). Paradigm change is the ultimate goal of all change efforts

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things differently; that is, he or she begins to have a different paradigm shaping his or her perceptions or reactions (Benne, 1976).

Paradigms are modified and changed, as the result of recognition, analysis, and

incorporation of new or discrepant information (Armenakis et al., 2001). The change message refers to this information and incorporates the components: discrepancy, appropriateness, personal valence, appropriateness (organizational valence) and principle support (Armenakis et al., 2001). Communication is a mean to change these paradigms (Armenakis et al., 2001).

2.2 Communication

Communication is not a one direction mean but an interaction to create fit between visions and concerns of multiple parties (Buiter et al., 1995). Communication is an interaction in which one or more parties are engaging and responding to each other (Cummings and Worley, 2005). Communication matters in the processes involved in implementing

organizational change (Difonzo & Bordia 1998; Lewis, 2007; Cummings & Worley, 2005). The outcomes that are achieved in the implementation of organizational changes depend in part on the interactions of implementers and other important stakeholders. (Lewis, 2007).

Communication aimed at self- efficacy, discrepancy, personal valence, organizational valence (appropriateness), and commitment of the formal- and informal leaders will enhance willingness to change (Holt et al., 2007; Armenakis et al., 2001). These determinants are acknowledged by many other authors but often labelled differently. In this section, the determinants of Holt et al. (2007), and Armenakis et al. (2001) will be elaborated separately and supplemented with additional theory.

2.2.1 Discrepancy

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Establishing the need to change is the first step in the implementation process (Galpin, 1996). Other authors labelled the need for change ‘sense of urgency’. Establishing a sense of urgency is crucial to gain needed cooperation. With low urgency, it is difficult to put together a group with enough power and credibility to guide the effort to convince key individuals to spend the time necessary to create and communicate a change vision (Kotter, 1995).

Communicating this sense of urgency throughout the organization is essential to change (Nadler & Tushman, 1989). As presented in table 1, need for change is related to co-worker attitudes which are believed to influence willingness to change. Therefore, it is hypothesized that communicating about the need for change has a positive influence on the willingness to change (H1)

2.2.2 Self- efficacy

The efficacy component of the change message offers information regarding the individual and organization’s ability to implement the change successfully and perform the behaviors required (Prochaska et al., 2008; Buiter et al, 1999; Armenakis et al., 2001). Holt et al. (2007) defined self-efficacy as the extent to which one feels that he or she has or does not have the skills and is or is not able to execute the tasks and activities that are associated with the implementation of the prospective change.

Bandura (1986) already acknowledged the role of self-efficacy. Efficacy, labelled ´perceived behavioral control´ or ‘ability to change’ is assumed to determine behavior (Ajzen, 1991; Metselaar & Cozijnsen, 2002). According to Ajzen (1991), the person, who is confident that he can master a certain activity, is more likely to persevere than the person who doubts his ability. The role of perceived behavioral control or self-efficacy is well known in change models (e.g. Armenakis et al., 2001) but is not well addressed in theory according to

Moulding et al. (1999). It is hypothesized that communicating about self-efficacy has a positive influence on the willingness to change (H2)

2.2.3 Personal valence

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1998). Even a scientifically reasonable guideline may simply not work well with the current circumstances; a change must resonate with currently felt needs and beliefs of individuals (Berwick, 2003).

Benefit is a relative matter-a matter of the balance between risks gains and of risk aversion in comparing the known status quo with the unknown future if the innovation is adopted (Berwick, 2003). Less beneficial innovations that are not compatible with the needs of stakeholders are unlikely to be sustained (Johnsen et al., 2004; Tornazky & Klein, 1982). Fleuren et al. (2004) and Greenhalgh et al. (2004) acknowledged the role of valence but defined it differently. According to them, relative advantage refers to the extent to which the innovation is perceived as advantageous.

The more (positive) information / knowledge individuals can gain about the expected consequences of an innovation-leading to what Rogers calls ‘’reduction in uncertainty’’-the more likely they are to adopt it (Berwick, 2003; Rogers, 1995). If the benefits of an

innovation are visible to intended adopters, it will be adopted more easily (Greenhalgh et al., 2004). Initiatives to make more visible the benefits of an innovation increase the likelihood of their assimilation (Greenhalgh et al., 2004). Successful adoption is more likely if adequate feedback is provided to the intended adopters about the consequences of adoption Greenhalgh et al., 2004). Vroom (1964), Ajzen (1991), Metselaar & Cozijnsen (2002) acknowledged the influence of valence on the willingness to change (table 1). Therefore, the third hypothesis assumes that communicating about personal valence has a positive influence on the willingness to change (H3)

2.2.4 Organizational valence

Organizational valence refers to 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). This component of the message (defined as appropriateness) provides information regarding the degree to which the proposed change is right for the organization (Armenakis et al., 2001).

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2.2.5 Principle Support

Principle support refers to the extent to which one feels that the organization’s leadership and management are or are not committed to and support or do not support implementation of the prospective change. (Holt et al., 2007). Social influence theory emphasises the role of others in decision making about behaviour, postulating that factors such as custom, habit, assumptions, and beliefs of peers and prevailing practices and social norms shape the interpretation of information Moulding et al., 1999). Vroom’s model (1964) lacks perceptions of ‘climate’ but the models of Ajzen (1991) and Metselaar & Cozijnsen (2002) labelled it ‘co-worker attitudes’.

Although principle support is normally aimed on support by executives, in this research, the focus is especially aimed on support of influential peers. Davenport et al (1998) concluded that strong support from executives was crucial for transformation-orientated projects but less necessary for improving individual functions or processes. This research is aimed at the implementation of a single process and not on a large transformation. Ferlie et al. (2005) concluded that in health care medical specialists are self-sealing groups with power to block changes, and according to Moulding et al (1999) ‘’guidelines appear to be more

acceptable to physicians if they are endorsed or promoted by a respectable peer’’. Evidently, perceived opinions of peers and opinion leaders play a major part in influencing the attitudes of individual practitioners and, most importantly, their decisions to act on new information (Moulding et al., 1999). Principle support for the intervention is observed as respected colleagues initiate and continue the adoption of the change (Moulding et al., 1999). In these cases, the desire to adopt the new behavior results from wanting to be identified with the adopters (Armenakis et al., 2001).

A supportive peer network among implementers of an innovation is important for implementing and sustaining innovations. Such peer networks provide support and prevent feelings of isolation among adopters (Johnsen et al., 2004; Green et al., 2002; Klinger et al., 1999). Champions who proactively promote an innovation from inside or outside of a system, are critical to creating an environment that supports and facilitates sustaining innovations (Green & Plsek, 2002; Davenport et al., 1998). It is important to have multiple champions of the innovations who cut across organizational disciplines and status hierarchies to ensure their successful and complete adoption (Calsyn et al., 1977). Intra-organizational networks among innovation stakeholders are important to ensure that those charged with sustaining the

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Communicating about principle support has a positive influence on the willingness to change (H5)

2.4 Conceptual model with causal relations

Elements of the change message (Armenakis’s model, 2001) which are believed to influence willingness to change, and ultimately behavior, are presented in the conceptual model below (figure 1).

Figure 1: Conceptual model

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3. Methods

3.1 Procedure

Professionals with different medical and non-medical backgrounds as managerial staff, head of the intensive care, transplantation cardiologist, thoracic surgeon, internist, donation coordinator and a transplantation coordinator were present in an expert team founded especially to improve processes related to donor hearts and transplantation. During the start-up of this research, extensive conversations were held with these professionals. According to Cooper et al., (2006) ’theory is a set of systematically interrelated concepts, definitions, and propositions that are advanced to explain and predict phenomena. To the degree that our theories are sound and fit the situation, we are successful in our explanations and predictions ‘’ (Cooper et al., ‘2006). Therefore, information of these conversations is used in the search for relevant theory about change in healthcare organizations.

Initial target of search were articles about implementing change in healthcare

organizations. The databases ESCBOhost and Pubmed were used in august 2009 to search for articles about implementing change in healthcare organizations. Keywords were

‘’determinants of implementation, determinants of innovation, change, and healthcare’’. Keywords were used interchangeably to create a broad scope of articles. No language or timeframe restrictions were applied on searching. I assumed that earlier studies and articles were incorporated into more recent articles. I screened for the most relevant literature on title. Determinants of articles were scrutinized by the author; relevant determinants were screened on relevance and applicability. Many irrelevant determinants as for example, the interests of patients were excluded.

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et al., 2006). In this research, it is hypothesised that elements of the change message influence the willingness to change.

3.2 Measures

Questionnaires (appendix 4; questionnaire) supplemented with interviews (appendix 5; semi-structured interview questions) were used to gain research data. During the

conversations which lasted between 15-45 minutes, a questionnaire was filled in, interview questions were asked and participants could elaborate and clarify their answers extensively. These conversations were planned in between their normal appointments with patients. Therefore, available time for these conversations varied each time. Often, due to a lack of time, not all interview questions could be asked. Based on experiences of other’s

(conversations during start-up of the research), I assumed that respondents who were willing to participate in the research could have more affinity with organ donation than their

colleagues. To overcome this bias and to decrease the influence of ‘social desirable’ answers, questions were aimed at colleagues and not on the individual respondent.

Qualitative methods provide incredibly rich change-specific information but can create an interviewer bias (Holt et al., 2007; Isabella, 1990; Cooper et al., 2006). A questionnaire can be used to prevent a bias of the researcher involved (Cooper et al, 2006). Quantitative methods are an appropriate supplement of qualitative methods, offering unique advantages to managers, organizational development consultants, and researchers in certain settings (Holt et al., 2007). Furthermore, questionnaires can be distributed widely in relatively short periods of time (Holt et al., 2007). But, quantitative methods are limited by the opportunity to probe respondents and the quality of the original data collection instrument. Therefore, in this research qualitative and quantitative methods have been used.

For the question in the questionnaire, the underlying source is pointed out, content validity, and construct validity has been assessed. A Likert scale was used to measure the constructs. Likert scale’s are accurate measurements for interval data, and are probably more reliable and provide a greater volume of data than many other scales (Cooper et al, 2006). All questions were phrased in such a way that participants could express their level of agreement with using a 5-points response format ranging from 1 strongly disagree to 5 strongly agree. Responses 2,3, and 4 were included to express moderate levels of agreement or disagreement.

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asked. In the last part of the questionnaire, respondents could react via open questions on the content of change or add comments.

Dependent variable

Willingness to change is the dependent variable. The DINAMO questionnaire,

developed by Metselaar & Cozijnsen (2002) has been used to measure willingness to change. Questions of this list have been adapted to the specific context and population under study. Originally, the list was aimed on middle managers. In this context the DINAMO

questionnaire was aimed on health care professionals.

Independent variables

Questions to measure elements of the change message have been derived of

questionnaires developed by Holt et al. (2007), and Metselaar & Cozijnsen (2002). They both designed questions to gauge readiness for organizational change at an individual level.

Similar to the questions Holt et al (2007) provide, the DINAMO questionnaire (Metselaar & Cozijnsen, 2002) consists of questions aimed at organizational valence, co-workers attitudes, and ability to change (self-efficacy).

3.3 Population

The transplantation region of Groningen (UMCG), consist of 21 hospitals. Four hospitals collaborate and share health care professionals with each other. Therefore, the region consists of 19 autonomous hospitals. Within these hospitals, cardiologists, intensive care practitioners, donor coordinators and transplantation coordinators those ones most affected by the changes. Roughly estimated, all 19 hospitals together employ about 129 cardiologists 138 intensive care practitioners, 25 donation coordinators, and 4 transplantation coordinators (meer samen = samen meer, 2008; Crommentuyn, 2009; memberlist NVVC, 2008.) Four transplantation coordinators, coordinate the transplantation process in the region of the UMCG.

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mostly one practitioner is representative for his/her partnership. For each hospital/partnership the representatives of these partnerships were approached. In general, in each hospital one cardiologist and one intensive care practitioner were approached. Furthermore, I contacted all donation coordinators, and one of the four transplantation coordinators. A network of

donation coordinators is used to contact the respondents. Within two months, all 19 respondents were visited. Table 1 presents an overview of the participants.

Specialty Frequency Percent

Cardiologists 13 30,2

Donor coördinators 15 34,9

Intensive care practitioners 15 32,6

Transplantation coördinators 1 2,3

Table 2: Overview of participants

3.4 Analyses

Data of questionnaires have been analyzed with various kinds of analyzes. Firstly, negative answers have been recoded, and ‘scale reliability’ have been applied. Based on the Cronbach’s alpha, within constructs questions have been left out. Factor analyzes have been applied on constructs with still an insufficient Cronbach’s alpha. According to Cooper et al., (2006), Spearman correlation analyzes should be used in case of ordinal data. Therefore, after factor analyzes, correlation have been indicated through a Spearman correlation analyzes. Non-correlating constructs or insignificant correlating constructs have not been examined further. Constructs with significant influence on the willingness to change have been

researched further with single-item regression analyses. Based on these regression analyses, hypotheses have been accepted or rejected. Gathered qualitative information has been recoded.

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4. Results

4.1 Descriptive Statistics

Table 3 presents for each construct the mean, cronbach’s alpha, standard deviation, and correlation among all constructs. Based on a reliability analyzes (cronbach’s alpha), constructs with multiple questions have been found reliable or insufficient reliable. Constructs with an insufficient reliable alpha (α > 0,70), have been tested multiple times with the option ‘cronbach’s alpha if item deleted’. Based on the results, questions were taken out and the alpha of some constructs improved. Insignificant cronbach’s alpha values might be explained by applying questions for another population and environment that they initially were

developed for. Furthermore, the relative low N of 44 might influence the alpha’s values negatively. Spearman’s correlation analyses have been used to indicate correlation among the constructs. Earlier draught hypotheses presumed positive correlations between the dependent and independent items. Therefore, Spearman’s analyses were 1-tailed (Huizingh 2006). As presented in table 3, Spearman analyses indicates that the dependent, and all independent variables are significant correlated.

Construct Questions α Mean SD H1 H2 H3 H4 H5

(Dep) Willingness to change 24-27 0,84 3,48 0,57 0,26* 0,70** 0,46** 0,55** 0,51**

(H1) Discrepancy 32-33 0,79 2,58 0,74 0,29* 0,33* 0,39** 0,29*

(H2) Self-efficacy 14-21, 23,35 0,87 3,24 0,53 0,35* 0,44** 0,63**

(H3) Personal valence 36-37 0,73 2,89 0,60 0,23 0,10

(H4) Organizational valence 8-9,39 0,77 3,24 0,59 0,55**

(H5) Principle support 12-13,40 0,46 3,76 0,44 * Correlation is significant at the 0,05 level (1-tailed)

** Correlation is significant at the 0,001 level (1-tailed)

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4.2 Accepting or rejecting hypotheses

All hypotheses presume a positive relation between the construct in question and the willingness to change. Therefore, single-item linear regression analyses have been used to indicate causal relations. Table 4 presents the R Square, Beta and Significance as a result of the regression analyses. R Square indicates to which extent variance of the willingness to change can be declared through the independent variable in question (Huizingh, 1989). Beta Indicate the relative importance of the variables, and significance means the level of

significance and will be used to accept or reject the hypothesises (Huizingh, 1989).

Item/construct R Square Beta Sig

(H1) Discrepancy 0,048 0,218 0,155

(H2) Self-Efficacy 0,451 0,672 0,000 (H3) Personal valence 0,144 0,379 0,011 (H4) Organizational valence 0,379 0,616 0,000 (H5) Principle support 0,218 0,467 0,001 Table 4: Outcomes single-item linear regression analyses

Communicating about the need for change has a positive influence on the willingness to change (H1)

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Item N Discrepancy

(need for change) 17 It never happens / the frequency is very little 14 We don’t miss any donor hearts in this hospital 8 The proposed concept is not a change

6 It is not my problem but of another specialist 8 It is a problem of the UMCG

3 All donation related improvements are good, unless extra work

4 All donation related improvements are good

Total Respondents 34

Table 5: Qualitative information about discrepancy

Communicating about self-efficacy has a positive influence on the willingness to change (H2 According to the results of the regression analyses, self-efficacy is statistically

accepted (sig=0,000<α) Communicating information regarding self-efficacy, explains for 45,1 the variance of the willingness to change. However, other factors also influence the

willingness to change. Table 6 presents data of interviews about change efficacy. 15

respondents elaborated their answers. In other conversations, time was not present to discuss this subject or not perceived as important issue. All respondents indicated that health care professionals should have sufficient skills to conduct the proposed changes. Only transmitting echo’s electronically, is not always possible with the current ICT systems, and internet

connections. Furthermore, 2 respondents argued that sometimes health care professionals were not present, or willing to conduct the assessment process when they were not at work.

Item N

Efficacy

(ability) 8 Lack of skills is no issue for my peers

5 Transmitting echo’s is not possible with current ICT systems 2 Conducting assessment process not always possible

Total Respondents 34

Table 6: Qualitative information about s

Communicating about personal valence has a positive influence on the willingness to change (H3)

Single-item linear regression analyses (table 4) shows sig=0,011 > α. Based on these values, hypothesis 3 is accepted. Communicating information regarding personal valence, explains for 14,4% the variance of the willingness to change. Other factors also influence the willingness to change.

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personal valence for your peers in this change process? Most respondents answered that valence is not present, or not observable. A large number of respondents argued to perceive intrinsic motivation as personal valence. Just a minority of respondents thought that their colleagues were financially driven. In many hospitals, financial revenues were in favour of the department instead of the health care professional in question.

Item N

Personal valence

(personal advantage) 16 Intrinsic rewards

11 Only valence for UMCG / receiver 10 No valence observable for us 2 Financial rewards

1 Sometimes valence

Total Respondents 34

Table 7: Qualitative information about personal valence

Communication about organizational valence has a positive influence on the willingness to change (H4)

Hypothesis 4 is statistically accepted (sig=0,000<α). R Square indicates that 37,9% of the willingness to change can be declared through organizational valence. Other factors also influence the willingness to change. Respondents provide qualitative comments, and answers on the question, ‘’what is the valence for your hospital?’’ Many respondents indicated that organizational valence consist of corporate social responsibility, or that there was no

organizational valence at all. About a third of the respondents argued that the UMCG should only initiate appropriate changes which are more effective than the current practices.

Item N

Organizational valence

(Organizational advantage) 10 Corporate social responsibility 8 None

3 Public relations

Total Respondents 34

Table 8: Qualitative information about organizational valence

Communicating about principle support has a positive influence on the willingness to change (H5)

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their answer on this item. Most respondents provided different answers as presented in table 9. None of the respondents argued that support was not important.

Item N

Principle support

4 Support of transplantation cardiologist 2 Support of transplantation coordinator 2 Support of board

2 Support of donation commission 2 Support of colleagues

3 All support is good

Total Respondents 34

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5. Discussion

Previous sections in this thesis provided information about the theoretical relation between the change message and the willingness to change, about the research method, and about the actual results the research produced. In this section, for each hypothesis quantitative and qualitative results will be interpreted and discussed. Reliability, validity and

consequences for theory and practice will be subject of discussion.

5.1 Answering the research question

Communicating about the need for change has a positive influence on the willingness to change (H1)

Regression analyses indicated no significant relation between discrepancy (H1) and the willingness to change. However, spearman analyses indicated significant correlation among discrepancy (H1), and the willingness to change. Furthermore, qualitative information indicates that ‘the need for change’ is insignificantly perceived by health care professionals employed in the region of Groningen. There are some reasons which may explain why

qualitative results are different than quantitative results. Questions in the questionnaire, aimed to measure discrepancy were not specifically developed to measure ‘discrepancy’ with

healthcare professionals, and in an intra-organizational context with multiple larger health care organizations. Most health-care professionals are assembled in partnerships, and

therefore more united than professionals in other sectors. Questions in the questionnaire were especially aimed at the individual level. Furthermore, Fleuren et al. (2004) indicated that circumstances in larger health care organizations are different than for individual general practitioners. Applying these questions these circumstances, may have influenced the validity of these questions negatively. Further research should resolve these questions, and provide questions which take these circumstances into account.

Cummings & Worley (2004) noticed that one should create a ‘felt need for change’ to enhance the willingness to change. Therefore, in the perception of an individual health care professional, employed within a donor centre, a certain ‘sense of urgency’ must be created and/or sustained. This perception of discrepancy is necessary to energize key

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perceived as a problem of the UMCG. A minority indicated that the proposed changes are similar to their current practices.

Armenakis et al. (1993) stated that organizations are composed of diverse groups of people, each with their own paradigms and with their own cultures within the broader

organization culture. Confronted with the same information and interventions, individuals can still be expected to react differently. Since the change process is present within twenty-one organizations, with much diversity, many individual health care professionals, and many different perceptions, it should be clear that no universal formula should be used to create/sustain a sense of urgency. Health care professionals must perceive the situation as their ‘problem’ in order to create a felt need for change (Cummings & Worley, 2004).

Cowan (1986) developed a three stage model about how individuals recognize problems, or a need for change. The first stage represents the period prior to any problem recognition activities, individuals are scanning for signals, and conditions are not perceived as a problem. The second stage (categorization) refers to the process by which an individual becomes aware that a problem exists. Cue discrepancy, persistence of discrepancy, and perceived urgency to respond determine whether the perceived discrepancy is experienced as a problem. In the third stage people attempt to achieve greater certainty about a problem. Therefore they will search for additional information. In the third phase of Cowan’s model (1986) familiarity with similar problems, one’s priority to solve a problem, and the

information availability determines whether one’s is certain of uncertain about a problem description.

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frequency resulted in less attention, less interest, less knowledge, and a low sense of urgency with their peers. Fleuren et al. (2004) already concluded that low frequency impedes the implementation of changes. They also concluded that not much research have been conducted about the influence of a low frequency. Further research should indicate to which extent the low frequency of organ donation influence the perceived need for change, and how to overcome this challenge.

Although the need for change is present, it is sometimes hardly visible. During the research, many respondents indicated that personal experiences with organ donation, or treating potential heart (organ) receivers as patients, enhanced their ‘sense of urgency’. For two reasons one can argue that the need for change is hardly visible for a health care

professional employed in a donor centre. Firstly, in organ donation, a potential heart (organ) receiver represents the actual ‘need for change’. In the current process, when potential heart (organ) receivers are placed on a waiting list, they are treated by cardiologists of the UMCG. Therefore, they are out of sight for the health care professionals employed in a donor centre. The need for change, represented by potential heart receivers is not visible for them.

Secondly, when a donation process happens in a donor centre, a heart is taken out, and transplanted in the UMCG. These organ receivers are also out of sight of health care

professionals employed in donation centres. Therefore, health care professionals, who are assumed to be present in the first and second stage of Cowan’s model (1986), won’t perceive signals about a possible discrepancy. They won’t perceive the current situation as a problem.

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Communicating about self-efficacy has a positive influence on the willingness to change (H2) Previous researches indicated that self-efficacy is an important determinant of the willingness to change (Armenakis et al. (2001); Metselaar & Cozijnsen (2002); and Ajzen (1991). Quantitative results confirmed that self-efficacy influence the willingness to change. Interview results indicate that the majority of health care professionals should have the necessary skills, or means to implement the proposed changes in the assessment process of donor hearts. Only ‘transmitting echo’s electronically’ seems to generate problems in some hospitals with the current ICT systems and internet connections. Further research should pay attention to these ‘challenges’.

It appears that self-efficacy influence the willingness to change significantly but should be present at a minimal level. In this research, the required degree of self-efficacy seems to be present. Therefore, not much attention is paid to self-efficacy.

Communicating about personal valence has a positive influence on the willingness to change (H3)

Many authors acknowledge that personal valence influence the willingness to change. It is surprising to notice that a majority of the respondents perceive that valence is absent or hardly ‘observable’ for them. A large number of respondents perceive that intrinsic

motivation, as a result of organ donation is personal valence for them. Some respondents argued that organ donation is frustrating when the results are not satisfactory.

In general, organ donation is perceived as an extra activity above the normal daily activities. Vroom (1965) already noticed that people’s behavior results from conscious

choices between alternatives, and that their choices are systematically related to psychological processes such as perception. During the research many respondents indicated that the

absence of personal valence results in less attention, and priority for organ donation. To increase the priority given to organ donation, personal valence should be present, but personal valence should also be observable.

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observable for health care professionals of a donor centre. To make this valence more

observable, more information should be provided about the valence of this change. Cummings & Worley (2005) concluded that feedback about results increased motivation. Since many respondents indicate to be intrinsically motivated to perform tasks for organ donation,

providing information about results will enhance their motivation. To increase the willingness to change, the UMCG should provide information about valence for heart receivers, and about the envisioned results of the change process. Since this research is prospective, and the

change process still has to be initiated, information about the success of past transplantation processes may provided initially. Further research should provide information about the possible absence of ‘real’ valence, and how to enhance the ‘observability’ of personal valence.

Communication about organizational valence has a positive influence on the willingness to change (H4)

Research results indicate a significant relation between organizational valence, and the willingness to change. There are reasons to believe that some arguments related to personal valence, also are valid to organizational valence. Just as with personal valence, many

respondents stated that organizational valence is also not present. Some respondents indicated that corporate social responsibility is valence for the organization. But, many of these

respondents were not able to explain in further detail which organizational valence was underneath it. Most often, they indicted that the hospital should serve the interest of society based on moral considerations.

In the current situation, respondents indicated that organ donation consumes much time, and resources of the hospital. Financial compensation is by far insufficient. They emphasised that due to the low frequency, the impact on the hospital is little but these processes consumed relatively much time in comparison with their normal daily practices. Therefore, for many hospitals, organ donation is not a high priority. Vroom (1964) already noticed that people will consider outcomes of multiple alternatives. To increase priority for hospitals, organizational valence must be created. Some respondents carefully suggested that hospitals should be rated on how they organize organ donation by the Ministry of Health. This would increase organizational valence, and enhance the priority given is given to organ

donation. Another aspect of organizational valence is related to the effectiveness, or

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about one third of the respondents argued that the UMCG should only initiate changes based on solid evidence . Therefore, evidence about the envisioned consequences of the change should be communicated to the health care professionals of donor centres.

Further research should be conducted about how to overcome the possible absence of ‘real’ organizational valence, and which information about organizational valence will

enhance the willingness to change.

Communicating about principle support has a positive influence on the willingness to change (H5)

Research results indicates that principle support influence the willingness to change. Opinions about ‘who should support this change’ were different but none of the respondents indicated that support was not important.

In essence, principle support refers to the support of principles. Health care

professionals are often assembled in partnerships, and have more influence in comparison to other industries (Ferlie et al., 2005). As a consequence, in health care, mangers have less influence. Furthermore, Davenport et al. (1998) concluded that support from executives is not crucial for improving individual functions of processes, as the assessment process. One respondent stated, not that the board dictate us what to do, but if they not clearly and actively express that they support the change, my peers won’t even pay attention to it. Hence, principle support appears to refer especially to support of peers. Due to the possible absence of

organizational valence, and no perceived sense of urgency by principles, some respondents complained about insignificant support of hospital’s board. In this change process, principle support seems be a requirement which must be present at a minimal level.

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that multiple champions who cut across organizational disciplines, organizational boarders, and status hierarchies should support the change. In all 21 organizations, at least one

champion should support the change. An intra-organizational network, should support these champions to ensure that they create, and sustain support from their peers.

It is clear that, there is no general formula which can be applied in predicting who should support the change in order to increase the willingness to change. Further research should reveal how to create support of hospital’s board, and how to find champions within these organizations. Communicating the support of hospital’s board, champions within the hospitals, and health care professionals of the UMCG should enhance the willingness to change.

5.2 Reliability & Validity

Research results originate from a small sample of 44 respondents. The sample size is sufficient to perform statistical analysis but a larger sample would give more statistical power. However, all hospitals, and functions affected were involved, and represented in the research. Furthermore, qualitative information has been used to extend, and confirm quantitative research results.

In this research, it is hypothesized that communicating information about: discrepancy, self-efficacy, personal valence, organizational valence, and principle support influence the willingness to change of individual health care professionals in the transplantation region of Groningen. However, other factors as for example politics, or other additional factors related to communication could also influence the willingness to change. Including more factors to the research, would have resulted in lower response rates.

In earlier researches, willingness to change, and the other constructs have been measured by making use of a questionnaire (Holt et al., 2007; Metselaar & Cozijnsen, 2002). Questions to measure the constructs were derived from questionnaires which have been found valid in previous researches. However, one can argue that questions were not specifically developed for health care professionals, or for the health care context. Furthermore, some items might have received a slightly different meaning because they were translated into Dutch. Results indicated that items have measured what these intended to measure in a valid way. Furthermore, qualitative information is used to confirm, explain, and extend quantitative results.

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or to save face or reputation, they create a social desirability bias (Cooper et al., 2006).

During the research, it has been stressed that no information would be passed on that could be related to a single respondent, and that information would be treated anonymous and

confidential. Furthermore, respondents were asked to rate their peers in stead of rating themselves.

It should be noted that this research have been performed prospective at a certain moment. Although conducting research after the change process, could create other results, it is believed that the current results are valid to this change process. Furthermore, results were different between individual health care professionals.

Another bias is related to the low frequency of organ donation. Most often, when health care professionals filled in the questionnaire, they argued not to think only about donor hearts, but also about organ donation in general. Although results originate from a small sample, all hospitals and affected health care professionals cooperated. Therefore it is believed that research results are not limited to the assessment process of potential donor hearts, or one hospital. The research results could be relevant for more changes in the field of organ donation.

5.3 Further research in general

This research focused on the change message. For each element of the change message, direction for further research has been proposed. It appears that beside

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Ministry of Health, Welfare, and Sports. <http://www.minvws.nl/dossiers/awbz/default.asp>. Accessed: 8 June 2009

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NIGZ Donorvoorlichting.

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APPENDIX ONE

Change content as suggested by experts of the UMCG

1) er altijd van een potentieel donorhart een echodiagram wordt gemaakt

2) een echodiagram zo spoedig mogelijk in het signaleringsproces wordt gemaakt 3) een echodiagram ter ondersteuning elektronisch opgestuurd wordt naar een

transplantatiecardioloog van het UMCG

4) de dienstdoende transplantatiecardioloog van het UMCG altijd drempelloos gebeld kan worden door professionals van andere ziekenhuizen

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APPENDIX TWO

Region Groningen

Region Number (autonomous) hospital Name hospital

Groningen 1 Universitair Medisch Centrum (Groningen) 2 Martini Ziekenhuis (Groningen)

3 Refaja Ziekenhuis (Stadskanaal)

4 Ommelander ziekenhuis groep locatie Delfzicht (Delfzijl) 4 Ommelander ziekenhuis groep locatie St Lucas

(Winschoten) Friesland

5 Medisch Centrum Leeuwarden (Leeuwarden) 6 Antonius Ziekenhuis (Sneek)

7 De Sionsberg Ziekenhuis (Dokkum)

8 De Tjongerschans Ziekenhuis (Heerenveen) 9 Nij Smellinghe Ziekenhuis (Drachten) Drenthe

10 Wilhelmina Ziekenhuis (Assen) 11 Bethesda Ziekenhuis (Hoogeveen) 12 Diaconessenhuis (Meppel)

13 Scheper Ziekenhuis (Emmen) Overijssel

14 ZGT Hengelo (Hengelo) 14 ZGT Almelo (Almelo)

15 St Jansdal Ziekenhuis (Harderwijk, Gelderland) 16 Medisch Spectrum Twente (Enschede)

17 Deventer Ziekenhuis (Deventer) 18 Isala Klinieken (Zwolle)

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APPENDIX THREE

Results of VAS Rating

Communic

ation Participation Politics Urgency

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