INFLUENCE OF TRANSACTIONAL AND RELATIONAL FACTORS ON PROMOTER-STAKEHOLDER COOPERATION DURING IS-PROJECTS,
IN A HEALTHCARE RELATED ENVIRONMENT
Master thesis, MScBA, specialization Change Management University of Groningen, Faculty of Economics and Business
January 11, 2013 JORIEN CONRADI Student number: 2055821 Sonnegaweg 13 8478 HB Sonnega tel: +31 6 40435782 email: j.conradi@student.rug.nl Supervisor/university Dr. J.F.J. Vos Second supervisor/university Prof. Dr. A. Boonstra Acknowledgment:
2 ABSTRACT
This study examines the extent to which transactional and relational factors contribute to the promoter-stakeholder cooperation during IS-projects, within a healthcare related environment. Additionally, an examination of how perceived promoter salience and perceived promoter
reputation relate to one another was performed. Data collection took place by the means of multiple case studies. Results indicated that the level of relational factors contributing to cooperation between promoter and stakeholder is higher than the level of transactional factors. Moreover, the study explained that the concepts of power and legitimacy, of the categories of promoter salience and promoter reputation, were broadly similar to each other. These findings suggest that it is for all actors important to invest in a long and lasting relationship with the opposite party to make a contribution to cooperation. Additionally the study suggests that further research on the concepts of power and legitimacy is necessary in order to make the difference between the categories of promoter salience and promoter reputation more clear.
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INTRODUCTION
In the literature on stakeholder management, many writers have discussed the difficulty of involving stakeholders in projects concerning the introduction of information systems (IS). For example, Legris and Collerette (2006) state that many IS fail due to weak implementation management, in particular related to stakeholder management. The question how implementers should manage their relations with the stakeholders is therefore a frequently discussed topic. A far less discussed topic is that of the perspective of stakeholders. This group may also wonder
themselves in which IS they like to be involved while this may cost them time. However, there is little attention for this perspective. This seems to be a bias that is apparent in multiple studies that have appeared on the subject of stakeholder management. The theory is more concerned with the perspective of the implementers of the IS than of the perspective of the stakeholders. This seems to be a limited starting point while in order to achieve high performance organizations need to take on a perspective that includes the demands and needs of multiple stakeholder groups (Harrison, Bosse and Phillips, 2010). Therefore, this study takes on a different angle and focuses on both
perspectives.
For developing a research model for this study, a distinction is made between promoter and stakeholder. Freeman (2010:46) defines a stakeholder as “any group or individual who is affected by or can affect the achievement of an organization’s objectives”. In this study the one ‘who can affect’ will be referred to as the promoter. A promoter is the individual that manages the
implementation of the IS, also known as the implementer. However, this will not directly imply that those ‘who are affected’ are the stakeholders here, while they may also have the power or
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term and are concerned with creating a long and lasting relationship in which multiple issues will be dealt with.
The study focuses on cooperation between promoter and stakeholder. In their research on management-stakeholder cooperation, Vos and Achterkamp (work in progress, further w.p.) refer to it as “a two-way activity in which management, as the organizational representative(s), and the stakeholder come to decisions about their mutual engagements.” This cooperation is not easily achieved when introducing an IS. An increasing scope and impact of modern information technologies makes managing a complex task (Achterkamp, Boonstra and Vos, w.p.).
In this study it is assumed that both transactional and relational motives play a significant role in the cooperation between promoter and stakeholder. Moreover, it is assumed that both these factors, in combination with the impact of the issue, determine the willingness of promoters and stakeholders to cooperate during IS projects.
Question is whether the distinction between transactional motives and relational motives are that much different from one another, in practice. Therefore, in this paper there is not only the focus on the extent to which transactional and relational motives are present in the cooperation between promoter and stakeholder, but also the focus on identifying similarities and differences between these two kinds of motives. However, this additional question only concerns the
perspective of the stakeholder, while it is assumed that this actor is more depended on creating a good relationship with the other party while it has only indirect control over decision-making device. In contrary to the promoter, that has, as manager of the group of stakeholders, direct control (Hill and Jones, 1992).
A key component of the study is that it concerns promoter-stakeholder cooperation in an IT-healthcare related environment. This setting was perceived to be suited for the study, since services provided in healthcare organizations are often supported by the use of advanced IS. Moreover, the field of healthcare is well-known of its great complexity because of the involvement of relatively autonomous parties (Boonstra, Boddy and Bell, 2008).
The study makes a contribution to stakeholder theory, while it focuses on both the perspective of the promoter as well as the perspective of the stakeholder. Furthermore, the study contributes to the development of tools for involving stakeholders into an IS-project. A more practical
contribution is made to managers, who are determined to create willingness amongst stakeholders for being involved in an IS adoption process.
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dual dimensions. The first one is that of the transactional motives versus relational motives, also referred to as the double-motive perspective of the study. The second dimension is that of the promoter perspective versus the perspective of the stakeholder, the so-called bilateral perspective of the study.
Figure 1. Research model, a summary of the discussed study
The following research questions are conducted from the research model:
A. To what extent do transactional and relational factors influence the level of cooperation between promoter and stakeholders, in a healthcare-IS context?
6 THEORY Stakeholder theory
Stakeholder theory has been widely used for all sorts of managerial understanding (Goodstein and Wicks, 2007; Phillips, 2003), and contributions have been made from different disciplines: strategy, law, organization theory, economics and ethics (Freeman and Phillips, 2002). Achterkamp and Vos (2007) have also contributed to stakeholder theory, by writing about the classification and prioritizing of stakeholders. They mention that in the literature on stakeholder management the most used classification model is the salience model of Mitchell, Agle and Wood (1997). Mitchell et al. refer to salience “as the degree to which managers give priority to competing stakeholder claims”. In their theory the writers mention that they believe that a stakeholder has a high priority when they have the power to influence organization’s resource control, the legitimacy to act and if there is the urgency that demands immediate action.
In similar vein as Mitchell et al.(2010), Harrison, Bosse & Phillips (2010) also struggled with the question whether stakeholders needed to be classified: ‘was it better to provide the same treatment to all primary stakeholders, such as managers, employees, firm’s owners, suppliers and customers, or should management pick certain stakeholders and a context in which to manage them?’. In addressing this question the writers take on a different approach than Mitchell et al. had done. The latter created a salience-model in which they have taken on a short-term perspective: ‘to which degree do managers give priority to a certain and specified stakeholder claim?’. In contrast, Harrison et al. (2010) have taken on a long-term perspective of stakeholder and organization. Their study examines stakeholder utility functions and shows how organizations can manage
stakeholders for creating sustainable competitive benefits. Vos & Achterkamp (w.p.) have also taken on this long-term perspective by making the notification that the promoter values cooperation on a specific issue, while for them it is an investment in a wanted and lasting relationship with the stakeholder. They continue by mentioning that stakeholder’s motives for cooperation with the promoter may be derived from experiences in the past and expectations for the future: these may help put decisions or actions an organization makes and are inconsistent with the needs and desires of a stakeholder in perspective. It is the function of an organization to fulfill their duties to the stakeholders, and it is a function of the stakeholders to fulfill their duties to the organization. This is a moral relationship, which is reciprocal (Goodstein and Wicks, 2007). It is Phillips (2003) who said the following thing: “Whenever persons or groups of persons voluntarily accept the benefits of a mutually beneficial scheme of co-operation requiring sacrifice or
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obligations of fairness are created among the participants in the co-operative scheme in proportion to the benefits accepted.”.
Transactional motives
Mitchell et al. (1997) have described their salience-model based on three concepts (power, legitimacy and urgency) that give priority to a certain and specified stakeholder’s claim. This trinity is important and concepts cannot be seen independently of one another. Mitchell et al. give support to this belief by stating the following: “an entity may have legitimate standing in society, or it may have legitimate claim on the firm, but unless it has either power to enforce its will in the
relationship or a perception that’s its claim is urgent, it will not achieve salience for the firm’s managers.” When looking individually to each of the three concepts, Mitchell et al. refer to multiple writers when stating that power is not hard to recognize: “it is the ability of those who possess power to bring about the outcomes they desire”. Etzioni (1964) elaborates on the subject of power or resources of control by dividing it in three categories: coercive, utilitarian and
normative/normative-social/social power. The first relates to physical resources, the second to material resources and the latter to normative and social resources.
However, power alone does not lead to a salient claim for cooperation. There are stakeholders without power but do matter to the organization and managers (Mitchell et al., 1997).Therefore also legitimacy and urgency are characteristics of a salient claim. Legitimacy is often coupled to power when the nature of relationships in society is under evaluation. Though, legitimacy is not inextricably linked to power: legitimate stakeholders are not, by definition, powerful and powerful stakeholders are not always legitimate. Legitimacy is the generalized perception of an entity’s action that is, within a socially constructed system of beliefs, definitions, values and norms, seen as appropriate or desirable. Urgency completes the salience-model by making it more dynamic: it is the catalytic component in a stakeholder identification theory. It is the degree to which a
stakeholder claim demands immediate action. Urgency is based on two characteristics: time sensitivity and criticality. The first is related to the unacceptability of managerial delay in paying attention to the relationship or claim. The latter is related to the significance of the relationship or claim to the stakeholder (Mitchell et al., 2010).
Relational motives
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perception is both based on relation assets and the likelihood that these will be achieved in the relationship.
As mentioned earlier the salience-model of Mitchell et al. takes on a short-term and specified issue-related perspective. The model that reflects reputation, and is derived from the theory of Harrison et al. (2010), takes on a long-term perspective focused on creating a lasting cooperative relationship between promoter and stakeholder. This reputation model, in similar vein as the salience-model, consists of power and legitimacy. However, in this model power and
legitimacy are not related to one specific issue but to general (future) issues. Urgency, like in the salience-model does not play a role in this model. Instead, reliability is a factor. Again, the trinity of these concepts is of importance, because when all concepts are only independently present a long and lasting relationship is not very obvious. When discussing the concepts, Harrison et al. (2010) mention that power is not, as legitimacy and urgency are, based on their method of ‘managing for stakeholder’. This method is used by organizations when they want to assign value and decision-making influence broadly across their primary stakeholders. Instead, power is based on the ‘arms-length’ approach, in which power is a primary criterion for influencing organizational decisions and distribution of value; stakeholders are only given voice when it is in the best interest of the
organization. The arms-length approach to stakeholder management deals with stakeholders as if they are interchangeable economic actors. Therefore, this method can be seen as the opposite of the managing for stakeholders-method. The method for managing stakeholders has a normative view of stakeholders: it is based on treating them in the right way. The arms-length approach has an instrumental view on stakeholder theory: the stakeholders are used in a way that helps the organization receives an economic advantage. Organizations tend to choose for a certain method, though in reality they never work in perfect alignment with it.
The reliance of organizations on specific powerful stakeholders, for achieving resources that are needed, may sometimes be in conflict with the organization’s ability to assign value to (other) stakeholders. However, stakeholder management should be better defined to serve the interests of legitimate stakeholders. While when only given attention to those stakeholders with substantial power in the organization, legitimate claims cannot be answered. This may lead to an organization that has trouble surviving. Legitimate stakeholders are those that are the most unified with the objectives or operations of an organization (Harrison et al., 2010).
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value propositions of which the organization would not have thought of. However, trust is an essential element when it comes to sharing utility functions. This is reflected in the extended literature on trust (Colquitt, Lepine, Zapata and Wild, 2011; Harrison et al., 2010;
Kannan-Narasimhan and Lawrence, 2012). Trust can be described as the mutual confidence in one another, so that nobody would exploit the other’s vulnerability in the exchange (Harrison et al., 2010). In any job in which employees are dependent on coworkers for being in able to fulfill their own tasks trust must be vital. Employees can focus on their own tasks when they are able to trust their coworkers. Task performance is prevented when employees are not able to trust their coworkers, while the flow of attentional and cognitive resources is hindered. Moreover, trust evolves through the
maturing of work relationships. It becomes differentiated (Colquitt et al., 2011). When information is obtained through the means of a trusting relationship it can be adopted to bring about value (Harrison et al., 2010).
An additional translation of the word trust can be found in the literature of Morgan and Hunt (1994). They described trust as the confidence of one party in the reliability and integrity of the exchange partner. Although Harrison et al. (2010) speaks of trust when addressing the issue of having confidence in the opposite party, this study will further refer to the word reliability when speaking of trust. It is assumed that, concerning the interviews of the case studies that are being conducted, people speak more widely of the word reliability than of the word trust.
Issue impact
The issue impact is used to weigh the transactional and relational motives. The assumption has been made that the issue impact influences the different motives the promoter and stakeholder have for cooperation. In their study on stakeholder theory, Vos & Achterkamp (w.p.) mention that the promoter’s willingness to cooperate with salient stakeholders increases when the issue impact is high. At that point it matters more to involve stakeholders with power, legitimacy and interesting resources. Stakeholder willingness to cooperate with the promoter is also more evident when the impact of the issue is high. The level of interaction with the promoter concerning the issue depends on the level of interest in the issue, and their perception of balance between perceived costs and benefits in dealing with the issue (Vos & Achterkamp, w.p.).
Information systems (IS)
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introduced is complex. It concerns internal, external and historical dimensions, with the essential idea that people shape the context, and the context shapes the people (Pettigrew, 1987). The external context consists of a general environment and a competitive environment. The general environment, also known as the macro environment, represents stakeholders who have more distance to the organization than the stakeholders of the competitive environment. This macro environment is concerned with technological, social, economic, political, legal and environmental factors, and influences the way managers develop the IS. The competitive environment, also known as the micro environment, is concerned with industry-specific stakeholders: customers, substitutes, competitors, suppliers and potential new entrants. Promoters are more concerned with the micro environment because it consists of stakeholders which may affect the performance of the
organization in a more direct manner.
The internal context is the environment in which people work and into which IS projects are introduced. The historical context reflects past events and future uncertainties (Boddy, Boonstra and Kennedy, 2008). Successful IS implementation needs promoters who cooperate effectively with important internal and external stakeholder groups (Achterkamp et al., w.p.).
Literature of information technology (IT) shows little about how to manage the implementation process with the involvement of stakeholders. It is mainly focused on technical requirements (Legris and Collerette, 2006). Though, managing IS projects is just as much an organizational challenge as it is a technical challenge. Managing an IS does imply changing the organizational internal context (Boddy et al., 2008).
Information systems in a healthcare related environment
The adoption of an IS, in a healthcare related environment may be critical while it is associated with human lives. Moreover, the adoption process is influenced by several different actors, amongst others: nurses, support departments and patients are part of the ‘stakeholder system’ (Payton, Paré, LeRouge and Reddy, 2011). They will often resist the IS adoption (Mantzana et al., 2007).
Promoter-stakeholder cooperation
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within the writing of the system to make the language of the system more humanistic and less systematic. Although cooperation by definition relates to a specific issue, the interrelations between organization and stakeholders often exceed this. The history and future expectations of these interrelations seem also of importance (Vos and Achterkamp, w.p.).
Mentioned earlier, successful IS implementation requires an effective cooperation between promoter and stakeholders. Therefore, it is important for the promoter to consider which
stakeholders to involve. Equally important is it for the stakeholder to consider when cooperation is beneficial.
As already been mentioned, promoter and stakeholder may be motivated by issue-based reasons which lead to interactions concerning a specific issue, or by establishing a long and lasting relationship in which series of continuing exchanges is generated (Achterkamp et al., w.p.). The first motive is transactional (Mitchell et al., 1997), the second is relational (Harrison et al., 2010). Promoter’s motives for cooperating with the stakeholder may have organization-based reasons. An organization’s welfare may be optimized when the needs of the most important stakeholder are being met in a win-win fashion. The focus of a promoter on the interests a large group of
stakeholders, instead of one or a few, may lead to high levels of performance amongst the
stakeholders (Harrison, et al., 2010). Stakeholders may have different intentions for being involved in an IS-project, which need to be satisfied if the promoter wants to gain and/or retain their
support. While the stakeholder’s attitude is based on their perception of how the IS will serve their interest. Moreover, the promoter, as being manager of the IS, is depending on the stakeholders (Boonstra et al., 2008). Stakeholders are motivated by a combination of human needs, the perception of the organization and its wider context. Stakeholders will begin an IS project when they perceive that the organization does not produces their desired outcomes or when they notice an external opportunity or threat (Boddy et al., 2008).
Promoter and stakeholder perspectives
The promoter’s willingness to cooperate relates to its perception of the stakeholder. Related to the theory of Mitchell et al. (1997) managers perceive stakeholders as having a high priority when they are salient. Therefore, cooperation from promoter’s side depends on how the promoter perceives the stakeholder’s salience. Related to the theory of Harrison et al. (2010), the perceived reputation of the stakeholder determines if the promoter want to cooperate. Stakeholder
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In a similar vein does stakeholder’s willingness to cooperate relates to the stakeholder’s perception of the promoter. Cooperation from stakeholder’s side may depend on how the stakeholder perceives the promoter’s salience. The stakeholder also may base its decision for cooperating with the promoter based on how it perceives the reputation of this actor. For both perspectives applies that the issue impact is used to weigh the benefits and risks of the IS that may occur when dealing with the issue.
METHOD Preparing Data Gathering
Qualitative multiple case study. In order to provide empirical evidence for explaining the research model, a multiple case study design (Gibbert, Ruigrok and Wicki, 2008; Yin, 2003), of contrasting promoter-stakeholder relationships, was adopted (Achterkamp et al. w.p.).
The replication logic of Eisenhardt (1989) was used for verifying and confirming/disconfirming the relationships mentioned in the research model. The comments of the respondents were compared by pattern-matching (Dul and Hak, 2008). Use of grounded theory made it possible to continuously compare the different case studies (Oktay, J., 2012). The questions of the interviews, which were conducted for the case studies, were focused on a certain issue. This issue was determined by the promoter and divers in every contrasting promoter-stakeholder relationship.
The technique of coding, which refers to linking previously or ad hoc developed categories and concepts to text fragments (Bauer and Gaskell, 2000), was used to categorize the phrases of the transcript.
The program that was used for qualitative analysis was based on a code-and-retrieve principal. Codes were attached to certain text fragments, and retrieval made it possible to, simultaneously, recall all fragments that were linked to a specific code (Richards and Richards, 1995). For going deeper into the theory and for being able to create truly meaningful patterns of facts, a fine-grained analysis of the text fragments was necessary for finding aspects that could serve as criteria for comparison (Bauer and Gaskell., 2000).
Next to the original three categories, which were decided upfront and could be withdrawn from the research model, a fourth category was detected by means of open coding (Bauer and Gaskell, 2000).
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advance of the interviews were based on deductive logic: reasoning from general to specific. The fourth category, as well as the seventh concept was achieved by means of induction: reasoning from specific to general. In table 1 an overview of the categories and concepts is provided.
TABLE 1
Overview of categories and concepts
Categories Concepts Salience Power Legitimacy Urgency Reputation Power Legitimacy Reliability Relational Issue impact Promoter-stakeholder cooperation
An interview protocol was created to serve as guideline for the confidential semi-structured interviews that were deducted from the promoters and stakeholders. The open-end questions of the interviews were directly derived from the research model (Gibbert et al., 2008). Two protocols were developed: one for the promoter and one for the stakeholder.
The interview protocols compromised three parts. The first part consisted of general questions, concerning the educational background of the respondent and the goals of the
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Example of interview questions
Interview part Interview questions
A. General questions Did you follow a specifically on Information System (IS) focused education?
Yes (which?) or No?
B. Identification of issues-stakeholder With which stakeholders was actively cooperated?
(one stakeholder per issue) C. Characterization of relation with respect to
stakeholder-promoter issue
In which phase played the issue with the stakeholder?
Table 3 presents a summarized overview of interview questions that have been asked to the promoter and stakeholder concerning the concepts of salience and reputation.
TABLE 3
Interview questions, concerning salience and reputation Concept Example interview question
Stakeholder salience What resources (knowledge, skills, etc.) does this stakeholder has that are necessary to set up/develop/implement/maintain the IS? What is exactly this power source?
Promoter salience What resources and skills does this promoter has that are necessary to develop the IS?
Stakeholder reputation
Did you collaborate with this stakeholder in the past? How do you look back on this?
How valuable do you experience the relationship with this stakeholder? Promoter reputation How competent do you think the promoter is, in situations of cooperation?
Do you think that this promoter has a lot of influence on/in future issues? The complete interview protocol can be found in the appendix.
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received a clear look into what was to be examined, on which sections or questions extra attention needed to be paid, and that a good preparation before conducting the interviews was of necessity.
Selection of projects. The selection of the projects was based on the combination of 1.Relevancy: cases in which IS-implementation in a healthcare related organization was supported by stakeholders, 2. Cross case diversity: cases of contrasting promoter-stakeholder relationships, and 3. Accessibility: to promoters and stakeholders in healthcare related IS- projects and to various promoter-stakeholder relationships, in compliance to different elements of the research model. A additional criterion was that all the case studies had a relation to healthcare related IS-projects (Achterkamp et al., w.p.).
In the result and discussion sections of this study the promoter and stakeholders of the first organization are referred to as promoter A, stakeholder A and stakeholder B. The promoter and stakeholder of the second organization will be referred to as promoter B and stakeholder C. Again, the case study of the second organization, of which only promoter B is interviewed, is used as support for the perspective of promoter A. Moreover, in both quotes, used in the result section of the paper and in the appendix, the names of the respondents are shortened into abbreviations. Therefore anonymity will be assured.
The case studies took place at two organizations. The organization of the first promoter (A) and stakeholders (A and B) is a healthcare providing organization, which takes care of elderly and care required people. The organization is a residence which facilitates primary care. Amongst others this care consists of physiotherapy, speech therapy, occupational therapy and daily nursing care. The organization has introduced an IS in order to create a multidisciplinary system in which a patient file is stored at one central place, instead of being placed across different sites. The purpose of introducing the IS was creating more efficiency within the organization. Moreover, the IS was introduced to comply with laws and regulations of the government, having the possibility of delivering data electronically and being capable of directing a vision and management. The promoter (A) is the project leader of the IS. This person was responsible for delivering the system in a most optimum manner. While introducing the IS the promoter needed to collaborate with stakeholders A and B, which also have been interviewed for this case study. The promoter has collaborated with stakeholder A with regard to a certain issue that came forward during the
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During this collaboration the stakeholder fulfilled the role of representative, of a larger group of speech therapists. However, this stakeholder was not the speech therapist which took place in the work group that was formed in favor of the introduction of the IS. The stakeholder (A) is connected with the IS in a way that this actor continuously needs to add information, concerning a client’s speech therapy, in the IS. The second stakeholder (B) is a care manager of the organization. The promoter has intensively cooperated with this stakeholder on another issue which emerged during the introduction of the IS. The issue concerned the use of standardize formulations within the IS. Together with the promoter, this stakeholder provided a training concerning the use of the IS. At this moment, the stakeholder (B) guides its own employees in the use of the IS.
The organization of the second promoter is an organization which develops electronic patient file systems for primary care organizations. Together with healthcare providing
organizations and (financial) partners the organization tries to make an innovative contribution to healthcare. The purpose of their products (the electronic patient file systems) is to make an attempt to enlarge the accessibility of health services by increasing the digital capabilities of the system. For example, the electronic patient files are focused on providing clients the service of reviewing their own patient file from their own homes. The promoter (B) is the product manager of a specific electronic patient file system that its organization has created. The promoter is the advertiser of the system amongst care providers and (financial) partners, and has collaborated with stakeholder C on a specific issue. This issue concerned the introduction of the electronic patient file system to purchasers of primary and secondary healthcare organizations. According to the promoter, this stakeholder (C) is an innovation manager within a healthcare insurance organization. The
stakeholder (C) is the matchmaker between the organization of the promoter and the purchasers of healthcare organizations.
The issues will be more extendedly discussed in the result section of the paper.
Data gathering
The data collection took place in 2012. Three case studies were conducted at two
organizations which were either concerned with the implementation of an IS in a healthcare related environment or were concerned with the developed of an IS for the healthcare sector.
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of the stakeholder one cannot speak of results from a contrasting promoter-stakeholder relationship. In the discussion this case study will used to support the promoter perspective. The interview was first conducted of the promoter, while this actor needed to decide on what issue, between itself and a stakeholder, the questions needed to be based. This implies that the promoter decided which stakeholders needed to be interviewed.
Data analysis
The responses of the promoters and stakeholders were analyzed for pattern matching (Gibbert et al., 2008) and afterwards assigned to the research model (Achterkamp et al., w.p.). An explanation was given to which extent transactional and relational motives contributed to promoter-stakeholder cooperation. Furthermore, these motives were, from stakeholder perspective, compared on similarities and differences.
The fully out written interview protocols and interview results can be found in the appendix.
RESULTS Case studies
Before providing the results of the empirical research the issues concerning the case studies are shortly discussed. As mentioned in the method section the study took place at two different organizations, where three case studies were conducted. The case studies are discussed
individually.
Case study 1: promoter (A) -stakeholder (A), organization (1). The issue between this promoter and stakeholder was by both actors perceived differently. The promoter describes the issue when saying that by the use of an IS the treatment record became visible for every employee. Previously there was also one treatment record, only this was physically more widespread: the different parts could be kept in different places. Everyone could have its own notes which were not readable for others. Now the treatment record is stored at one place: the intranet, where it is clear and
transparent for everyone. The promoter mentions that the stakeholder and her closest colleagues were anxious about this transparency and about the fact that a comment, written by any
professional, could get a life of its own and therefore may be incorrectly interpreted by someone else.
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the system. Some headings look very similar. This had lead to questions concerning what should be written where in the system. The stakeholder pleaded for making the system clearer in terms of headings.
Case study 2: promoter (A) -stakeholder (B), organization (1). The IS is very much based on standardization and this is a bit contradictory of where care is all about. With standardization clients are grouped and merged, while care is based on each person uniquely. The IS is based on standard formulations. The stakeholder and her closest colleagues have difficulties with this approach, while they are very client oriented. The promoter understands were the stakeholder is coming from, though believed that people should try to work with it, simply because this standard package was already purchased. Moreover, the promoter mentioned that the care between care provider and client would still be uniquely. The stakeholder acknowledged that it is naïve to think that in this setting, of care, you should be treated complete individually. Though, the stakeholder believes that you have to find out how you can be as close to that as possible.
Case study 3: promoter (B) –stakeholder(C), organization (2). The organization of the promoter, which had developed the IS, was looking for organizations that would support their IS and in the future help financially. The organization of the stakeholder was such an organization and the stakeholder saw certainly something in the system. With the help of the stakeholder and its organization the promoter ensured that all issues surrounding the IS became clear. When this was achieved, the stakeholder ensured that the IS was introduced to the main purchasers of primary and secondary care.
The results of the study will be provided per variable. The first variable is transactional motives, the second is relational motives, the third concerns the actors own perceived legitimacy, the fourth is the issue impact and the last variable concerns promoter-stakeholder cooperation. Each variable will first discuss the results from promoter perspective and later on from the stakeholder perspective.
Transactional motives
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middle management officers. This position had moreover, given the stakeholder a direct legitimacy, in respect to the issue. The other stakeholder (A) did not have this immediate legitimacy, though; from the perspective of its practice and work processes the stakeholder could have asked questions to brightening the situation. For both stakeholders there was an urgent need for immediate action or attention, in relation to the issue. The promoter said the following about why it seems logically that both stakeholders needed this immediate action: “In the end, you cannot work with a program if you are not thinking: ‘Well, I am going to [work with] it’.”
Promoter perspective (of second organization). The promoter (B) explains that the stakeholder (C) is responsible for innovation. This entails dealing with innovative business, and reporting to the board. The promoter mentions that you have to have ‘something’ with someone, its personality and that this was truly the case with this stakeholder. The promoter talks about the personality and skills of the stakeholder as followed: “Mr. H. [the stakeholder] is a good fellow, he thinks clever, is critical, so he knows quite how to challenge you, to ensure that your proposition is clear enough and such. (…) [He] has skills and experience and the things that he brings along.” Moreover, the results explain that the promoter believes that the stakeholder is the right man [for the job]. He explains this in the following manner: “On one hand he has sufficient knowledge of the organization [A.], he knows with who he should be, and on the other hand he has sufficient experience and stature within the organization, as in: ‘people listen to him’; he just brings that skills with him.” The promoter
explains that the stakeholder is needed for creating space for a still wanted goal of the organization. The promoter additionally explains that the stakeholder may certainly influence the future of the IS and other projects. Though, this is also for the benefit of the promoter himself: “Look, (…), if you ask him the question: ‘but, what do you think of the environment, what do you think is the most important thing the IS is going to do?’ You do ask those questions, of course, because you want to ensure that, at least, a part of their agenda will actually be filled by P. [the IS].” Concerning legitimacy the promoter says that the stakeholder is the responsible one for innovation within its own organization.
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Stakeholder perspective. Promoter salience was perceived by both stakeholders. Although, in a different manner. Interview findings show that both the stakeholders perceive the promoter (A) as a capable person. They both find the promoter skilled in the things it is appointed for. One
stakeholder (A) said the following about the skills of the promoter: “He is analytical; knowing what there is, hearing what is going on with us [the SLP’s] and sometimes, of course, just what I said:
making sure that you stay connected. He can do that very well; thinking like ‘oh, the system can do this, so we have to go in that direction/solution’.” The other stakeholder (B) said the following think about the promoter’s skills and knowledge: “He is digitally savvy and also around the systematic, which run here, he is doing fine.” Though one stakeholder (A) said the following think about what would have happened to the IS if the promoter did not consult them: “When noting was in consultation with us [as stakeholders] and that the system was just the way it was?.Then everyone would have ‘throw in the towel’.” Concerning communication skills both stakeholders believe that the promoter is sometimes ‘not on the same page’ as they are; both perceiving different things. Moreover, both stakeholders mention, in a more or less direct manner, that the promoter is a legitimate representative of the organization, when it concerns his own position and the tasks that belong to that position. One of the stakeholders (B) mentions that the legitimate decisive role is appointed to the management team (MT). The stakeholders disagree on the point of perceived urgency of the promoter. One stakeholder believes that it was important that the issue was quickly dealt with and said the following: “If you let things just happen everybody will get his own way of working. And now things are just fixed, there is just a protocol that is made by all of us and what is in consultation with the promoter. That is just fixed and everybody sticks to it. It is just really good that this has happened in the short term.” The other stakeholder contradicts this, believes that everybody had different interests and says the following about this matter: “It was not necessary for the
promoter that the problem [the issue] was quickly dealt with. (...) Though he does thinks/mull about the business.”
Relational motives
Promoter perspective (of first organization). The stakeholders both are perceived as being competent. One of the stakeholders (A) is being described as competent in her position, and capable of influencing, fixing or restraining future problems and issues. Concerning the other stakeholder (B) the promoter (A) is very positively. Skills of this stakeholder are: easily approachable,
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manager;] “she therefore, has truly the knowledge and position to mean something in other processes. I believe she is present with a lot of projects that matter. She also has her businesses in order. I believe she is a valued person.” Moreover, the promoter says about this stakeholder, which shows that the stakeholder is perceived legitimate within the organization: “I guess people might think that if she thinks something is a good plan, than it will be quite a good plan.” In addition to what the promoter says about this stakeholder it also mentions that officially requests of the staff run through the ‘line’ by means of a portfolio holder, but, as the promoter speaks about the second stakeholder: “She may always just approach us and ask.” Also the other stakeholder (A) is perceived as legitimate. The promoter explains this in a following manner: “(…) that is just the way we are organized; in the end we are a professional bureaucracy; you need to involve the professionals by the things you need them for.” The promoter says that with both stakeholders it has a good relationship, and is willing to work with them in the future. About its relation with one stakeholder (A) the promoter says: [he already had a relation with her, and] “that makes cooperation, I guess, easier. Then there is
acceptation and goodwill coming from both sides.” In relation to the other stakeholder (B), from which the promoter proclaims that it will also provide help in the future, the following thing has been said: “I can always ask her something, and then she does it for me and the other way around.”, and, “It is always pleasant to work with her. I always have the feeling that we are looking in the same direction.”
Promoter perspective (of second organization). The promoter believes that the stakeholder is a good person, who thinks clever, is critical and knows how to challenge you to make your
proposition clear enough. The promoter finds the stakeholder very critical during the latter. Moreover, ones again, the promoter said the following, after it describes the stakeholder as the right person [for the job]: “On one hand he has sufficient knowledge of the organization [A.], he knows with whom he should be, and on the other hand he has sufficient experience and stature within the organization, as in: ‘people listen to him’; he just brings skills with him.” Concerning legitimacy the promoter brings the attention to the employer of the stakeholder. That is the sponsor of the network of the promoter’s organization, and additionally the stakeholder is within the supervisory board of the organization of the promoter. The promoter acknowledges the connection between the stakeholder and the organization of the promoter by saying the following: “So, there is just a strong relation with V. [the promoter’s organization].” Concerning reliability, the promoter says that there are a lot of reasons to work again with each other, in order to make use of the innovation
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promoter’s organization. Moreover, the promoter says the following about its relation with the stakeholder: “And separated of his role, which he had, do need the idea that you could do something with that persons and that is what we definitely had with Mr. H.[the stakeholder].”
Stakeholder perspective. One of the stakeholders (A) values the promoter (A) of his knowledge and his unusual way of thinking. The stakeholder explains this latter by saying the following: “Because he is a bit further away, sometimes has a different way of looking at things, and sometimes his unusual way of thinking makes that he comes to different perspectives. I appreciate him for this.” Moreover, the stakeholder explains that they (the promoter and the stakeholder) always come to a mutual agreement. The other stakeholder (B) perceives the power level of the promoter different. The stakeholder mentions that when it wants to move in a certain directions, together with three fellow team-managers, they will present their idea to the MT and “(…) than there is a very high change that he [the promoter] will needs to bow [ the promoter has then no power to restrain this action].” Moreover, the stakeholder (B) believes that the promoter holds on to his past experiences of the nursing care sector. And that the promoter should take into account the interests of all stakeholders when it makes future decisions. The following will support this believe: “He works in our service, in the support service and I think that that says enough. Yes, it is the intention to help each other therein.” One of the stakeholders (A) believes, firmly, that the promoter has the reasonable right to participate in future issues, based on his position and knowledge. The other stakeholder (B) believes that it depends on the sort of issues if the promoter or just the MT that has the formal right to participate in or influence future issues. Emphasis is put on ‘everybody in his own field of
expertise’, which is supported by the stakeholder by the following: “I am also empowered to make decisions about numerous businesses; Mr. R. [the promoter] cannot make decisions about my businesses.” One of the stakeholders (A) believes that the promoter has the perceived right to ask for the stakeholder for help. Though, the stakeholder additionally mentions that there are layers between their positions and that the promoter not immediately comes to the stakeholder and asks for help. The other stakeholder (A) perceives this differently, and says that they (the stakeholder and the promoter) will seek each other where necessary. Both stakeholders speak highly of the promoter when it concerns reliability. One of the stakeholders (A) believes that the promoter keeps into account the stakeholder’s interest when it concerns future cooperation, also when the
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to him and that he is approachable.” Both stakeholders speak of a good working situation between them and the promoter. However, they also both speak about adjusting themselves (both
stakeholder as promoter), in order to come to mutual decisions. One of the stakeholders (A) explains why this happened: [about why it takes sometimes a bit more effort to come to mutual understanding] “(…) but that comes from being different form character, though we always harmonize.” The other stakeholder (B) is not afraid of speaking to the promoter is a direction fashion. According to the stakeholder is their relation allowed to do so. The stakeholder (B) reflects on making adjustments in the cooperation with the promoter as followed: “We have a good
cooperation [in relation to the issue]. However, occasionally we have to admit things, which are sometimes difficult for the both of us.”
Own perceived legitimacy
In table 4 the results concerning this category are summarized. The promoter speaks about its own legitimacy for being the leader of the IS implementation. Stakeholder A perceives its own legitimacy as being able to speak about what is wrong and missing of the IS. Stakeholder B
perceives its own presence within the IS process as being legitimate while it is its field of expertise, and not that of the promoter (A).
TABLE 4
Results concerning a the category of own perceived legitimacy
Quotes, concerning own perceived legitimacy
Promoter A That there is a project manager who knows the people, and also knows the history of the organization a little. This project is in some organizations conducted by an external project manager, so someone who was hired to implement the ECD [the IS]. This had its advantages: you would be a bit more objective, but I also believe that this has many disadvantages, because you do not know the road, because you do not understand the people. And I did know them, of course.”
24 consultation meetings.”
Stakeholder B “(…) and the nursing care part: he [the promoter] should leave it to us. (…) I always say: ‘let the cobbler stick to his last’; he has knowledge of the digital world and we have knowledge of nursing care.”
Issue impact
Promoter perspective. Between one promoter-stakeholder (promoter A and stakeholder A) pair it was not entirely clear what the issue exactly was, because both parties had experienced it
differently. In relation to this first issue and how the promoter has experienced it, it argues that the IS made it possible to effectively collaborate. The promoter supported this benefit by the following: “In the end, we all have come closer to each other. That you have understood each other, that
clinicians still more see the limitations of the system.” A risk was that people could actually read each other’s reporting and that what not what they were used. The promoter says that there was a bit of tension at first, in a following manner: “It gave a sense of discomfort.”
Moreover, the promoter says that resistance was noticeable when it performed a training concerning the introduction of the IS. The promoter believes it was a good choice to choose for a standard IS package instead of a tailor-mode IS system by saying the following: “Otherwise, you are constantly busy searching for exceptions for individual wishes and then this will keep you busy, then you will drown, which will ultimately lead to an unworkable something.” Another risk, which the promoter mentions, was that it was insufficiently clear what implementing an IS meant. This is supported by the following: “I think that the risks, and fortunately you do not realize that in advance, were quite big; namely simply no acceptance of the system, resistance. And that you, in the end, would simply have an unworkable product. That could have happened.”
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attention to this issue, the promoter said that the following think would have happened: “You will receive fewer facts, you will get less information from the ECD and the ECD is less efficient. As
organization: you will receive less management information of it and you are more busy putting time in ‘words’ than you are with nursing care.”
Promoter perspective (of second organization).The issue concerns the introduction of the promoter, by the stakeholder, to the two most important care purchasers of the primary nursing care level. The promoter says that his company doesn’t want the organization of the stakeholder [and other similar organizations] in their consortium. The promoter wants them to ‘hook on’ and think with them, with the intension that they will put money on the table, in the end. Although, the promoter, contradictory, also says the following: “So not asking for money, but just ‘think with us’, to ensure to create a good proposition, so that also the interest of the insurance organizations will come forward in a good manner.” When talking about the issue the promoter says the following thing about the stakeholder: “He has created this opportunity and we seized it with both our hands.” The promoter believes that the stakeholder placed himself in a ‘helper ‘position, which has lead to the stakeholder’s commitment to the promoter’s organization. Although the promoter says that possibly in a further stadium the negotiations with the stakeholder will lead to financial support, it also mentions the following: “Without the help of insurance organizations we will make it, no matter what.” The promoter is glad that the organization of the stakeholder is already stimulating the IS in the region, “because there is where the real earnings are. Simulation, in any way, of the insurance organization, may actually simply accelerate the implementation of P. [the IS].” Again, the promoter explains that without the help of other organizations they will become successful in the end, but that (about the help they are now receiving): “It can just help with the further scaling up and the acceleration of the scaling up of P. [the IS]. (…) and from the sponsoring that we have received from O. [other insurance organization] we just can take some steps in the further product development and the expand of P.”The results show that when the insurance organization of the stakeholder would not have been interested in the IS, the promoter would have tried to find other entrances. Its organization would have contacted the hospitals in a more direct and extended manner than they are doing now.
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there at first.” The stakeholder (A) explains that the introduction of the IS has been a positive development: this is what they [the SLP’s] have been asking for, for years. The IS allows everyone to simply watch each other’s writings and see how the clients develops. The stakeholder reflects on how the issue has influenced her own work by mentioning the following: “Well, it actually has just ensures more commitment.” In accordance to what the promoter (A) believed the issue was, the stakeholder said :“(…) at the beginning of the implementation of the IS everyone was thinking ‘oh dear, now we can see, indeed, that everything is becoming transparent. (...) But after one and a half month they were getting used to it.” Reflecting on its own perception of the issue, the stakeholder said: “There are some ‘names’ [headings] used in the IS that we had difficulties with. (…)So many have disappeared in ‘between’; advices and action plans, and now [after everything is placed one file] it is just the question if everything is read.” The stakeholder also mentioned that when the promoter did not have done anything in consultation with them the following thing would have happened: “(…) then everybody would have thrown in the towel. Then you get a lot of resistance.”
Concerning the second issue the stakeholder (B) said the following thing about the IS: “We wanted work with an ECD [IS] because it is a thing of the present, and it [the IS] absolutely gives a lot of efficiency.” Moreover, the stakeholder (B) believed that a good solution was necessary, while it was affected its work. The follow was said about this: “Yes, that definitely has influenced my work, because, as I always say ‘I have a sandwich position’; when I do not get everything pouring over me from one side, I will get it over me from the other side.”
Promoter-stakeholder cooperation
Table 5 gives an overview of the quotes that the actors have used to describe the importance of the promoter-stakeholder cooperation, concerning the issue.
TABLE 5
The importance of promoter-stakeholder cooperation concerning the issue Respondents Quotes
Promoter A over
Stakeholder A
Interviewer: “Can you indicate how important the cooperation with Mrs. J. was with regard to the resolution of the issue? Compared to other stakeholders?” Promoter: “Compared to other stakeholder she was not very important.” Promoter A
over
Stakeholder B
Interviewer: “Can you indicate how important the cooperation with Mrs. W. is, in relation to other stakeholders?”
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DISCUSSION & CONCLUSION
The purpose of this study was to examine to which extent transactional and relational factors contribute to promoter-stakeholder cooperation in an IS healthcare related context. Moreover the study has examined how promoter salience and promoter reputation relate to one another. In this section the results concerning these questions will be discussed. This will be done per research question. Furthermore practical contributions will be made. And finally are the limitations of the study discussed, as well as suggestions for further research are provided.
First question A. will be discussed. Question B follows.
Question A. To what extent do transactional and relational factors influence the level of cooperation between promoter and stakeholders, in a healthcare-IS context?
Results concerning salience have showed that both stakeholders (stakeholder A and stakeholder B) had the power to block and restrain the IS. One of the stakeholders (B) moreover was perceived as a legitimate actor. This was based on her position within the organization. The promoter believed that both stakeholders had the urgent need for action, while the issue was affecting their work. This implies that the promoter (A) perceives the stakeholders (A and B) as being salient actors when it concerns cooperation on the issue. In terms of the salience-model this indicates that the stakeholders have gained their salience of the promoter, which means that the stakeholders are able to influence the activities of an organization. Stakeholder B is even called a definitive stakeholder, possessing power, legitimacy and urgency (Achterkamp and Vos, 2007). The
team managers necessary for creating goodwill and the support you needed.” Stakeholder A
over promoter A
Interviewer: “(…) How important do you find the cooperation with him [the promoter]?”
Stakeholder: “When I look at K. [IS], is that cooperation of great importance.” Stakeholder B
over promoter A
Interviewer: “Can you indicate how you found the cooperation with Mr. C., in respect to solving this problem?(…)”
Stakeholder: “Well, yes, very important. I think that good contact with your colleagues is always important.”
Promoter B over
stakeholder C
Interviewer: “(…) Can you indicate how important you found the cooperation with Mr. H., in relation to resolving this issue, the next issue and future, suggest that they come, in comparison with other stakeholders?”
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promoter (B) of the second organization perceives the stakeholder (C) as powerful: the stakeholder is resourceful, experienced and has stature within the organization that people will listen to him. Moreover, the stakeholder has strong connections with the organization of the promoter and is perceived to have the reasonable right to ask the promoter for help. The perceived level of urgency is low, because it was not relevant for the stakeholder’s organization to handle the issue in a fast manner. This implies that promoter (B) perceives the stakeholder (C) as being very salient when it concerns his power and legitimacy regarding the issue. However, the promoter does not perceive the stakeholder as salient when it concerns urgency.
Both stakeholders believed that the promoter (A) is a capable person, although less developed when it concerns communication skills. One of the stakeholders (A) believes that the power of the promoter is not very sufficient: people would not have cooperated with the promoter when he had not consulted them. The promoter therefore, shows that it has the ability to create satisfaction amongst primary stakeholder groups. This is one of the features on which an
organization’s survival and continuing success may depend (Jawahar and McLaughlin, 2001). Both stakeholders believed that the promoter is the legitimate representative of the organization when it concerns his own field of expertise. Only one stakeholder believed that there was an urgent need for the promoter to quickly deal with the issues. This implies that the stakeholders (A and B) do not perceive the promoter (A) as being very salient in cooperation regarding the issue.
Concerning the individual issues between promoter and stakeholders, the promoter (A) finds stakeholder (A) not very important, though stakeholder (B) very important. Both
stakeholders (A and B) find working with the promoter (A) on the issue of importance. Stakeholder (B) even finds working with the promoter of great importance. Promoter (B) does not find
stakeholder (C) very important.
Concerning their own legitimacy for being involved in the introduction of the IS promoter (A) and stakeholders (A and B) perceive themselves as legitimate. They all seem to claim that the promoter or stakeholders could not have made the introduction of the IS as most effectively without their contribution, or that of their colleagues.
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also perceived legitimate, though this seems less while the underlying reason is more general: the organization is perceived as a professional bureaucracy therefore, the organization needs
professionals. The promoter claims to have a good relationship with both the stakeholders and shows willingness to work with them concerning future issues. This implies that the promoter (A) values the reputation of both stakeholders (A and B). The promoter recognized the importance of involving stakeholders into the process. However, stakeholder (B) is perceived more legitimate given her position in the organization. The promoter, again, shows the importance of this particular stakeholder, which relates to a feature of the resource dependence theory: management is in particular concerned with those sources that have critical resources (Jawahar and McLaughlin, 2001).
In the second organization the promoter (B) perceives the stakeholder (C) as a capable person, with experience and stature. Moreover, the promoter mentions that there was an already established relationship between itself and the stakeholder. Based on personality there is a strong connection between them both. Additionally, the promoter shows that the stakeholder is a reliable person while it wants to work with the stakeholder in the future. This implies that the promoter (B) values the reputation of the stakeholder (C) as high.
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The summarized research models (shown in figure 2, 3 and 4) provide a clear overview of the amount to which salience and reputation was perceived by the promoter or stakeholder, in each individual case study. Moreover, the models show how the promoter and stakeholder have
perceived the impact of the issue on the IS. By providing these research models an overview is given to show how respectively the promoter and stakeholder come to willingness to cooperate with the other party.
Figure 2. Summarized research model of case study 1
31 Figure 4. Summarized research model of case study 3
To conclude question A, both transactional and relational factors seem to have a high and positive amount of influence on promoter-stakeholder cooperation, from promoter perspective. However, the promoters (A and B) do not find cooperation with stakeholders (A and C) of much importance when it concerns the issue. Moreover both promoters (A and B) claim to have a good relationship with the stakeholders. Therefore, from the perspective of the promoters the extent to which relational factors influences cooperation is a little higher than transactional factors.
Relational factors seem also be more important and present when it concerns cooperation from the perspective of the stakeholder. While the stakeholders find the promoter (A) not very salient. However, they find working with the promoter on the issue of importance. The extent to which relational factors contributed to cooperation is higher, although the opinions of the stakeholders are more widespread. One of the stakeholders (A) perceives the reputation of the promoter as being present. The other stakeholder (B) finds the promoter (A) reliable and seems to appreciate its good relationship with this actor. However, the level of power and legitimacy of the promoter is perceived as low.
Question B. How do promoter‘s salience and reputation relate to one another?
When speaking of the concept of power, in both categories of salience and reputation, stakeholder (A) mentions the skills and capabilities of the promoter (A). Compared to stakeholder (B) is stakeholder (A) more critical when it concerns the salience of the promoter: without
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when it concerns the reputation of the promoter. Ironically enough is the reason for being critical almost similar to what stakeholder (A) mentions about the level of salience of the promoter. The level of power of the promoter (A) is not perceived as very high, without its consultation with other parties. Moreover, this stakeholder believes that the promoter should have more attention for the interests of the stakeholders. The answers concerning the legitimacy of the promoter (A) is in both categories of salience and reputation rather similar. Stakeholder (A) finds the promoter a legitimate representative of the organization, although in the category of salience this legitimacy is limited to the tasks that belong to its function. Stakeholder (B) believes that the legitimate decisive role belongs to the MT. However, in the category of reputation the stakeholder mentions, more or less the same as stakeholder (A) when mentioning ‘everybody in his own field of expertise’.
Cooperation with regard to the issue has lead to more commitment, of the side of the stakeholder (A). Stakeholder (A) therefore, has benefit from its relationship with the organization, while cooperating with the promoter, in an intangible way: (organizational) commitment (Goodstein and Weick, 2007). Stakeholder (B) found working on the issue of importance while it was affecting the work.
To conclude the question, the concepts of power and legitimacy, in the categories of salience and reputation, have many interfaces. This means that these concepts relate strongly to one
another. A nice detail for mentioning is that the stakeholders perceive much similar experiences. However, they both name these similar features in the different categories. The additionally concepts of urgency, reliability and relational, of which the first belongs to the category of salience and the others belong to the reputation category, were not comparable. They were completely focused on different aspects of the cooperation between promoter and stakeholder. Cooperation with the promoter on the issues was for both stakeholders (A and B) of importance.
Practical implications
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attempt to comprehend this language by focusing on the stakeholder perspective of the promoter-stakeholder cooperation.
Limitations of the study and further research
The number of case studies, on which this study is based, is rather limited. This implies that the results of the study are not generally applicable for all organizations with promoter-stakeholder cooperation in a healthcare-IS context. In order to increase the applicability of a study further research should make use of larger numbers of respondents. Another limitation was the solely use of semi-structured interviews as data for the study. The theory of Jick (1979) describes the use of triangulation, which means that when studying a same phenomenon a combination of
methodologies is used. When making use of triangulation the results from the study can be cross validated if the methods show comparable data and are found congruent. Further research can provide more detailed results when it not only and solely makes use of semi-structured interviews but also use multiple methods for studying the same phenomenon.
In further research also more detail may be given to the concepts of power and legitimacy. Both categories of salience and reputation make use of these concepts. By providing more detail and therefore make distinctions between the two concepts an attempt is made to make the difference between the categories of salience and reputation more extended.
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