Recipients' Narratives During Strategic
Change
Why different narrated responses influence change outcomes
July, 2020
Daan (D.J.) van der Schot Student Number: S3836142 d.j.van.der.schot@student.rug.nl
Master Thesis
MSc. Business Administration: Change Management Faculty of Economics and Business
University of Groningen Supervisor: dr. J.F.J Vos Co-assessor: dr. O.P. Roemeling
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ABSTRACT
The construction of meanings of individuals is essential to understand the intended and unintended outcomes of strategic change initiatives. Therefore, this research evaluates the role of individual change narratives during strategic change in a healthcare setting. Narratives uncover how individuals make sense of situations thus leading to a better understanding of organizational change. By doing an explorative case study of a strategic purchasing initiative in a regional hospital, different individual narratives were present. This resulted in opposite stability and progressive narratives, which defined the narrated responses and consequently change outcomes of the strategic change initiative. These findings were summarized in the Narrative-Strategic Change Model, which explains how narratives influence strategic change outcomes. As a result, this model adds to previous literature and can be explored in other settings other than healthcare.
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INTRODUCTION
Strategic change takes place when an organization tries to align differences in form, quality, or state with its environment over time (Hutzschenreuter, Kleindienst, & Kreger, 2012). When sudden changes happen in the environment of an organization, change agents aim to take actions to realign the organization with its environment again. (Balogun & Johnson, 2005). Change agents often use reasoning and symbolic materials, such as change narratives, to erase existing meanings of change recipients and try to establish new ones in order to change the organization (Sonenshein, 2010). However, most of the intended change strategies result in unintended outcomes (Balogun & Johnson, 2005). Therefore, scholars suggest that the construction of meanings of change recipients is essential to understand the intended and unintended outcomes of strategic change initiatives (Balogun & Johnson, 2005; Sonenshein 2010; Vaara, Sonenshein, & Boje, 2016). This study contributes to the strategic change literature because it views the intended and unintended change outcomes via change narratives.
Sonenshein (2010) argues that change narratives are a tool that people use to make sense of situations, a tool to influence others’ sensemaking and an outcome to agree upon a
construction of meaning among actors. Therefore, a narrative could be used to create a sense of urgency, because the sensemaking of others is influenced via narratives (Deszca, Ingols, & Cawsey, 2020). The creation of urgency is often described as the first step in the change process, for example in Lewin’s famous three stage change model (Burnes, 2004). Furthermore, capturing change narratives helps improve contextual knowledge on the sensemaking processes and
understanding the differences of meanings between individual change recipients (Gertsen & Søderberg, 2011). Vaara et al., (2016) argue that a narrative approach in organizational change research could help to address issues which other research methods left unresolved, such as unintended outcomes. An explanation for this is that a narrative captures the temporal nature of change, as most plots include nonlinear references to the past, present and future (Elliott, 2005). Therefore, taking a narrative lens in theory development research contributes to the current stream of literature.
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had already been implemented. One feature of narratives is that they help to explain
organizational change (Buchanan & Dawson, 2007), which is the aim of the previous listed retrospective studies. Nevertheless, change narratives could also influence organizational change during the process (Buchanan & Dawson, 2007). As a result, it is unknown how narratives could promote organizational change or undermine its success over time. This means there is a gap in research how narratives give insights about the convergence and divergence of meaning during change implementation (Vaara et al., 2016). This paper aims to fill this gap by capturing narratives and their influence on strategic change implementation.in an empirical setting where change is in the procedure of being implemented
Some scholars suggest that managers in practice are the architects of strategic change initiatives as they fulfill a role as ‘sensemaker’ in organizations and create the dominant change narrative (Gioia & Chittipeddi, 1991). This process called sensegiving supports the idea that managers construct the desired meanings of recipients. Similar findings are present in the research of Dalpiaz & Di Stefano (2018), who state that managers undertake narrative practices in order to construct the desired narrative representation of change. In contrast, the findings of Balogun & Johnson (2005) suggests that intended and unintended outcomes occur in the process of constructing meaning of reality among individuals. This process is called sensemaking, which is a narrative interpretive process where actors attribute meaning to events (Reissner, 2011). Taking both the sensemaking and sensegiving processes into account, it is not clear if change agents are able to use change narratives to influence recipients’ construction of the meaning of reality. Therefore, this paper aims to develop new insights by examining the role of recipients' narratives on strategic change outcomes.
Knowledge on narratives is relevant to the field of change management because meanings of individuals shape both social realities and the reaction actors compose towards the
organization and its environment (Hardy, Palmer, & Philips, 2000). Therefore, understanding of the construction of meanings improves the knowledge about how employee responses change and influence change outcomes (Sonenshein, 2010). In order to gain more understanding about this topic, the following research question is formulated:
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This question was answered by conducting research in a real-time change initiative. This change takes place in a regional hospital’s purchasing line where the intended change is to switch from multiple suppliers towards a single supplier. As a result, the (medical) specialists, who are the change recipients and end users of the purchased products, will have less influence on which products could be purchased. This change initiative is characterized as a step towards strategic purchasing, which is defined as the process of a continuous search for interventions to purchase, who to purchase from and best contract arrangements for purchasing (Sanderson, Lonsdale, & Mannion, 2019). Knowledge about the recipients' change narratives is needed in order to see their view on the intended and unintended change outcomes (Sonenshein, 2010). As differences in institutional logics (for example managerial logic and medical professionalism) could co-exist in a medical setting (Reay & Hinings, 2009), it is likely that different individual narratives are present. Healthcare organizations, in comparison with other industries, are in general conservative in implementing changes regarding supply chain management (Lee, Lee, & Schniederjans, 2011). However, effective supply chain management enhances organizational performance and changes business processes towards more efficiency in this industry. One of the ways effective supply chain management could be fulfilled is via strategic purchasing (Sanderson et al., 2019) Therefore, this study contributes to the literature by giving more insights in the emerging theme of change narratives in a real-time change initiative and their influence on strategic change implementation in a healthcare purchasing setting. Furthermore, this research adds to more knowledge on why change initiatives succeed or fail, which is needed because there is still limited understanding of the causes of failure of change (Burnes, 2017).
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THEORETICAL BACKGROUND
This section provides a theoretical overview of strategic change and change narratives. Furthermore, the concept of strategic purchasing is explored in order to provide more theoretical background on the change initiative of the empirical setting. In the change narrative section, more information is given about sensemaking and sensegiving to explain the dual function of change narratives. Lastly, the relationship between the two concepts is explained followed by the research framework.
Strategic change
Definition of strategic change. Most scholars agree that strategic change is essential for an organization’s survival (Balogun & Johnson, 2005). A way to define ‘strategic change’ is to disconnect the two words. Strategy refers to the fit between an organization and its environment (Zajac, Kraatz, & Bresser, 2000). Secondly, change is defined as the differences in form, quality, or state of an organization over a period (Van de Ven & Poole, 1995). Therefore, strategic change can be defined as the process of aligning the differences in form, quality, or state with an
organization’s environment over time (Hutzschenreuter, et al., 2012). Moreover, strategic change is mainly involved with adapting the organization to critical changes in the environment
(Goodstein, Gautam, & Boeker, 1994). This definition is used throughout this paper when speaking about strategic change.
According to Jansson (2013), literature in the field of strategic change focuses mainly on the role of leadership in strategy making in the past. This traditional view considers strategic actions to be a linear and top-down process (Balogun & Johnson, 2005). However, the context of power from human actions was mostly overlooked (Jansson, 2013). In contrast, a more recent view is that strategic change is an emergent process, in which intended actions can lead to unintended outcomes (Balogun & Johnson, 2005; Sonenshein, 2010). Strategic change aims to alter the construction of meanings of individuals (Sonenshein, 2010). Therefore, it is essential to view strategic change as well through the lens of recipients and not solely through the view of change agents.
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for change is understood. To assess recipients their need for change is important for change agents and often they must strengthen this before executing change initiatives. Although change recipients could understand the need for change, they do not have to be necessarily willing to change (Deszca et al., 2020). Only when recipients their perceived benefits of change are higher than the perceived costs of change, change is likely to occur (Hardy, 1994). Benefits and costs of change could be explained via the perceived dissatisfaction of change recipients with the status quo and perception how likely the change is to be successful (Desca et al., 2020).
Strategic purchasing. An example of a strategic change initiative which takes place often in the healthcare industry is the move towards strategic purchasing for greater efficiency (Lee et al., 2011). Strategic purchasing in healthcare is defined as the process of a continuous search for interventions to purchase, who to purchase from and best contract arrangements for purchasing (Sanderson, et al., 2019). Furthermore, many buying firms in healthcare, for example hospitals, now work with a limited number of suppliers to improve the flow of materials and ideas (Wu, Choi, & Rungtusanatham, 2010). As a result, these buyers can influence suppliers in for example product development or production capacity, because they have a greater stake in the
organization.
Many organizations in different industries, such as healthcare organizations, have internal clients who make a purchasing request at the department in charge (Thorne, 2002). To switch from employee centered purchasing towards organizational purchasing, conflicts of interest and competing power centers among employees are likely to be present (Lonsdale & Watson, 2005). The findings of Lonsdale & Watson (2005) show that three sources of these potential conflicts arise in situations where internal purchasing clients are present. Firstly, bounded rationality is present and results in different perceptions between purchasers and internal clients about what the optimal point of consolidation is. Secondly, there could be a difference in departmental cultures which also result in different perceptions of the optimal point of consolidation. Lastly, principal-agent issues could result in conflicts because gains or losses of these changes could be different for individuals or groups than the organization as a whole. As a result, undertaking a strategic purchasing initiative could lead to power difficulties and influence the strategic change outcome.
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Doing research in the field of change narratives is part of the growing interests of scholars to focus on the role of Organizational Discourse (Grant, Michelson, Oswick, & Wailes, 2005). Discursive analysis systematically studies the role of talking and writing on organizational subjects (Grant, Hardy, Oswick, & Putnam, 2004). This helps in doing research through a postmodern or critical lens (Grant et al., 2005), which is beneficial because it helps to challenge taken-for-granted truths (Gephart Jr, 2004).). Therefore, taking the lens of change narratives in research is useful for addressing how meanings of individuals are different from each other (Sonenshein, 2010). Furthermore, this lens contributes to the understanding of how these differences play a role during strategic change implementation. Narratives form an integral part of an organizations’ culture and identity, as it shapes the everyday beliefs of organizational actors (Reissner, 2011). In general, change narratives help to improve contextual knowledge on the sensemaking processes and understanding of the differences between individuals (Gertsen & Søderberg, 2011). This is relevant for the field of change management, because a better
understanding of differences leads to more knowledge on the intended and unintended outcomes of strategic change initiatives.
Sensemaking. External forces in an organization’s environment are part of the creation of new meanings of change recipients via narratives, as they potentially alter the sensemaking process of individuals (Gioia & Thomas, 1996). Besides external forces, the sensemaking process takes place mainly in the internal environment. One internal influence is the current strategy-in-use (Thomas & McDaniel, 1990). The strategy-in-strategy-in-use shapes the interpretation of key issues for an organization and tightens the interpretive focus of recipients. Another internal influence is the information-processing structure that is present in organizations. Factors such as information interaction among co-workers, frequency of interaction and degree of participation in decision-making affect individuals’ interpretation of events (Thomas & McDaniel, 1990). The strategy-in-use and information-processing structure of an organization are therefore a key factor and both a medium and outcome of the sensemaking process (Gioia & Thomas, 1996). Given this
information, it is clear that sensemaking shapes the strategy and information process structures in an organization. Yet it is unclear how this narrative interpretive process affects the strategic change outcomes in different change settings (Balogun & Johnson, 2005).
Sensegiving. Besides the creation of new meanings, narratives also facilitate
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experiences (Bryant & Wolfram Cox, 2004), and therefore could be used by change agents to influence other organizational actors with storytelling (Sonenshein, 2010). This happens because organizational change challenges the interpretive schemes of individuals and confronts them with unknown or unexpected events (Reissner, 2011). The study of Reissner (2011) shows that
recipients’ change narratives enable change agents and recipients to exchange their thoughts with each other. As a result, organizational actors find meaning in a narrative which helps them to bridge the gap between expectations and experiences and make it possible for change agents to influence the desired narrative interpretation process. Furthermore, this process is influenced by values and norms that exist in the organizational culture and the societal culture an organization operates in.
Dual purpose of narratives. Recipients’ narratives are essential for understanding strategic change outcomes because multiple perspectives are considered to view the same event (Buchanan & Dawson, 2007). Therefore, change agents and recipients could view a change initiative differently. Although every change narrative may be unique for every individual, narratives can be used by change agents to influence recipients' sensemaking process and
therefore the unique narrative of an individual, which is called sensegiving (Gioia & Chittipeddi, 1991; Dalpiaz & Di Stefano, 2018). Not only narratives are used to influence recipients, but also, they help to enable individuals their construction of meaning (Sonenshein 2010). This dual purpose is also concluded from the research of Reissner (2011), who states that narratives are not only powerful sensemaking tools that contribute to an recipients' ability to deal with the
contradiction between experiences and expectations (Bryant & Wolfram Cox, 2004), but also helps to create new meanings. In conclusion, narratives both engage in sensemaking and
sensegiving processes and exist on an individual, group and organizational level. In this research, the definition of the dual function of change narratives is further used to understand the effect narratives fulfills on strategic change outcomes.
Narratives and change outcomes
It is important to note that narratives are temporarily captured, like change events, which means that they can be influenced and appear or disappear over time (Vaara et al., 2016).
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explain their exact influence on the change outcomes. Sonenshein (2010) explains how employees have the power over informal systems in the organization, because they construct meanings to a narrative that in potential could alter the meaning of the change in their response to it. Therefore, sensegiving tactics by change agents influence only to a small extent how change recipients’ narratives, because recipients construct their own meanings. This results in different managerial and employee narratives in strategic change events and influence outcomes
potentially via the three sources of conflict in strategic purchasing situations described by Lonsdale & Watson (2005), because recipient narratives shape and challenge the perception of power relations in organizational change (Sonenshein, 2010). This potential relationship is a key topic of this research and is presented in the research framework in Figure 1.
Besides the potential existence of different narratives in strategic change events, a focus on stories of organizational actors allows a better understanding of their experiences whose views may contest the ‘official’ top of the hierarchy stories, thus leading to a better understanding of organizational change (Reissner, 2011). Therefore, multiple views are present to see the different contexts in which an organization operates. A comparative study where multiple individual narratives on the same event are compared is essential to vary how meanings and contexts are understood. Based on these theoretical insights, the following research framework is presented in Figure 1.
Figure 1. Research Framework
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This research aims to unravel the influence of change narratives on strategic change implementation. Therefore, theory development was used because “theory development is needed when the business phenomenon has not yet been addressed in academic literature” (Van Aken, Berends, & Van der Bij, 2012, p. 5). This developmental approach is suited for changing, confirming, or adding on the current literature (Edmondson & McManus, 2007). Furthermore, a qualitative approach was used in order to capture complexity and rich details of the topic of interest (Yin, 2013). This is especially relevant for research on change narratives because a narrative aims to describe the temporal nature of change, as most plots include nonlinear
references to the past, present and future (Elliott, 2005). This study was performed using a single-site case study, as case studies are appropriate approaches in which new theory can be developed (Eisenhardt, 1989; Van Aken et al., 2012). Lastly, this research used qualitative interviews in order to learn with an open mind and identify the key variables over the length of the study (Edmondson & McManus, 2007).
The context of this research was a strategic change initiative in a hospital's purchasing line. In the selected change initiative, the purchasing of goods was going to be centralized which resulted in a limited number of suppliers and less choice for the end-users which product to use. According to Lonsdale & Watson (2005), shifts in power were likely to take place as a result of this strategic purchasing initiative. Therefore, a theory development approach on narratives was well suited.
Empirical setting
For this study, a regional hospital in the northern part of the Netherlands was selected. During the length of this study, the organization-wide purchasing structure was undergoing a strategic change. The hospital had around 3.000 employees, of which 70 percent was
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purchase once this change was implemented. As a result, different individual narratives were present as potential conflicts arose due to power shifts of internal clients (Lonsdale & Watson, 2005). These internal clients were interviewed with the aim to capture their individual narrative, as they were considered the change recipients and potentially could alter the desired managerial narrative (Sonenshein, 2010). This empirical setting is well suited for this research because the strategic change initiative was not fully implemented yet at the time of data collection and therefore the potential impact of narratives on strategic change outcomes could be captured.
To collect these narratives, a target audience was defined to generalize the results. Robinson (2014) defines a four-point approach for qualitative sampling, which was used to define the target audience for this research. The sample universe consists of every employee who was involved in the purchasing of goods with the aim to use it for their respective departments. Only employees who met this criterion were included and considered as internal clients. Differences in the target audience appeared based on the type of employment contract because individuals could be self-employed or employed by the hospital. Secondly, this research follows a case study design, in which a sample-size is hard to define as it takes a more integrative view (Robinson, 2014). Therefore, a guideline of a small sample size of 12-16 interviews is set to permit individuals a defined identity, instead of having a more anonymous role in the research. Thirdly, participants were selected using stratified sampling. As a result, potential respondents were invited non-randomly based on their type of employment, leading that both groups were present in the target audience. Lastly, participants that fit the inclusiveness requirements were invited via a one-pager sent by email, which can be found in Appendix F However, as
participation is voluntary, this leads to a self-selection bias because volunteers could be more likely to be open or interested in the topic.
Data collection
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possible, but also the follow-up questions the interviewer asks must be specific and show
understanding of the organizational and cultural context. Furthermore, this narrative interviewing features qualitative interviews in which the respondents' experiences of the organizational change event are the main topic of discussion (Reissner, 2011). Research suggests interviewers should prevent asking steering or leading questions during qualitative research, because this could potentially create narratives which do not represent the respondents own narrative and therefore negatively influence the construct validity (van Aken et al., 2012).
I made sure these criteria were met by doing desk-research about the (medical) specialism before every interview in order to understand potential examples that were brought up. An
example of this desk-research is gathering information about the department of interest on the intranet of the organization. Furthermore, internal documents about this change event were reviewed to understand the organizational context of the change event. After every conducted interview, I listened to the recording and evaluated the follow-up questions asked and possible interruptions in order to improve this for the next interview. This resulted in a small amount of changes in the interview protocol.
Due to the Covid-19 outbreak during the period of data collection, interviews were
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All the interviews were conducted in Dutch, because this is the mother tongue of the interviewees and the interviewer and therefore increases freedom and ability for participants to express themselves (Ozfidan, 2017). To make sure the data was treated confidentially, the names of the respondents were removed from the interview transcripts in order to ensure them to be anonymous. Furthermore, the unit of interest of the unit managers is not mentioned as well,
Table 1. Interviewed respondents. Respondent Code Job Type of employment Gend er Date interview conducted Length interview
ICT01 ICT specialist Payroll M 16/4/2020 35:42 ICT02 ICT specialist Payroll V 17/4/2020 34:40 ICT03 ICT team
manager Payroll M 20/4/2020 32:50 MSP01 Geriatrician Payroll V 8/5/2020 38:44 MSP02 Trauma surgeon Self-employed M 12/5/2020 36:01 MSP03 Gynecologist Self-employed V 11/5/2020 45:19
MSP04 Hart surgeon Payroll M 12/5/2020 39:19 MSP05 Dermatologist Self-employed M 12/5/2020 38:05 MSP06 Cardiologist Self-employed M 13/5/2020 35:32
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because they are the only one responsible and would otherwise be recognizable. All the
respondents granted permission for their answers to be used in this research and to be recorded during the interviews.
Data analysis
Firstly, the conducted interviews of each participant were transcribed, where every word in the interview from start to end was written down. This process can be seen as an act of representation (Oliver, Serovich, & Mason, 2005). Secondly, individual narratives were constructed based on these transcripts. These individual narratives contain lots of single cases with extensive data and contribute to the composition of collective constructions of meaning (Langley, 1999; Plowman, Baker, Bek, Klulkarni, Solanski, & Travis, 2007; Sonenshein, 2010) However, most individual narratives only cover a certain part or view of the collective
narrative(s) (Sonenshein, 2010). I used these pieces of individual narratives as input for the composite narratives. The individual narratives can be found in Appendix G. Consequently, unit managers were included in this research, because of their key role in the purchasing process. After the individual narratives were developed, I started the coding process in Atlas.ti. Firstly, deductive codes based on emerging themes found in the literature were used to add a
classification to the data. Examples of deductive codes are ‘bounded rationality’ or ‘information processing structure'. Thereafter, I developed inductive codes to spot emerging topics which were not covered by the deductive codes. The full codebook and data structure can be found in
Appendix A and Appendix B
After all the interviews were transcribed, analyzed and first order coded, general first order categories were formulated. Based on these categories, second order codes were developed in order to gain more insights in the patterns of the data. Ultimately, this resulted in three
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RESULTS
As the strategic change initiative unfolded, the individual narratives showed differences between the incentives to change, perceived change in work processes and the perceived responsibility for purchasing. Therefore, the results of this study are presented via two different composite narratives to illustrate the differences and similarities between the two groups. Both the 'progressive' and 'stability' composite narratives contain respondents who are internal clients. Furthermore, the composite narratives are presented via the aggregated dimensions derived from the data analysis. The data structure with the aggregated dimensions is presented in Appendix B. At the end of this chapter, the results are summarized in the Narrative-Strategic Change model.
Progressive narratives of change
This section presents the composite narrative of the group of respondents who viewed the change event as a significant change and therefore affects their daily work. This group consists of medical specialists and unit managers who see the purchased goods as an important tool for executing their work. Furthermore, this group can be seen as aware of the change and have a strong opinion towards it. Consequently, they are called 'progressive'.
Perceived change in work processes. The involvement in the change process affects how individuals perceive the change in their work processes. The unit managers and doctors believe that they are involved in the change but are not satisfied with their role in this process as
explains: "Sadly I am involved a lot in this purchasing change. However, my opinion is that as a medical specialist, you should work with the best material for your patients. (…) Currently my requests get evaluated by people who have no medical expertise. That frustrates me." (MSP02). This quotation shows that although medical specialists are involved in the change, they do not have the same priorities as the purchasing department, which results in frustration and tiredness. Furthermore, medical specialists, although involved, feel like they have difficulties being heard in this change initiative: "I do not think we have a good structure for consultation. (…) The board of directors gives a lot of assignments to the purchasing department and they are in the middle of it. We give them (purchasing department) feedback, but I sense that they do not hear what we say, because they must carry out those assignments. If we could talk to the board, the strategy makers, you could have more constructive meetings. The board does not get any input from the
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'about them' instead of 'with them''. This leads to the perception where the board decides how the work processes of the medical specialists are affected, in which the medical specialists feel they are not consulted.
Besides the involvement, the stake in material usage turned out to influence the
perception of change in work processes as well. Firstly, the emotional attachment of the doctors in this group towards their products is high. Especially surgeons have the desire to work with the best materials possible: "I wish we could help people without looking at the costs, but that is a fantasy and I hope every doctor could work in this fashion. For example, that we can use band aid that we for sure know it does the job. But at the moment, there is always a cheaper one." (MSP02). This quotation shows how the medical specialists see the change initiative as a decrease in quality. Therefore, the change influences their work processes resulting in not being able to work with the best materials possible. For specialisms such as surgery or cardiology the materials are essential in the care delivery. Therefore, the stake in having great quality materials is high. Consequently, individuals in this group have strong preferences for suppliers, which can result in multiple suppliers for the same product: "We as surgeons want, of course, for our patient the best quality heart valves. Sometimes there are heart valves with different specifications. It also depends on the usability. One surgeon could feel more comfortable with heart valve A and the other surgeon with heart valve B." (MSP04).
In conclusion, the members of the progressive group feel that their work processes are changing, because the materials they work with are being changed. In this process they feel that the board of directors decide what is going to happen without consulting the medical specialists. Furthermore, the medical specialists have high stakes in the materials they use, because they are attached to their products and directly influence the quality of their work. As a result, the change initiative is perceived as significant by the progressive group members and their daily work routine is undergoing changes.
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centralized purchasing department is believed to be needed in general: "In my specialism it (purchasing expenses) is not that costly. But that is different for Orthopedics and Cardiologists. There are a lot of expenses that could be reduced significantly, and that is a topic of discussion right now. Why do we need five different hip prostheses and are we willing to change that? Until now, we have not asked those questions, because we did everything the way we did." (MSP03). This quotation symbolizes the understanding of the need for change by the medical specialists. However, in every interview of the progressive group, the respondents refer to the high expenses of ‘other' departments, which shows a need for change in the hospital in general, but no need for change for their own work practices. Nevertheless, the employees are aware of the need for change for both cost-savings in general and changes in purchasing structure.
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physician, I have more insights in the financial flows and am more involved in creating a better reputation for myself, because this will lead to more patients. Therefore, I look at the stake of the partnership and which products fit our wishes. (…) Therefore, I think that self-employed
physicians have a bigger stake in purchasing" (MSP05). These quotations show the importance of quality for the practitioners and result in a lower willingness to change, because the quality of goods is believed to be cut in order to implement the centralized purchasing structure.
In conclusion, the respondents of the progressive group are aware of the need for change. However, due to their attachment to their used products and the possible dangers for quality they sense because of this change event, they are not willing to change. Quality of products used in care delivery are for this group the main incentive to change. Because the quality is perceived to be decreased due to this change, respondents tend to be not willing to change.
Responsibility for purchasing. Given the current and future purchasing processes, the data shows a big difference in perceptions of who should be responsible for the process of purchasing goods. Firstly, the progressive group states that there is a difference of viewpoints between the medical specialists and purchasing department which result in departmental
differences. A medical specialist explains this difference as follows: "What I want is when I need a product, they (purchasing department) are just going to buy it. I can explain to them that we should use certain products because, for example, it could prevent wound leakage. But you see dollar signs in their eyes they do not know what I am talking about. They only want to know how many times a year I use it and in what quantity”. (MSP04). As a result, the medical specialists view purchasing as a process which serves their needs, while the purchasers are viewed as people who only look at the financial aspect of products. Furthermore, the process of purchasing is unknown to most respondents: "At this moment, I can do what I want and behind the screen and people take that into account. That has some disadvantages. Firstly, I have no idea what my materials cost, I am not conscious at all. So, I think more integration of purchasing will lead to a more cost aware doctor." (MSP03). This quotation symbolizes the departmental differences and bounded rationality between purchasing and medical specialists
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to work with materials that are less good because of decisions made by people who have no expertise in this field" (MSP02). In contrast to the role medical specialists should fulfill, the purchasing department should, according to the progressive group, have a more collaborative role: "They have to reach their targets without knowing anything about the medical qualifications of the product (…) At the moment our role is assisting instead of collaborating. They choose materials based on costs, instead of asking us about the medical qualifications." (MSP06). This shows how the medical specialists think that they should fulfill a role where they are responsible for the medical part of the purchasing process, while they think this role is currently being neglected or fulfilled by the purchasing department. Medical specialists feel like it is difficult to express their concerns about this because of principal-agent issues: "They (the purchasing department) gained responsibility from the board of directors for executing the change, which makes purchasing a serving hatch and you never know what is the topic in their meetings with the board of directors." (MSP06).
Lastly, the responsibility for purchasing is also a topic of discussion for the progressive group of respondents. The medical specialists and unit managers believe that purchasers should be involved in medical units to serve their purchasing wishes, which was the case in the past. A unit manager explains this past role of a purchaser: "There is no routine right now, what I would wish for. Together you should discuss material use and contracts on a regular basis (…) A couple of years ago we had this dedicated purchaser for who did this." (UM03). In this case, the unit and purchaser are jointly responsible for the purchasing process and work together. In contrast, some medical specialists and unit managers believe that purchasing should be the responsibility of the medical specialists, because: "In the ideal world, everyone (medical
specialists) should have a limited budget and deal with that." (MSP02). These quotes show how medical specialists think that they should be responsible for purchasing. As a result, specialists have direct contacts with potential suppliers where the purchasing of new equipment is discussed. In this process, the purchasing department is only involved in the final stages of contract
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value, then the purchasing department is involved." (MSP04). This quotation explains the responsibility that medical specialists take for their own purchasing of goods.
To conclude, the decisions about what to purchase should be the responsibility of the internal clients according to this group. Departmental differences and bounded rationality are present between internal clients and the purchasing department. Ultimately, the respondents of the progressive group favor a purchasing structure where the purchasing department facilitates the wishes of the internal client.
Stability narratives of the change
This section will present the composite narrative of the group of respondents who view the change initiative as insignificant. Members of this group consist of ICT specialists, unit managers and a medical specialist. In contrast with the progressive group, respondents view the change initiative as not radical, not affecting their daily work and business as usual. They do not feel involved in the process of purchasing at all, therefore this group has the label 'stability'.
Perceived change in work processes. The stability group believes they are not involved in the change. A reason for this is the lack of involvement in the purchasing process in general, as an ICT specialist explains: "I am aware and know what activities need to be performed.
Therefore, I take the decisions and say what we have to do, but the further settlement with purchasing is the responsibility of my manager." (ICT02). This quotation symbolizes the low stake of internal clients in the purchasing process and results in a feeling that they shouldn't be involved: "if there were task forces or something similar, I would not want to participate.
Keeping me posted is enough." (ICT03). As a result, respondents not only argue that they are not involved in the change, but also do not want to be involved.
Besides the involvement, the stake in material usage is also different for the stability group compared to the progressive group. Firstly, the respondents of this group use less materials as a medical specialist explains: "I am not a surgeon who is used to working with particular gloves or stitching material. (…) I have my own tools, my reflex hammer, which is my possession. I don't use more than gloves or alcohol." (MSP01). This quotation shows how the medical
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have to make choices in other areas, for example an implant or hip, it is totally different. That is a situation where the specialist himself has a preference for a product (…) If a PC is from HP or Lenovo, nobody cares! However, when you touch the delivery of care, it becomes way more complicated and emotional." (UM02). According to this quotation, stake in material usage is low, because internal clients do not have a strong preference themselves. Therefore, it does not matter for internal clients via which suppliers’ goods are purchased.
In conclusion, the stability group does not have a strong preference for purchased goods. Therefore, the change in purchasing structure is not perceived as significant and does not change their way of working to a big extent. This group is not involved in the change initiative but does not want to be involved either.
Incentives to change. Firstly, the stability group views the new purchasing structure as part of a broader change in which cost-savings are implemented throughout the organization. Therefore, they think the change is legitimate, but would not affect their department. The respondents of this group state that their unit's expenses are limited compared to other
departments, which result in the belief that they are less involved in the purchasing process. An example of this is given by a unit manager: "As a unit we have high costs, but those are mainly medicines which are purchased by the pharmacy. Our costs are also materials, but looking at the total budget of the hospital it is very relative. (…) So a better collaboration is important, but our role is limited." (UM01). This quotation symbolizes not only the acceptance of the change, but also how the change will not affect their department or profession. Also, the change is not seen as significant and could be characterized as business as usual: "In the end, I do think we will still have good communication with purchasing, the short lines of contact. That would not change. So, no, I do not think my work routine will change." (ICT02). Consequently, the stability group believes there is a need for change, but not for their particular departments. Also, the change initiative is not seen as significant, which results that members of this group are accepting towards the change.
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how the stability group views the change initiative as something in line with their current tasks. Furthermore, employees are convinced that certain aspects of the strategic purchasing initiative are already implemented: "I think we have a medicine commission who already looked at why we use certain brands and not different ones. That is what I thought and it is a good idea. In our specialism we make arrangements of what we use from substance 1 and substance 2." (MSP01). According to this quotation multiple initiatives are already being part of the work activities in order to reduce the number of suppliers.
To conclude, the need for change is understood by the stability group, but, like the progressive group, belief that their respective departments do not play a big part in the change initiative. Furthermore, cost savings are already ought to be part of the job. The incentives to change are to commit to the (financial) needs of the hospital. However, the respondents do not think their respective departments can contribute to that to a big extent.
Responsibility for purchasing. Firstly, the stability group did not mention the departmental differences as much or as explicit as the progressive group of respondents. However, this group characterize themselves as being cost-aware: "As a medical specialist you have a social responsibility to save costs and look at efficiency. This is a part of my activities." (MSP01). This quotation shows that being cost-aware, which most respondents of the progressive group think is solely a task of purchasing, is part of the daily work of the stability group. As a result, departmental differences between purchasing and the other departments are not believed to be big.
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following example: "The collaboration between the organizational units and healthcare units is alright. We have done some suggestions for it. One of our medical managers is fulfilling an active role in this. Therefore, I think there are more advantages once you give medical specialists a role in this." (UM01). This example shows how the collaboration has been improved in the past and now is a responsibility of both care units and organizational units.
In conclusion, the perception of responsibility is more clear compared to the progressive group of respondents. Due to the absence of departmental differences, clear division of tasks and improvement in collaboration, the perception of responsibility is clear.
Narratives and change outcomes
Following the previous sections, there is a big difference between the two composite narratives. As a result, the incentives to change differ. The progressive group members have a big stake in their materials and therefore are afraid that the change initiative will result in quality loss. As a result, their incentive for change is based on the quality of products and consequently care delivery. In comparison, the stability group values the (financial) needs of the hospital and are more likely to commit to change initiatives serving these needs.
Another difference between the two groups was the perceived change in work processes. The progressive perceived the change initiative as significant because their main tools to execute their work were to be changed. As internal clients they want to be more involved in this change. The employees in the stability group on the other hand have a low stake in material usage and therefore do not perceive the change as significant. Consequently, they do not have the need to be involved in the change.
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Table 2.
Summary of composite narrative
Progressive group Stability group Perceived change in work
processes
Change initiative changes daily work routine
Insignificant
Involvement Desire to be more consulted in this change
Not involved, but also no need to be involved
Stake in material usage High Low
Incentives to change Quality of care delivery Commit to the needs of the organization
Need for change Aware of the need for change Aware of the need for change Willingness to change Negative, because of emotional
attachment to materials
Neutral, do not perceive the change as significant Responsibility for
purchasing
Purchasing is the responsibility of the internal clients
Purchasing is a collaboration between internal clients and
purchasers
Departmental differences Big departmental differences Small departmental differences Roles in the purchasing
process
Internal clients demand, purchasing facilitates.
Both internal clients and purchasers search for solutions Purchasing structure Purchasing is responsible, but it
should be the internal clients
Both internal clients and purchasers are responsible
Based on these results, The Narrative-Strategic Change Model was developed. Figure 2 describes how a strategic change process is influenced through individual narratives. Overall, the model shows how individual change narratives in strategic change influence the narrated
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Firstly, the organizational wide strategic change initiative influences the individuals' narratives. In this process, change recipients construct their meanings to the event. In the current change initiative, the respondents describe the change as a strategic purchasing initiative where the purchasing is going to be more centralized. This process is moderated by the change context, which is case specific and different for every change initiative. As the previous sections showed, the perceived changes in work practices, stake in material use and involvement influence the incentives to change.
The construction of meanings, moderated by the change context, results in different individual narratives. These narratives were different based on the stake in material use, involvement in the change and consequently perceived changes in work. Firstly, individuals in the progressive group attached a lot of value towards their materials in-use, while members of the stability group value the purchased goods as less important. Furthermore, individuals in both groups felt like they were not involved in the change initiative. However, the progressive group wanted to be involved, which is different compared to members of the stability group. As a result, individuals in the progressive group saw the change as significant, while stability group members saw it as insignificant. These individual narratives resulted in the classification of two different composite narratives.
Consequently, the narrated responses of the two groups differed about the perception of responsibility, desired purchasing structure and perceived departmental differences, as
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DISCUSSION AND CONCLUSION
By evaluating the role of change narratives on strategic change initiatives and seeing how composite narrated responses were influenced via different types of narratives, this research showed how the constructions of meaning of individuals influence strategic change outcomes in a healthcare purchasing setting. This evaluation offers some theoretical and practical implications for the role of strategic change initiatives, which are presented in this final section.
Discussion
Most previous change narrative research described already implemented change events via narratives (I.e. Sonenshein, 2010; Gertsen & Søderberg, 2011; Reissner, 2011; Dalpiaz & Di Stefano, 2018), while this research has shown how narratives influence strategic change as it is carried out. Therefore, the findings of this study are different. Past research described how
strategy-makers can engage to construct desired narrative interpretations of change (Dalpiaz & Di Stefano, 2018; Brown & Thompson, 2013; Sonenshein, 2010). Furthermore, change agents engage in sensegiving activities, such as enhancing significance through refocusing to gain more acceptance (Dalpiaz & Di Stefano, 2018). This is in contrast with the findings of this research because the perceived change in work processes are deeply embedded in the current tasks of change recipients to an extent that sensegiving activities would not change these perceptions. This results in inability to construct such desired narratives to create change acceptance. Conducting research from a retrospective viewpoint may suggest that these change context factors could undergo changes via sensegiving activities, however this was not the case in this study. This could be explained through the high stake some employees attach towards their materials in-use, which plays a central role in care-delivery and therefore is not a negotiable topic for change recipients.
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familiar simultaneously by different actors. This research expands these insights by assessing not only different types of narratives which were simultaneously present during the strategic change implementation, but also the underlying dimensions which caused these different types of narratives. As the perceived changes in work practices, involvement and stake in material use were different for the employees, there was a difference between individuals regarding the change willingness and understanding the need for change. This resulted in two groups of composite narratives, which are the stability and progressive narratives.
Traditionally, internal clients have a great position of power in healthcare organizations (Llewellyn, 1997). While change in other industries often requires narratives that voice a
dominant coalition (Dalpiaz & Di Stefano (2018), hospitals could be considered different because of the power centers at the 'bottom'. This research shows how the power centers of a few
specialisms already is fruit for conflicts and affect the change outcomes. As a result, this study contributes to the strategy literature in healthcare settings and how narratives play a role in the outcomes of change initiatives. In this research, conflicts were present and mainly originated from differences in perception of responsibility for purchasing between internal clients and the purchasing department. Previous research showed how these conflicts are caused by technical drivers, for example scientific evidence of usability of products, inter-departmental collaboration, and politics (Lonsdale & Watson, 2005). In comparison, this research showed how sensemaking processes of strategic change regarding purchasing were also fruitful for conflicts. The
progressive group saw a challenge in the status quo and their individual power because of the change initiative. As a result, they reacted negatively towards the purchasing department which could result in conflicts. A different reaction was seen in the stability group, where no power challenges were present, because of the low stake in material use, and as a result no potential conflicts arose. Furthermore, the content for material change ought to be solely recognizable for the internal clients, resulting in conflicts about jurisdiction. Therefore, this could also be
categorized under the political spectrum Lonsdale & Watson (2005) sketch. As a result, this research shows that inter-departmental collaboration, sensemaking and politics are the main drivers for conflicts in healthcare purchasing. Therefore, this research expands the role of these conflicts and by adding their influence on strategic change outcomes.
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The findings of this research extend the knowledge about recipient narratives during strategic change. Traditionally, change agents were seen as the creators of dominant narratives in change events, and therefore in control of change outcomes (Gioia & Chittipeddi, 1991).
However, more recent studies argue that change recipients play a key role in the intended and unintended outcomes of change initiatives, because they have the power over the informal systems of the organization (Balogun & Johnson, 2005; Sonenshein, 2010; Jansson, 2013). This study confirms the view where change recipients mostly influence the change outcomes by showing how different recipient narratives result in a variety of responses towards the change. Consequently, change outcomes were influenced through these responses and sensegiving activities by change agents were not effective to get acceptance. Therefore, the extent to which change agents are able to create a desired narrative is unclear. The role of change recipients remains to be of importance in understanding strategic change.
Furthermore, this study also found mechanisms which shaped recipient narratives. Previous literature found how multiple types of narratives could co-exist during strategic change (Sonenshein, 2010; Dalpiaz & Di Stefano, 2018). This research confirms and expands these findings by showing the mechanisms that cause different types of narratives. The recipients' sensemaking of change initiatives, moderated by the change context, turned out to influence the individual narratives and therefore the strategic change context. In this study, the perceived changes in work practice, stake in material use and type of involvement appeared to be the drivers of differences in individual narratives, because they differed between the two narrative groups causing different change outcomes. Therefore, this study contributes to the existing literature by showing how the construction of meanings of individuals is moderated by the change context. This offers new insights in the development of how individuals in strategic change make sense of change initiatives and therefore contributes to the understanding of organizational change.
Practical implications
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representation of a change event (Dalpiaz & Di Stefano, 2018), this research shows how some change context factors could not be manipulated and are of big importance in the narrated responses towards the change. Therefore, individual recipients play a key role in the success of change initiatives and managers should take this into account while developing strategic change initiatives. They could do this by evaluating their initiative in the prospective Narrative-Strategic Change Model.
Additionally, this research also challenges the view that coalitions are necessary to create dominant representative narratives in an organization. An example of this is the existence of two different composite narrated responses towards the strategic change initiative. Although change narratives are not a mirror of reality (Gertsen & Søderberg, 2011), they do represent the
individual interpretations of events. This research shows that different composite interpretations of events could co-exist in the same setting, due to differences in the sensemaking processes. Therefore, change practitioners should carefully consider the different narrated responses and take them into account while executing strategic change.
Limitations
As with most exploratory case-studies, this research offers a set of limitations (Yin, 2013). In this research, respondents were only at one point in time. As change narratives and change initiatives could be influenced, appear, and disappear over time (Vaara et al., 2016), having one interview per respondent does not provide these possible changes. At the time of data collection, the change initiative was not considered to be fully implemented, which makes it difficult to evaluate the exact change outcomes. As a result, the link between the composite narrated responses and strategic change outcomes in the Narrative-Strategic Change Model is an assumption based on the possible future reactions narrated by the respondents. Therefore, more explicit coverage based on actual outcomes was needed.
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This makes it difficult to generalize the results, as different purchasing structures were present within one case.
Lastly, due to the outbreak of Covid-19 during the length of this study, data collection in a hospital where daily work practices radically changed appeared to be quite a challenge and
resulted in some difficulties. Unfortunately, it was necessary to conduct the interviews via phone call, resulting in communication errors, failure of recording software, lack of non-verbal
communication and more tightly wrapped questions. Especially in narrative research, the interviewer must be careful to interpret the answers right and ask the appropriate follow-up questions (Gertsen & Søderberg, 2011), which was a real challenge in phone calls. However, these features were aimed to be present as much as possible. This affected the quality of the data and therefore the level of confidence the findings of this research could be stretched out.
Future directions
Derived from the limitations of this research, future studies could use a longitudinal design to evaluate the influence, divergence or appearance of meanings over time during strategic change. Also conducting research with prospective and retrospective elements could offer a broader view on the influence of change narratives on strategic change outcomes. This broader perspective will also contribute to narrative research in change management literature, which is still often neglected and has a high potential (Vaara et al., 2016). Furthermore, new longitudinal studies offer a possibility to test and validate the Narrative-Strategic Change Model in a
healthcare context.
Right now, the findings of this research are specific to the Dutch healthcare system. New studies could explore the applicability of the Narrative-Strategic Change Model in other
healthcare systems, because domestic healthcare systems tend to vary a lot between countries and incentivize different ways of working (Böhm et al., 2013). Furthermore, as strategic change initiatives happen in all sorts of industries and organizations, future research could explore the Narrative-Strategic Change Model in industries other than Healthcare. In these studies, special attention to the role of power needs to be given, because power centers at the bottom in
healthcare organizations (Llewellyn, 1997).
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This study explored the influence of narratives during strategic change. In particular, the individuals' responses towards a strategic purchasing initiative were evaluated during a real-time change implementation in a healthcare setting. Therefore, temporal factors influence individuals' narratives in a strategic change context. Different type op narrated responses were present influencing the change outcomes. Important is the role of power and change context influencing the individual narratives. In conclusion, Recipients' narratives played a key role in strategic change implementation by influencing the composite narrated responses and consequently change outcomes. Therefore, desired representative narratives are not easily created, and agents should focus on the influence of strategic change initiatives on individual narratives.
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APPENDIX A
1st order code categories Definition Example
Explaining the need for internal consensus
Explaining how internal-clients and the purchasing department are in need of change.
“It is the only way, you cannot expect from a
purchaser to have knowledge about healthcare and from a doctor to have business knowledge. They cannot represent that view.” (UM02) Explaining why change is
necesarry
Explaining why the
organization needs to change
“I think that the board of investors is in need of more (financial) space to do things that are necessary to improve the organization.” (ICT01) Finger pointing Stating that other departments
need to change
“In my unit, it (purchasing costs) isn’t that much. But ortopedia and cardiology. There are way more higher costs which could be lowered via purchasing.” (MSP03) Responses to the change temporarily captured
reactions, similar to change events, which means that they can be influenced and appear or disappear over time (Vaara et al., 2016)
“For applications and hardware, we’re already collaborating on the functaional side of a lot of things. (…) I think the change won’t affect that, but only could improve our
communication.” (ICT02) Legitimizing the change Explaining why the change
initiative is appropriate
“The goal is to become financially stable again (..) and that’s a good thing if you look at the financial side” (MSP04)
Personal incentives for change
Personal motivations why change is needed
