Marco Haak The actualization of shared affordances within healthcare

(1)

0

Marco Haak

S3835073 m.haak@student.rug.nl

MSc Business Administration – Change Management Faculty of Economics and Business

University of Groningen 17-01-2021

Supervisor: Dr. I. Maris–de Bresser Co-assessor: Dr. O.P. Roemeling Word count: 13.354 (excluding tables)

The actualization of shared

affordances within healthcare

(2)

1

Abstract

Over half of all IT projects in healthcare do not deliver as they should and result in a gap between the expected potential benefits of health IT and the documented outcomes. For a large part, the success of a technology is dependent on how the technology is used by the end-users. In order to better understand how groups of users determine to actually use a system and its features, this study uses the affordance actualization literature to study how and what actions are taken by different groups of users in order to transform potentials for collective system use into concrete results. Part of this can be explained using existing literature. Known is that users’ individual abilities, the technology’s features, and the work environment affect the actualization process. This study found that differences in the actualization process of shared affordances occur through variations in perspectives whether functionalities support or constrain users in achieving group-level goals, the pre-implementation phase of the IT, the readiness for change, the extent discussion and coordination takes place within a user group, and the actualization strategy individuals take within a user-group.

1. Introduction

Over half of all IT projects in healthcare do not deliver as they should and result in a gap between the expected potential benefits of health IT and the documented outcomes (Kaplan and Harris-Salamone, 2009). For the most part, this is due to organizational barriers rather than technological ones (Avgar et al., 2012). Health IT implementations in particular fail when the IT does not sufficiently complement the ways in which care is delivered and work is organized, which results in a gap between the design and the utilization of information systems (Avgar et al., 2012; Piscotty, 2015). One prominent reason why organizations fail to meet the expected benefits of IT implementations, is the lack of employee buy-in of the IT and employees’ underutilization of the system (Hornyak, Rai & Dong, 2020). In other words, the success of a technology is for a large part dependent on how the technology is used by the end-users and successful use is largely dependent on how it is implemented (Obstfelder et al., 2007 IN Morilla et al., 2017: 2). This means that a large part of a technology’s success or failure is determined by the extent to which end-users accept and use it (Avgar et al., 2012).

Since ‘use’ of the technology is such an important determinant of the success of a new IT, it is interesting to investigate how these new technologies are perceived by end-users. Because prior to an actor actually uses a technology, he/she must first perceive what he or she can do with it. That is what the affordance literature focuses on. Affordance theory stems from the ecological psychology and has been translated into other fields, like the information systems field, and helps to understand the relation between the material nature of the technology and its social context of use (Anderson and Robey, 2017). Affordances

(4)

3 are basically the potentials for action: things that the user perceives the technology allows him/her to do. This is well exemplified by Michaels and Carello, who state that “humans do not perceive chairs,

pencils, and doughnuts; they perceive places to sit, objects with which to write, and things to eat” (1981:

42). This quote illustrates that humans do not perceive the technical details of an object, but what that object allows them to do. One can perceive technology either as affordances or as constraints based on how the technology fits with their current goals (Anderson and Robey, 2017). Affordances can be defined as “the possibilities for goal-oriented action afforded to specified user groups by technical

objects’’ (Markus and Silver, 2008: p622) and have been frequently studied in information systems (IS)

literature.

What is less known in the literature, is how affordances are actualized. Affordances are only the potentials for action, which means that they do not guarantee results. The process of realizing that potential generates the value of a technology (Godé et al., 2020). In order to transform potentials into results, users must take goal-oriented actions, which is referred to as affordance actualization. Strong et al. (2014) were the first to open up this black box of the actualization process and defined the concept as “the actions taken by actors as they take advantage of one or more affordances through their use of

the technology to achieve immediate concrete outcomes in support of organizational goals” (Strong et

al., 2014: 70). In their study of the implementation of an Electronic Health Record (EHR) within a healthcare organization, Strong et al. (2014) found that in order to transform potentials (perceived affordances) into results, actors must take goal-oriented actions (actualizations) to use the technology to achieve an outcome. However, Strong et al. (2014) only focused on individual affordances, which are the possibilities for action perceived by an individual and therefore only has value to the individual who enacts it. But with multiple members in a group, and multiple features available for use, the possible number of affordances that may be perceived and actualized is very large (Leonardi, 2013). Therefore, Leonardi (2013) distinguishes between individualized affordances, collective affordances, and shared affordances. As Strong et al. (2014) focused on individualized affordances only, the collective, and shared affordances are in need for future research. Shared affordances can be defined as “affordances

that are shared by all members of a group” (Leonardi, 2013: 752), and represent similar feature use that

is necessary for achieving organizational and group-level goals. But ‘how’ this similar use of the technology is achieved and coordinated is rather unknown, as more research development is needed in this area (Strong et al. 2014). Therefore, in order to understand how employees perceive what they can do with a technology and how they operationalize these potentials for action, this research looks at actualizations of shared affordances within a healthcare organization. I do this by answering the following research question: How are shared affordances actualized?. This research question helps to understand how and what actions are taken by groups of users in order to transform potentials for system use into results.

(5)

4 This research tries to answer this research question by conducting a qualitative case study within a healthcare organization that recently implemented a new information system. The goal of this study is to understand how and what actions are taken by different groups of users in order to transform potentials for collective system use into concrete results. This research responds to Strong et al.’s (2014) call on further research and development on organizational level actualization, and on Anderson and Robey’s (2017) call for more research on the actualization process. It also extends the theory on shared affordances developed by Leonardi (2013). Further, I contribute to the IT implementation literature in healthcare, by studying the use of new IT on a user group level. Researching this, makes this study of direct value to healthcare managers who implement new technology within their organization as they gain insight in how users perceive new technologies and functionalities and how they translate these perceptions into actual use of the system. More managerial insight in how new IT systems are used and how shared affordances are actualized could lead to more effective IT implementations. I begin by evaluating literature about IT implementation in healthcare, followed by reviewing affordance theory and affordance actualization theory. After this theoretical development, I describe the research methods, present the findings of this study, and discuss what these findings imply for the literature and practice.

2. Literature review

The goal of this study is to understand how and what actions are taken by different groups of users in order to transform potentials for collective system use into concrete results. In order to do that, I will dive deeper into the affordance literature. First, I will review the IT implementation literature, aimed at healthcare organizations. Next, I will explain the affordance lens, which is suitable for understanding how system use can be perceived differently by different groups of actors. Lastly, I will clarify the concept of affordance actualization which transforms the potentials for action into results.

2.1 IT implementations in healthcare organizations

“Organizational challenges in healthcare like high costs, medical errors, variable quality, lack of coordination, and administrative inefficiencies are all closely related to inadequate use of health information technology as an integral part of medical care” (Thompson & Brailer, 2004: 1). In order

to deal with fundamental problems as the quote above indicates, many firms implement an Enterprise System (ES) to redefine work processes and replace the fragmented incumbent systems (Hornyak, Rai & Dong, 2020). Great effort, time, and money are invested in implementing the new technology, but healthcare organizations see a gap between the expected potential benefits and documented outcomes (Avgar et al., 2012). Although IT has become more and more important in healthcare organizations (Strong et al., 2014), literature reports that over half of all IT projects in healthcare do not deliver as they should (Kaplan and Harris-Salamone, 2009; Jasperson, 2005). Also Leonardi et al. (2013) researched this and state that in many cases, new technologies that are implemented fail to bring about

(6)

5 the types of changes that were envisioned beforehand. Four main causes are mentioned for the high failure rate of IT implementations in healthcare, which are: “a lack of strategic macro-management,

shortcomings in standardization, uncertainty around financial issues and ignorance of eHealth among both patients and professionals” (Ossebaard and Van Gemert-Pijnen, 2016: 416). Existing information

systems in healthcare are built in ‘silos’ and lack the ability to interact with other systems effectively (Weber-Jahnke et al. (2012). Therefore, achieving integration and collaboration of the systems is difficult. Additional challenges such as dealing with privacy and security complicate this matter (Islam et al., 2015). Part of these problems can be allocated to technical issues regarding functionalities and interoperability, but consensus is emerging that problems with healthcare IT projects are more related to managerial factors, rather than technical ones (Kaplan and Harris-Salamone, 2009; Avgar et al., 2012).

Three stages are present in each health IT implementation process: (1) the decision to invest in health IT, (2) the implementation process, and (3) the institutionalization of the technology (Avgar et al., 2012). Managers and end-users face different barriers and challenges in each of these stages. For the first stage, it is important to understand that even if the health IT serves the organization’s overarching strategic objective, the end-users’ skills and abilities and the preparedness of the workforce for the implementation mainly determine the expected return on investment of the technology (Avgar et al., 2012). The second stage, the implementation process, has a big impact on the extent to which the technology is accepted and the way it is used (Morilla et al., 2017). For the technology to succeed, it should be implemented in such a way that is complementary to the ways in which care is delivered and work is organized (Avgar et al., 2012). As implementing a new technology is fundamentally a collective learning process, organizations that are better equipped at facilitating learning at both the individual and collective level, are likely to see greater technology related gains than those who do not (Avgar et al, 2012). The extent to which employees feel ready for the change will have lasting implications in terms of effective use of the technology. The final stage, the institutionalization, is about embedding the technology in the daily use of the employees. It has been researched that organizations who create an environment in which employees are encouraged to seek out new knowledge and to share this knowledge with colleagues, yield greater benefits from innovations, such as new information systems (Avgar et al., 2012).

Other studies mention factors that explain the failure of adopting IT systems in healthcare organizations, which include the characteristics of individual end users (e.g. anxiety, motivation), skills and abilities in order to successfully adopt the system, attributes of the technology (e.g. usability, performance), clinical tasks and process, and lastly, lack of communication between end users and designers (Courtney et al., 2008). Especially the issue of communication is important in having the employees perceive the health IT as supporting their work rather than imposing additional barriers (Avgar et al., 2012). Due to

(7)

6 these factors and obstacles, management does not fully understand how their intentions and goals regarding system use is translated into actual use of the system by the end-users. The affordance literature is helpful in understanding this transformation process.

2.2 Affordances

Affordances is a concept developed by the ecological psychologist Gibson (1986). He came up with the term as he was studying animals’ perception of their surroundings. The term reflected his belief that animals do not perceive every little detail of an object and then calculate the combined value of those details, but they directly perceive what the object will enable them to do (e.g. a snake considers a rock not by its angels and size, but as a place to hide from the burning sun) (Gibson, 1986). Gibson believed that animals and people directly interpret the information that is relevant to their needs from the objects in their environment (Markus and Silver, 2008). The type of affordance an actor perceives is for a large part dependent on the action-oriented goal the actor has. In the example of a snake, the rock affords shelter when the snake seeks shadow, but if the goal is to find a safe place to lay her eggs, the rock has a whole other meaning.

This ecological perception of affordances has been translated into the IS literature by several authors (Pozzi et al., 2014; Leonardi 2013; Majchrzak and Markus 2012; Markus and Silver 2008; Volkoff and Strong 2013; Zammuto et al. 2007) The affordance theory helps to understand the material nature of the technology and its relationships with its social context of use (Anderson and Robey, 2017). Markus and Silver developed the concept of ‘functional affordances’ which refers to “a type of relationship

between a technical object and a specified user (or user group) that identifies what the user may be able to do with the object, given the user’s capabilities and goals” (2008: 620). In other words, functional

affordances refer to potential uses of the IT artifact related to the actor’s goals and capabilities. Especially the ‘relation’ element in these descriptions is important, as it highlights the connection between the IS with certain features and a users’ goals and intentions to which this IS should be used (Majchrzak et al., 2016). The user does not perceive features of the technology by its technical details, but as what it allows him or her to do in meeting a goal. For example, an affordance identified from the study of Strong et al. (2014) about implementing a new EHR system in a healthcare organization is:

‘Accessing and using patient information anytime from anywhere’. The affordance does not say anything

about the feature’s technicalities (e.g. structured entry fields, database) but it does tell what it allows the user to do. In development of the affordance literature, Anderson and Robey (2017) introduced the concept of ‘planned affordances’, which are the relations between designed system features and anticipated user abilities within an expected context. They are the affordances that designers ‘think’ users will enact. However, planned affordances may vary significantly from perceived affordances, which are the affordances that are actually perceived by users in the actual context. This is due to variations in the way system features are implemented and variations in the abilities of the actual users

(8)

7 (Anderson and Robey, 2017). So in order to align planned and perceived affordances, it is crucial to understand the intended user during the design phase.

With multiple users, and multiple features available for use, the possible number of affordances of a technology that may be perceived is very large. Therefore, Leonardi (2013) distinguishes between individual, collective, and shared affordances. Individualized affordances are at play when someone enacts an affordance that is not perceived by others in his/her workgroup. So that affordance only has value to the individual who enacts it, which means that the individual can use the technology to do something that others cannot. Collective affordances are mutually created by members of a group, which allow the group to do something that it could not otherwise achieve. Lastly, there is the shared

affordance, which is shared by all members of a group. Shared affordances are different from collective

affordances, as they represent similar use of the technology by all members in order to achieve group-level goals, while collective affordances represent different feature use that is necessary for completing noninterdependent tasks that achieve the group-level goal. Whereas collective affordances are likely to arise when work is highly specialized and where there is no or little work interdependence, shared affordances are more common in teams whose work is characterized by high degrees of reciprocal interdependence. These shared affordances allow the group to easily coordinate their work and achieve individual and group goals (Leonardi, 2013). They particular become enacted when everyone in the group uses the technology and its features at roughly the same frequency and same way.

By looking at technologies as sets of affordances, it becomes possible to explain the relationship between the material nature of the technology and its social context (Anderson and Robey, 2017), and ultimately, understand the existence of the gap between the design and the utilization of information systems. However, identifying affordances is only a first step in understanding how introducing a new information technology results in discrepancies between the organization’s intention and actual system use. The affordance-actualization lens developed by Strong et al. (2014), helps to understand how the potentials for action are realized.

2.3 Affordance-actualization

As described above, actors identify affordances as they link specific properties of the technology with their own experience and practical goals (Pozzi et al., 2014). However, affordances are only the potentials for action which means that they do not guarantee results. The process of realizing that potential generates the value of a technology (Godé et al., 2020). In order to transform potentials into results, users must take goal-oriented actions, which is referred to as affordance actualization and can be defined as “the actions taken by actors as they take advantage of one or more affordances through

(9)

8 (Strong et al., 2014: 70). In this definition, immediate concrete outcomes are specific outcomes arising from the actualization process that contribute to realize overarching goals of the actors (Tim et al., 2018).

Strong and colleagues (2014) identified three factors that influence the actualization process. In their study on the implementation of an EHR system within a healthcare organization, they encountered both supporting and restricting factors that affected the actualization of individualized affordances. Key factors that led individuals take different actualization actions included (1) individual abilities and preferences (e.g. typing abilities and work preferences), (2) the technology’s features (e.g. user interface, medicine search), and (3) the work environment’s characteristics (e.g. resources for trying new ways of working). If these factors were perceived as constraints, actors tried to reduce or eliminate them (Strong et al., 2014). For example, nurses who see their own typing skills (ability) as a constraining factor for actualizing an affordance, could try to ask for training options to develop their typing skills, but they could also try to change the EHR to better fit their preferences by developing templates (so they do not have to type that much). This understanding is in line with Leonardi’s (2011) finding that when a user perceives the technology as a constraint, the user will try to change the functionality of the technology. On the contrary, when a user perceives the technology as an affordance, the user will try to change the routines to take advantage of that affordance.

The research stream of affordance actualization has been expanded by different authors after Strong et al. (2014). Anderson and Robey (2017) extended the affordance actualization literature by introducing the concept of ‘affordance potency’, which is the product of the three factors that Strong et al. (2014) identified that influence the actualization of individualized affordances. According to Anderson and Robey (2017), affordances potency, along with perception of the affordances and a users’ individual goals, determine the actualization process of individualized affordances. These factors help to explain that although technology designers try to create (planned) affordances, this is not always in line with how the users perceive and actualize them. Besides that, not all perceived affordances are actualized. Also, Anderson and Robey (2017) add that the user’s goals and perceptions must be understood in order to recognize how affordances are actualized. They state that if there is a disconnection between the affordance and user’s goals, the affordance will not be actualized. This is in line with the findings of Petrakaki et al. (2014), who found that affordances are actualized when healthcare professional’s (individual and shared) perceptions of technology fit with their user goals. If affordances are not aligned with goals of the users, the chance of workarounds increases (Petrakaki et al., 2014), which is again in line with Leonardi (2011). More recently, scholars took more confirmatory strategies in researching affordance actualizations and addressed Strong et al.’s (2014) call to theorize the process of affordance actualization. Tim et al. (2018) applied the affordance actualization lens on social media, and Godé et al. (2020) studied how the affordances of a predictive analytics are actualized. In this study, I will take a more explorative strategy in the search of how perceived shared affordances are actualized.

(10)

9 In order to clarify the actualization process, this study exemplifies this from an IS perspective, and I will illustrate this in the context of individualized affordances, and shared affordances. I do this based upon an affordance identified from the research of Strong et al. (2014).

The implementation of a new EHR allows a nurse to faster document a patient’s health

information (individual affordance) as she uses all ten fingers to type (actualization). The

implementation of the new EHR allows the group of nurses to ‘capture and archive digital

data about patients’ (shared affordance). Individuals record all appropriate data about

patients and document this in the EHR so they hold all relevant information about the patients

(actualization). This allows the organization to ‘avoid legal liabilities’ and ‘provide high

quality care’ (organizational goal).

This example shows how affordances and actualizations contribute to an organization’s goal. It illustrates that an actor uses a technology in such a way that it allows her to do something (faster documenting) others cannot (others might be more slowly as they cannot type as fast, or have trouble in finding overview in the new IS). In order to enact shared affordances, actors must use the technology in similar ways. So in order to achieve organizational goals, individuals must capture and archive digital data about patients at roughly the same way. If this actualization process would be different, and nurses differed in how they archive data, it would disturb the group of achieving organizational goals.

The question of how the actualization process takes place with shared affordances, is rather unknown, as the general focus of scholars is on individual affordances, including that of Strong et al. (2014). However, these individualized affordances identified by Strong et al. (2014) can be interpreted as collective or shared affordances, as they can only be realized as a group. For example, the individualized affordance of ‘Standardizing data, processes, and roles’ must be actualized in a shared way, as different actualizations would not contribute to standardization. Unknown, however, is what factors affect the actualization of shared affordances. Therefore, this process is being explored during a case study within a Dutch healthcare organization. The research question that fits this exploration is: ‘How are shared

affordances actualized?’. I conducted empirical research within a healthcare organization, that recently

implemented a new information system. I followed Anderson and Robey’s (2017) lead to identify what the planned affordances are in the expected context. Next, I conducted interviews in order to find perceived shared affordances of the system in the actual context, followed by analyzing how these shared affordances are actualized. Following this path I built on Strong et al. (2014) by expanding their theory with the work of Anderson and Robey (2017) and Leonardi (2013). It allowed me to study how shared affordances are actualized.

(11)

10

3. Methods

In this section I will describe the research design of this study, which is a blue print for getting from the initial set of questions to be answered, to the set of answers and conclusions. (Yin, 2009). I will start with describing the research approach, followed by the research setting, the data collection strategy and analytical strategy.

3.1 Research approach

As the research question of this study - ‘how are shared affordances actualized?’ – is of explanatory nature, I will conduct a qualitative case study. A case study is “an empirical inquiry about a

contemporary phenomenon (e.g. a case), set within its real-world context – especially when the boundaries between phenomena and context are not clearly evident (Yin, 2009a: 18). Although the

study focuses on a single organization, two groups of users were interviewed at different locations, which make the case study multiple-case and embedded with an overall holistic approach (Yin, 2012). The case study method is well suitable when conducting evaluations (Yin, 2012), which is applicable in studying this research question. Furthermore, shared affordances and their actualizations are reflected in the actions of a group, which means a case study is needed to uncover embedded insights (Leonardi, 2013; Strong et al., 2014). The qualitative type of research is interesting, as it fits better with the novelty of the concepts, which means the study is a theory development type of study (Edmondson and McManus, 2007). By answering the research question, I am building on the theory of Strong et al. (2014) and Leonardi (2013), as I further develop the concept of shared affordances. Also, I address Anderson and Robey’s (2017) call for more research on the actualization process. As I am interested in gaining a deeper understanding of how organizational goals are transformed into actual usage, I follow Volkoff and Strong’s (2013) suggestion to study the affordances themselves in order to understand how change occurs following the introduction of a new IT. First I will discover the organizational goals of system use, next I will identify perceived shared affordances, and lastly, I will analyze how these perceived shared affordances are actualized.

3.2 Research setting

The research setting of this study lies within a Dutch healthcare organization called ‘Huisartsenzorg Drenthe’, which is a cooperation that provides acute and general healthcare. In this organization, general practitioners work on regular business hours in their ‘normal’ practices, but they also work a certain part of their time (based on the amount of patients they hold in their practices) in healthcare centers, outside business hours. These shifts are called ANW shifts (Avond-, Nacht, en Weekend) and serve to provide acute care for urgent matters that cannot wait till the next day (or in weekends, till Monday). Besides general practitioners (GP’s), triagists work at these healthcare centers to make the first care assessment and its urgency. There are four of these centers in the province of Drenthe. They are located in hospitals in Assen, Meppel, Emmen, and Hoogeveen. The research setting is interesting for this study for several

(12)

11 reasons. First, as the organization recently implemented an IS, the setting allows me to study affordances that are still being developed and are not yet deeply embedded in user behavior. This is interesting, as the actualization process still takes place. As of July 2020, this IS was implemented over all four locations and is called ‘Topicus Huisartsenpost Informatie Systeem’ (HAPis). A second reason why this setting is interesting, is because a careful assessment was done by an external party in the pre-implementation phase in order to find out what the HAPis and its features should do. Seventeen ‘use cases’ were developed which suggest what the planned affordances are. The use cases exist out of a standard description of the goal, purpose, and result. As the use cases are applied in the design of the system, it allows me to analyze how these pre-defined intentions of how the technology should be used relate to actual usage behavior. A final reason why this research setting fits within the design of this study, is the healthcare context of the organization. This allows me to study IT usage behavior of healthcare professionals and contribute to literature on IT implementation in healthcare.

3.3 Data collection

In order to get familiar with the research setting and to establish valuable connections, I designed this study at the main office of the organization. Three main steps were developed in order to answer the research question. The first step – discovering planned affordances regarding system use – was mainly realized by thoroughly reading existing documentation. The use cases are the most important form of data in describing this step, as they were leading in the design of the IS. Other documentation contained records from meetings, mailing, FAQ, project plans, and instruction video’s. Next to the documentation, I discussed the system and its goals with the initiators of the project through informal conversational interviews. This form of interviewing is created by a spontaneous selection of questions in a natural interaction (Turner, 2020). This type of interview might be reviewed as unstable or unreliable because of the inconsistency of the interview questions. Therefore, data retrieved from this interview is only used to triangulate the data gathered from the documents. Finally, I participated in the e-learning program for end-users and watched the webinar, which allowed me to visualize the goals of the system.

Data for the second and third step – ‘identifying perceived shared affordances’ and ‘analyzing the actualization process’ – was gathered by conducting semi-structured interviews. Initially, the plan was to observe users using the system and their behavior. However, due to COVID-19 restrictions, I was only able to do interviews. Seventeen interviews were conducted, from which eight were from GP’s, and nine were from triagists. Both these groups were interviewed, as a different actualization process was expected. This expectation developed during the informal conversational interviews. Also, since the work of GP’s rely very much on the work of triagists, it is very likely that shared affordances are enacted, as they are more common in teams whose work is characterized by high degrees of reciprocal interdependence (Leonardi, 2013). By focusing on shared affordances between two groups of users, it allows me to see how different factors influence the actualization of the same shared affordances.

(13)

12 Semi-structured interviews were used as this form allows room for flexibility in composition of the questions (Turner, 2010). This allowed me to interact with the respondents in a relaxed and informal manner which afforded me to ask follow-up questions and learn more about the in-depth experiences of system use. Part of the interviews were conducted online, while the majority were conducted on site. In a few interviews on site, respondents showed me the IS to clarify their answers, which allowed me to visually understand certain points. As the development of affordances is an iterative process (Strong et al., 2014), the interview questions were asked in a chronological way, reflecting the phases of how the implementation got planned. The interview scheme can be found in Appendix II. It was created based upon three themes: the pre-implementation phase, the identification of shared affordances, and the actualization of perceived shared affordances. Example questions for these themes are: ‘What would the organization try to accomplish with implementing Topicus HAP’, ‘Can you explain what you use the system for?’, and ‘Can you explain how you have discovered what the system allows you to do?’. Due to work circumstances where respondents had to be available to deliver acute care, the duration of the interviews was restricted by the director to a maximum of 30 minutes. The selection of the sample was somewhat challenging. With regards to the triagists, a distinction could be made between key users and non-key users, and with regards to GP’s, a distinction could be made between practice owners and interim GP’s. I wanted a diverse selection between these roles, together with age and location. The scheme below describe the respondents anonymously:

# Code Function Role HAP location Interview type Date Duration

1 TA2 Triagist Key-user Hoogeveen Online 26-10 38:10

2 TA4 Triagist Key-user Meppel Online 27-10 32:03

3 HA2 GP Practice owner Assen Online 28-10 27:25

4 HA4 GP Practice owner Assen Practice 28-10 31.:06

5 HA5 GP Interim GP Assen Practice 30-10 45:19

6 HA1 GP Practice owner Hoogeveen HAP 03-11 23:57

7 TA3 Triagist Non key-user Hoogeveen HAP 03-11 29:03

8 HA6 GP Practice owner Emmen HAP 04-11 28:26

9 HA3 GP Interim GP Emmen HAP 04-11 27:21

10 TA5 Triagist Non key-user Emmen HAP 04-11 24:28

11 TA6 Triagist Non key-user Emmen HAP 04-11 26:05

12 HA7 GP Interim GP Meppel HAP 05-11 24:07

13 HA8 GP Interim GP Meppel HAP 05-11 34:27

14 TA1 Triagist Key-user Meppel HAP 05-11 31:58

15 TA8 Triagist Non-Key user Assen Online 11-11 44:39

16 TA9 Triagist Non-Key user Assen Online 11-11 24:50

17 TA7 Triagist Key-User Emmen Online 12-11 31:58 Table 3.1: Respondents

3.4 Data analysis

In order to validate the data and improve its quality, the interviews were recorded and transcribed (Yin, 2009). These transcripts can be found in Appendix IV. The analytical strategy used to analyze the data, involved inductive and deductive coding. Excel was used as the software to create overview of the data,

(14)

13 which allowed me to provide codes to the text in order to discover important patterns. The reviewed literature helped identifying important concepts that could be applied as codes for the analysis of the data. However, as the literature on shared affordances is relatively underdeveloped, I used general understanding on the actualization process of affordances, rather than applying concrete existing concepts. The coding process existed out of three steps. First, I used open coding. I read through the data multiple times and marked important concepts and data that attracted my attention and labeled them. Second, I used axial coding in order to categorize different codes and explain their relationships. Four main categories evolved out of this using selective coding, which where the pre-implementation phase, the identification of shared affordances, the actualization process, and factors affecting the actualization process. To exemplify, open codes like ‘needs’, ‘innovation’, ‘current system’ (Callmanager) resulted in the axial code ‘perception of organizational goals’, which became part of the selective code of the pre-implementation phase. Another example is that open codes like ‘try and error’, ‘check out’, or ‘seek’ resulted in the axial code ‘exploring’, which became part of the selective code of ‘the actualization process’. The entire codebook can be found in Appendix I.

4. Findings

In this chapter I will describe the findings that emerge from the data. The research question ‘How are shared affordances actualized?’ will be answered by splitting it up into three parts and by analyzing it from an triagist perspective and a GP perspective. First I will address the pre-implementation phase and the planned affordances. Second, I will identify the three most discussed shared affordances that were perceived by both groups of users. This allows me to see how different factors influence the actualization of the same shared affordances. And third, I will analyze how these perceived shared affordances are actualized.

4.1 Planned affordances and pre-implementation phase

In this section I describe what has been done prior to the implementation of Topicus HAPis. I will focus on the organizational goals, the design of the IS with its planned affordances, the communication, the training, and the readiness for change of both groups of users.

4.1.1 Organizational goals and intentions

In the summer of 2018, the Huisartsendiensten (HDS’) of the four northern provinces (Groningen, Friesland, Drenthe, Overijssel) decided to collectively purchase IT regarding the GP care units, or in Dutch ‘huisartsenposten’ (HAP). After a long and intensive selection period, the four organizations decided to go with Topicus as the supplier of the information system (HAPis) that was going to be implemented. By collectively purchasing the IS, the organizations saw thirteen benefits that would make this initiative interesting (Kernteam Noord Nederlandse ICT samenwerking, 2018). The major benefits include (1) jointly distributing the costs of a new HAPis, (2) personnel is exchangeable between the locations, (3) jointly organization of training of personnel, (4) bigger influence on roadmap of the

(15)

14 supplier, (5) optimizing patient transfer between regions, and (6) better benchmark on management information. These mutual benefits, identified by the steering committee, were the key drivers for the four organizations to start this initiative. Together they purchased a standard package of Topicus, which was locally modified in each of the four provinces. So the organization did rapport the benefits they saw with the mutual buy, but did not clearly state objectives they had regarding the system itself. They did write requirements from the perspectives of users in the form of use cases, but did not formulate organizational goals and objectives regarding Topicus HAPis. As the method section describes, this research focuses on the HAPis in the province Drenthe which exists out of four sublocations: Assen, Emmen, Hoogeveen and Meppel. For the HDS in Drenthe, next to the mutual benefits the buy would yield, the most important reason for replacing the incumbent system, was that it was no longer supported by other systems and it could not be further developed.

4.1.2. System requirements

In the selection period of the HAPis, a committee was created that was researching which supplier would fit best with the needs of the organizations. In order to determine this fit, a delegation formed out of multiple disciplines (GP’s, triagists, quality employees, controllers, IT personnel, managers, committee members) formulated functional requirements, general requirements, technical requirements, and requirements with respect to the supplier. All these requirements are documented in the ‘program of requirements’ (PvE) and represent all four organizations, but still allow flexibility to offer local modifications at each of the locations. Especially the functional requirements are of interest for this research, as they are formulated in the form of ‘use cases’, which are the functionalities from the viewpoint of the user. The functional requirements can be seen as the planned affordances, as they represent what the system should be able to do, according to the users. The committee mentioned above analyzed all main processes and sub processes and identified seventeen use cases, which are illustrated in the scheme in Figure 4.1 .

(16)

15 Each process is analyzed and translated into use cases that tell what the system should do to support that process. Each of these use cases is described in Appendix III. To exemplify this, I will describe two uses cases, starting by use case 9: organize the agenda. The goal of this use case is to organize the agenda of GP’s, triagists, and other employees working at the HAP, so that planning is urgency based. Examples of planned affordances (functional requirements) are ‘the ability to plan for multiple agenda’s and different types of consults’, ‘visibility in availability of cars’, and ‘visibility of medical information within the agenda’s’. Another example is use case 3: control and authorize. The goal of this use case is to determine by a qualified employee if the right urgency has been determined, the proper consult has been given, and the right treatment has been executed. It basically means that if an incorrect judgement has been made, a qualified employee holds the ability to place the patient back into the process. Examples of planned affordances are ‘the ability to place a patient back into the triage list’, ‘the ability to see who executed the contact’, or ‘to provide an overview of contacts made by an non-qualified employee’. In both examples, the planned affordances tell something about what the system should do, and not how it should do it. As seventeen use cases were formulated, and there exist multiple requirements for each of these use cases, the number of planned affordances is very high.

4.1.3 Communication and perception

There were multiple ways of communication regarding the implementation of Topicus HAP. In April 2020 the first official statement was sent out by mail to every user working at one of the four HAPs. In this first e-mail, it was stated that the reason for the implementation of the new HAPis was that the incumbent one (Callmanager) was increasingly facing obstacles. Also, benefits coming with the new IS that would affect the user were named, such as a better overview, more speed, and more stability. About two weeks later, a new mail was sent announcing the date the system would go live (June 22), and how the training of the users was going to look like. Also, some instruction video’s about Topicus HAPis were placed on the extranet, which everyone could access. The extranet is the place where other information, prior communication, and frequently asked questions about Topicus can be found. A bit closer to the go-live date, a reminder e-mail was sent to the GP’s to do the e-learning and was stated that doing it was essential for a good start of their first shift.

In the interviews that were conducted with both the triagists and GP’s, questions were asked about why they thought the organization wanted to change the incumbent HAPis, and what the communication was like. Triagists emphasize that a new system was needed since Callmanager did not function properly anymore and that Topicus had to be implemented out of necessity, which is in line with how the organization communicated it to them. Also, triagists indicate that they were informed very well since the beginning, and that, closer to the going-live date, key users had a role in the informal communication, as this quote of TA6 indicates: “[…] the key users told us that ‘it was okay’, and ‘it was an easy system

(17)

16 that key users comforted colleagues, emphasized the benefits, and minimized negative associations. The benefits of the new system were communicated repeatedly by key users, which resulted in positive minded triagists. In contrast to triagists’ unified perception of why a new HAPis was implemented, GP’s have more varied answers. Key in their answers is that they actually do not know why a new system was implemented, resulting in speculations about why the change has been made. For example, HA6 states: “I do not really know actually, I guess it is innovation. But the reason behind the innovation… I

do not know. I think it has something to do with the future and that it should connect more with the daily practices”, or HA1 states: “Good question, I do not know actually. I guess to ease the job of the general practitioners and the triagists”. GP’s also state that the communication was fine by mail, but that they

did not give a lot of attention to it. As HA1 indicates: “it reaches us less, which is also a bit due to the

fact that it is not your own business. It is the CHD, which is something else as your daily practice. Than you already have less of a connection with it”. This quote suggests that the connection someone has with

the organization, might explain the sympathy and interest someone has with the change.

4.1.4 Training

Both the triagists and GP’s were offered an e-learning which would help them prepare for their first time using Topicus HAPis. Besides that, some triagists were trained as key users, who would serve as ‘specialists’. The key users organized workshops where they trained every triagist in how to use the system and where they could ask questions. The GP’s were invited to participate in a webinar that would virtually guide them through the HAPis. Lastly, the triagists and GP’s were offered hand-outs with instructions about how to use the HAPis. Both training interventions were mandatory to participate for the triagists, while it was voluntarily for the GP’s to participate. Accurate participation numbers do not exist, but data retrieved from multiple interviews suggest that not all GP’s participated in the training.

The triagists were positive about the e-learning, as TA8 states: “That was definitely nice to have as

introduction… let’s say, that you get a feeling with it, but also that you have seen it before you actually start working with it.”. Also, the workshops were perceived as helpful, as stated by TA4: “It was fun, because you already could gain some skills and were able to ask some questions”. So both training

interventions gave the triagists the feeling that they were prepared for the implementation of the HAPis. The experiences about the e-learning for GP’s are more varied. Half of the interviewees were positive and felt that the e-learning helped them prepare for the first shift, two were more skeptical, and two did not participate. Also, the intensity by which GP’s participated in the training differs, which is illustrated by the following quotes. HA2 states: “I think I scrolled pretty fast through the whole thing, but it was

quite clear”, while HA1 states: “I did the e-learning twice, because I wanted to understand it before I started working my first shift”. So it differs how intense people participated in the training. Besides the

e-learning, only two of the respondents stated that they listened to the webinar. So looking at the training of the users, triagists had a more intense training program than GP’s had.

(18)

17

4.1.5 Readiness for the change

Considering the perception and training of both groups, there was more attention for the implementation of the new HAPis by the triagists, then there was by the GP’s. while both parties have been informed about the change, triagists seem to have better remembered why the change was made. This is partly due to the connection users have with the organization, as working at the HAP is triagists’ primary job, while it is something for the GP’s where they occasionally work. Also, triagists were confronted more with advantages the IS would offer, leading to high expectations regarding the system, while GP’s maintain an attitude that states ‘I will see it when it’s there’. A factor that affects the readiness for change is age. There is a lot of difference between ages in how users experience the pre-implementation phase, but which seems to be more of an issue for triagists than for GP’s. The younger generation of triagists was mostly curious about the HAPis and some were even excited, while the elderly were more anxious, as the following quotes indicate. The younger TA4 stated that: “I was very curious. I am always open

to change, so I was excited for it”, while the older TA7 stated: “Honestly, the idea kept me up at night”.

Key users had a role in the informal communication and to calm down their anxious colleagues. Age was also a factor that influenced the readiness for change of the GP’s according to the younger GP’s, although that thought was not shared by the older GP’s themselves.

4.2 Perceived shared affordances

For this study, I will outline three perceived shared affordances which were perceived by both groups of users, that were named most frequent in the interviews. It differs per group and per affordance to what extent benefits and constraints are perceived. To remind: shared affordances represent similar use of the technology by all members in order to achieve group-level goals. These shared affordances allow the group to easily coordinate their work and achieve individual and group goals. Before I will go into detail how these shared affordances are perceived, I will first identify shared goals of both groups.

4.2.1 Group-level goals

As described in the literature review, the type of affordance a group perceives is to a large extent dependent on the goals the group of actors have. Although triagists and GP’s work closely together and will unquestionably share the same goal of providing the best medical care for the patients, goals towards the system might differ. Triagists seem to be very focused on having overview and on minimum administrative actions the system demands. TA4 states: “If I review the system, administration is very

important. The reporting of the contact has to be clear and obvious, so that the consult or visit is clear for the GP”. Clarity, speed, and user friendly are words that are used frequently to describe their

requirements regarding Topicus HAP. When identifying the goals of the GP’s towards the system, it is notable that they are very oriented towards the basic functionalities. For example, HA5 states: “I think

there are a lot more possibilities with the system than how we use it right now. But is it valuable to know what else you can do with the system, while in reality you only use the basic functionalities… I do not

(19)

18

think it is”. Or HA4 who states that: “The basics just have to work smooth and that’s that”. These quotes

regarding requirements of the system are representative for other GP’s as well, who use words like efficient, clear, and simple. So triagists and GP’s do share similar goals towards the system of achieving efficient work, creating overview, and saving time, as words as ‘clear’ and ‘minimum administrative actions’ are in line with words such as ‘efficient’ and ‘smooth’. A difference is that triagist seem to be more interested in additional functionalities in how the system can support their work, while GP’s want the system to be as simple as possible. For example, TA8 states that “we use the basics now, but there

is a lot more to extract” or TA1: “We use more functionalities than GP’s do”.

4.2.2 Affordance 1: Consulting with the GP digitally

Topicus HAPis allows the triagists to discuss a patient’s case digitally with the GP. When a patient calls for consultation, the triagists does her routine job, by identifying the patient, reviewing prior medical history, retrieving all relevant data from the patient, so that she can make a well-considered first care assessment. If she needs a GP to review the case or approve her advice, the triagist hangs up the phone and documents what she just heard according to the NTS protocol and thinks of an advice to give to the patient. When she has done that, she saves this in the system, and the GP will be notified that he/she has to approve and authorize the contact of the triagist. When the GP has done that, he/she saves that in the system, and the triagist will be notified that she can return the call to the patient to discuss the advice. Before Topicus HAP was implemented, triagists would walk to the GP’s office themselves to discuss it, but now both parties can communicate by typing in the system. In the illustration below, it is shown what GP’s see when triagists ask for digital consult on a specific case. These quests for consultation are prioritized by color. The contact automatically changes color when it takes too long or when it is priority.

Figure 4.2 Affordance 1: Consulting with the GP digitally

Besides a few exceptions, there is a unified perception about this shared affordance by triagists. TA7 states: “What I really think is an advantage is the ability to digitally consult with the GP. […] That is

way more efficient”. This triagist refers to the efficiency gains which is a direct reflection of their

group-level goal of achieving efficient work and saving time. GP’s hold more mixed views. For example, HA1 states: “[…] They do not walk in which means you can think quietly. […]. So I really like it that that’s

digital now”. This GP describes that this affordance allows her to work more efficient which is a direct

group-level goal of the GP’s. On the other hand, not everyone feels the same. HA8 states: “I prefer they

(20)

19

always have questions”. This GP states that the digital way of consultation between triagists and GP is

less efficient. So while the goal is the same, it differs whether the functionality is perceived as an affordance or as constraint in relation to achieving these goals.

4.2.3 Affordance 2: Accessing more detailed medical information about patients

Topicus HAPis is better integrated with other information systems on the daily practices. Therefore, patient’s medical information that is stored on these daily practices, can be better retrieved by Topicus HAP. This allows both triagists and GP’s to see the medical history and medication list of the patients. When a patient calls to the HAP, the triagist picks up the phone and immediately sees all medical information. A side note is that patients need to have granted access to this information. Triagists state that the functionality allows them to better understand and assess the need for help of the patient and, especially, it saves them a lot of time, since they do not have to ask all that information from the patient anymore. TA3 states: “In my opinion it is working very fast, it saves us time because you do not have to

ask the patient for everything about prior medication and medical history. And you do not have to archive all that, so that saves a lot of time.” Or TA6, who states that: “loading all the data of the patient’s own GP is easy. It is just one click and you can see prior consults of their own GP, which is very clarifying in a conversation”. So these triagists explain that the affordance helps them to work faster as

they do not have to identify and document all the medical information, which is a direct reflection of their shared goals regarding the system. Also GP’s see this functionality as an affordance, since it helps them to better and quicker understand a patient’s problem, which is illustrated by the following GP. HA8: “[…] so that I can see which medication a patient uses. A lot of times, patients come in and when

we ask what medication they use, they say something like ‘these little brown ones and large blue ones’. Well, as GP’s we know all the names, but I do not have a clue how these pills look like. So it is really nice that you can see what the patient actually uses and in what doses. Also, the most recent things his own GP wrote, that I really like as well”. So the affordance of accessing medical information about

patients directly contributes to the goals of both groups regarding achieving efficient work and saving time.

4.2.4 Affordance 3: Having continuously insight in the status of the patient

According to the webinar, the biggest difference with Callmanager is that they worked in an agenda which is horizontally visualized, and Topicus HAP uses a work list which is vertically visualized. That results in all information being stored in one page and less clicks needed. Due to this design, all follow-up actions are visualized, like consult by phone, consult at the HAP, a doctor visit. Besides, a short overview of patient data is already visible in the work list. This is illustrated in the screenshots below.

(21)

20

Figure 4.3 Worklist triagist

These work list helps to see where each patient is located in the process. Underneath each blue header an additional work list can be unfolded, where patients are stored. Triagists see the total overview of the HAP location and GP’s can open their personal work list, where they only see patients they have to treat. The triagists plan the consults and doctor visits by using this screen and are able to approach other locations when it becomes too busy and work needs to be spread, which is also stated by TA6: “I can

see much quicker and better how busy it is somewhere” or TA1: “It is clear if a patient has been treated or if someone is in the waiting area”. These quotes are in line with the group-level goals of the triagists

of achieving efficient work and overview, where they give credits to the design of the HAPis. TA8 states: “It is obviously very different. There is more color what I personally like as it is clearer and more

of this time. It is the design I am sensitive to”. The GP’s are less unified regarding how they feel about

the work lists. Some are very positive and think it creates a better overview, while others feel the opposite and lost the overview. For example, HA7 thinks: “It is less click work in my opinion. It all goes

a bit faster and is clearer”, while HA8 thinks: “I find it a big disadvantage that I lost the overview. Before, you had this time path with cubicles [which was much clearer]. The sense of time is gone now”.

So there are mixed feelings about the work list among the GP’s. Both quotes refer to their shared goal of creating overview and saving time, but opinions vary in ways to what extent these goals are achieved. Triagists recognize that GP’s have trouble with the work lists. TA3 states: “people really had to get used

to the work list. [GP’s] are still not used to it. I still hear frequently that it so messy and that they cannot find it. The majority is still nagging about it”. This quote tells that GP’s are still not used to the worklist.

TA8 adds that GP’s simply start working at the top of the list and work downwards, which is more comparable with the old way of working. So while triagists have perceived the shared affordance of having continuously insight in the status of the patients, GP’s are more divided in that, where a large part of the GP’s see it more as a constraint.

Next to these three perceived shared affordances, there are more shared affordances to discuss. Some are only perceived by triagists, some only by GP’s, but key is the same. When triagists perceive affordances, they are generally unified towards it and see similar benefits. When GP’s perceive shared affordances, they are more divided in how they feel about them and to what extent they support them in achieving group-level goals. Some see benefits, while others see constraints. I only discuss the shared

(22)

21 affordances that are perceived by both groups, as it allows me to see how different factors influence the actualization of the same shared affordances.

4.3 Actualizing perceived shared affordances

As discussed in the literature review, affordances are potentials for action and actualizations are actions taken to realize those potentials. So, perceiving shared affordances is only a first step which identifies potentials for collective action. The process of realizing that potential (actualization) generates the value of a technology. In the previous sections it became clear that triagists are more unified in perceiving shared affordances than GP’s are. In this section, I will analyze how perceived shared affordances are actualized by both groups of users. There are different mechanisms through which the users of Topicus HAPis actualize shared affordances. Table 4.1 summarizes all mechanisms and mentions a quote of a group member that reflects how the group used the mechanism. When the group is divided upon their feeling of the actualization process, two quotes are cited. The actualization process per group is discussed next.

Mechanism Triagist General Practitioner

Prio r to t h e im p lem en ta tio n

1. E-Learning TA8: “That was definitely nice to have as

introduction… let’s say, that you get a feeling with it, but also that you have seen it before you actually start working with it. That’s very pleasant. It’s not that after the e-learning that you know everything, but it’s nice that you have a feeling with it”

HA3: “The E-Learning is some kind of basis, that you have already done it. That is nice”

HA6: “I thought it was kind of limited. I passed it but when I had to work with it the first time, I couldn’t work with the system. That was a shame, because you expect something based on the E-Learning, but then it turns out it is harder than expected. I also made mistakes because of that” 2. Training by

key user

TA4: “That was fun, because you already could gain some skills and were able to ask some questions”

X

3. Webinar X Not a significant number of respondents watched

the webinar, so a representative quote can’t be given Po st -im p lem en ta tio n 4. Presence key user first 2 weeks

TA6: “In the beginning, the key users were always extra on the shifts, they knew everything. So you could ask them and they would explain to you”

GP’s didn’t distinguish key users from other triagists

5. Coming in early before first shift to practice

TA5: “We have had a few colleagues who worked extra shifts, so that they could run by the system on their own initiative”

HA4: “I made sure I was on time at my first shift, so I was able to play and practice a bit and see where are the buttons, and what happens”

6. Try and error

TA2: “Often I went out exploring myself. I think that when you are less scared for the system like I am, you will easier check out what happens when you do this or that”

HA1: “I am not someone who is just going to press some buttons and finds out what else is there” HA5: “I go out exploring myself a bit, probably more than the older generation does” 7. Asking

questions to colleagues

TA9: “Of course, the one asks questions sooner than the other. But yeah, I think especially between ourselves we were able to solve it”

HA6: “I ask a lot about my assistants [triagists]” HA7: I just have to know where the buttons are in order to do the things that are standard, for the rest I don’t really care. Then, if I don’t know something I will ask someone. I am not going out on research myself”

(23)

22

8. Experience TA5: “I think you learn the most by

experience. You just have to find things out yourself. And I think the systems is design pretty logical, so then it’s easy to find” TA9: “Right after implementation, I worked a lot, so then it’s easier to get used to the system than when you work only once a week”

HA1: “The triagists know everything. As it is their only job, they work in the system all the time and especially much more than we do”

HA6: “It is mainly about making progress during the consults and the visits”

9. Discussing the system

TA7: we discuss with each other all the time and once in two months we have a team meeting. Then it’s discussed anyway. And anyhow, if we confront an issue, we talk about it with colleagues and ask how they deal with it”

TA8: “Still, many times, a colleague or myself discovers something in the system and then we share that with each other. But then it stays with the group of people that we work with that night”

HA8: “I never really spoke about it with colleagues”

HA6: “I have never seen anyone working in the system, except for my student, but that was in the beginning”

10.

Coordinating Workarounds

TA1: “We just had a team meeting this morning. Someone mentioned she faced this problem that she didn’t knew who wrote what. So we clearly said: ‘put your initials there and then it’s done’”.

HA1: “There is this referral function but that hasn’t worked properly. Then I notice that I easily drop out and feel that it takes too long. Then I will just write it down and it will work out as well. Table 4.1 Mechanisms used for actualizing perceived shared affordances (continued)

4.3.1 Actualization mechanisms of triagist

It already became clear that prior to the implementation of Topicus HAP, triagists faced relative intense training and were more aware of the change than GP’s were. Also after implementation, Topicus HAP gained a lot of attention by triagists. Especially in the first two weeks after implementation this was the case, as key users were present at the shifts. This was experienced as very helpful and satisfying, as questions and obstacles were addressed immediately and that people who worked their first shifts had someone who could explain the system to them. Also, many triagists who felt insecure worked an extra shift, came in early, or did the e-learning again to get used to the system. Due to this thorough preparation of the triagists, they experienced the change as a smooth transition.

What stands out is that users who were more nervous about the change, showed different behavior in the actualization process than users who were not. For example, TA7 who was relative nervous and told that the idea of working in a new system would keep her up at night, asked many questions about system use to colleagues and key users, and stated that she was not able to try things out, as the system was not a test system. Or TA3, who stated that she was afraid to let go of old habits, said that she heavily relied on the help of key users and other colleagues. Confident triagists are more explorative, as illustrated by TA5: “sometimes I just click on things, and then I find things that are pretty convenient”. So anxious triagists seemed to rely more on asking questions and help of colleagues, while confident triagists were more explorative. This means that the initial reaction to the change has an relation with the actualization process of shared affordances. Next to fear, age seems to have a big impact in how easy triagists get