Communication and behavior as facilitators of integration: a single case study

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Communication and behavior as facilitators of integration: a single

case study

By

Rick Martijn Haarman S2210231

Master Thesis Msc BA: Change Management Faculty of Economics and Business

University of Groningen

Supervisor: dr. O.P. Roemeling Co-assessor: prof. dr. E.W. Berghout

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2 ABSTRACT

This paper adopts a change perspective and focuses on the roles of communication and behavior, and how these facilitate integration in a professional service environment undergoing a major transition. A

single case study was conducted at a Dutch healthcare organization. Findings of this study indicate that integration can be facilitated by communication through understanding, tactful communication, coordination and the use of an information system for the planning of capacity. Behavior can facilitate integration by setting good examples, the empowerment of employees and flexible protocol adherence. Furthermore, restraining forces with regard to integration are identified. These include busyness and organizational culture. Resistance behavior can foster the negative organizational culture of distrust.

Word count: 12.700 (excluding appendices)

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1. INTRODUCTION

Organizations continuously face new challenges and need to adapt to changing environments. As a result, organizational changes are abundant (Oreg & Berson, 2011). Especially in the healthcare sector, changes rather than stability are considered to be the norm (Lee & Alexander, 1999). However, attempts to implement organizational changes are predominantly unsuccessful (e.g., Beer, 2000; Elrod & Tippett, 2002; Kotter, 1995; Pettigrew, Woodman, & Cameron, 2001), with Candido and Santos (2008) reporting failure rates for organizational change implementation as high as 93 percent. Not surprisingly, failure to successfully implement change initiatives in organizations has long been recognized as widespread, commonplace, and costly (Decker, Durand, Mayfield, McCormack, Skinner & Perdue, 2012).

This paper adopts a change perspective and focuses on the roles of communication and behavior, and how these facilitate integration in a professional service environment undergoing a major transition. Integration refers to the central idea that distinct and interdependent organizational components should constitute a unified whole (Barki & Pinsonneault, 2005), and its importance is not in doubt (Pagell, 2004). In supply chain management, integration has been an effective method in increasing flows (Drupsteen, van der Vaart & van Donk, 2013) and empirical evidence indicates that integrating internal supply chain functions will lead to higher performance (Pagell, 2004). However, most hospital departments still function independently (Lega & DePietro, 2005), and there appears to be a lack of integration between departments (Drupsteen, van der Vaart & van Donk, 2013; Bakker & van der Vaart, n.d.). Even though improving the flow of patients is seen as crucial for increasing hospital productivity and increasing patient satisfaction (Litvak, 2009; Villa, Barbieri, & Lega, 2009).

Within manufacturing firms, Pagell (2004) argues that communication is a key enabler of integration and a lack of communication is a serious inhibitor of integration. Lega and DePietro (2005) also point out the importance of communication in a healthcare setting by stating that hospitals cannot support the negative effects as a result of poor communication between departments and disciplines. Furthermore, Rabøl, Andersen, Østergaard, Bjørn, Lilja and Mogensen (2011) state that existing descriptive studies of hospital staff communication have been labelled as non-exhaustive and recommend to add depth to the studies of communication.

This paper covers the overall concept of communication with several distinct types of communication derived from literature. These types of communication are synchronous and asynchronous communication (Coiera, Jayasuriya, Hardy, Bannan & Thorpe, 2002), as well as formal and informal communication (Pagell, 2004; Coiera et al., 2002).

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Next to communication, gestures, actions and behaviors in general are of importance (Matos Marques Simoes & Esposito, 2014). However, the role of behaviors when striving for integration appears to be underdeveloped in the current literature.

According to change management literature, communication is the most prevalent determinant of a change process (Johansson & Heide, 2008; Miller, Johnson, & Grau, 1994; Nelissen & van Selm, 2008; Rogiest, Segers, & van Witteloostuijn, 2015) and suggests that the uncertainty associated with change processes results in a variety of psychological and behavioral responses that require careful choices with regard to communication (Brahers, 2001). The two most prominent types of behavior in change literature are readiness for change and resistance to change (Bouckenooghe, 2010).

Padovani, Orelli and Young (2014) state that professional organizational members often have deeply entrenched values that are not necessarily consistent with – and often are in direct opposition to – the goals of the organization’s senior management team. A dilemma that is especially evident in the healthcare sector, where a considerable body of evidence suggests that the clinical professional can have an agenda that is in direct contrast to that of the non-clinical managers (Kitchener, 1999; Weick, 1976; Young & Saltman, 1985). Furthermore, Padovani, Orelli and Young (2014) argue that this resistance from clinicians, is an issue of great importance in change efforts in healthcare organizations. In line with this statement, Curtis and White (2002) argue that management literature suggests that resistance often greets change and that managers must be aware of the reasons why people resist change and the strategies for overcoming this resistance. Landaeta, Mun, Rabadi and Levin (2008) claim that the results of their investigation suggest that there are sources of resistance to change that are specific only to the healthcare sector. The aim of this paper is to identify whether the medical personnel in this particular case will either resist or show readiness for more integration between departments and how this display can facilitate interdepartmental integration.

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Literature, as shown above, has provided some insights by suggesting that communication and behavior play a vital role in the process of integration. This paper will thus focus on identifying pitfalls of the current process and barriers to change by analyzing communication and behavior of the involved organizational members among different departments. The research question for this paper is build up from the gaps previously mentioned in this introduction. Moreover, this research question is driven by a real life business problem in a healthcare organization in the northern parts of the Netherlands. This results in the following research question:

“How can communication and behavior of employees facilitate interdepartmental integration in a healthcare context?”

2. LITERATURE REVIEW

This section provides a literature review of the concepts of interest for this research. The theoretical framework in this section will first focus on the concept of integration, followed by the role of communication and the role of behavior. Lastly, a summary of the relevant literature for this paper will be provided.

2.1 Integration

Throughout Throughout literature, integration is a concept that is used extensively, but no generally accepted definitions have been provided (Mendes Primo, 2010; Pagell, 2004). However, the central idea of integration is that distinct and interdependent organizational components should constitute a unified whole (Barki & Pinsonneault, 2005). In general, integration has been studied at two levels of analysis. The first level of analysis is external integration which focuses on integration between different organizations. Whereas the other level of analysis, internal integration, focuses on integration across various parts of a single organization (Pagell, 2004). Integration is thoroughly rooted in both organization theory (Lawrence & Lorsch, 1969), operations management (Hayes & Wheelwright, 1984) and is also considered as an important concept in supply chain management (Flynn, Huo, & Zhao, 2010). However, little is known about the roles of communication and behavior with regard to integration in a professional service environment.

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Even though Drupsteen, van der Vaart and van Donk (2013) state that limited integration results in sub-optimal performance, Evans, Baker, Berta and Barnsley (2013) argue that initial integration efforts primarily emphasized changes to organizational structures (i.e., mergers, acquisitions, and alliances) with few corresponding modifications to care processes and administrative operations. Furthermore, they state that it is widely believed that the greater alignment and synergy achieved through integration enhances quality of care, efficiency, and patient satisfaction. However, other authors have provided contradicting evidence by arguing that while the intuitive potential value of integrating care remains, integration may not be necessary or beneficial in all circumstances and contexts, and may not be desired by some patient groups (Ahgren & Axelsson, 2005; Burns & Pauly, 2002).

2.2 Communication

Overall, agreement is widespread that the practice and delivery of healthcare fundamentally and critically depends on effective and efficient communication (Agarwal, Sands, Schneider & Smaltz, 2010). Furthermore, Agarwal et al. (2010) argue that care delivery is a complex enterprise that involves multiple interactions among multiple stakeholders. Miguel, Ana, and Victor (2003) acknowledge this complexity and state that hospital communication typically involves different locations, work hours, and communication paths. Moreover, studies have shown that there is strong evidence that care providers such as doctors and nurses spend a significant amount of their time communicating (Hendrich, Chow, Skierczynski & Lu, 2008; Soto, Chu, Goldman, Rampil & Ruskin, 2006).

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Studies have suggested that departmental integration in healthcare organizations is lacking (Drupsteen, van der Vaart & van Donk, 2013) and that communication could be an important factor for the facilitation of integration (Pagell, 2004).

Several forms of communication have been identified that could potentially influence integration. The first distinction that can be made is between synchronous and asynchronous communication (Coiera, Jayasuriya, Hardy, Bannan & Thorpe, 2002). Synchronous communication occurs when two parties exchange messages across a communication channel at the same time, whereas asynchronous communication entails a communication exchange that does not require both parties to be active in the conversation at the same time and the recipient can deal with communication at a time of his or her choosing (Coiera et al., 2002). Agarwal et al. (2010) argue that all healthcare professionals need to be able to communicate information about the status of a patient either asynchronously or synchronously. It can be argued that both types of communication have potential benefits with regard to integration improvement. Synchronous communication could facilitate integration because an immediate response is required and the sender of the message knows that the information has been processed. However, synchronous communication can cause an interruption for the receiver of the message and when communication is not urgent, communication in an asynchronous fashion may be the the preferred way of communicating with busy individuals because it is not inherently interruptive (Coiera, 2006). Moreover, Chisholm, Collison, Nelson and Cordell (2000) state that these interruptions have been implicated as a cause of error in both medical and nonmedical workplaces.

The second forms of communication have been provided by Pagell (2004) who argues that integration can be enhanced by both formal and informal communication. According to Pagell (2004) his data and the literature show that there is evidence that informal communication is preferable to formal communication with regard to integration. However, informal communication is sometimes difficult to achieve and therefore, formal communication is also necessary in order to enhance integration. Anderson and Narus (1984) provide a definition for the concept of formal communication by stating that formal communication is the exchange of messages via communication channels that are recognized officially by the organization. Instruction and information are passed downward and upward along these channels. The definition of informal communication that this paper will adopt is provided by Kraut, Fish, Root and Chalfonte (1990, p. 5), who argue that “informal communication is that which remains when rules and hierarchies, as ways of coordinating activities, are eliminated and is spontaneous, interactive and rich.”

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Next to communication, it has been argued by Matos Marques Simoes and Esposito (2014) that communication generally includes behaviors. In line with this statement, the next paragraph will discuss literature about behavior.

Table 1 Type of

communication

Definition Examples

Synchronous Two parties exchange messages across a communication channel at the same time. (Coiera et al., 2002).

Telephone conversation, Skype. Asynchronous Communication exchange does not require both parties to

be active in the conversation at the same time. Thus, the recipient can deal with communication at a time of his or her choosing. (Coiera et al., 2002).

Email, Whatsapp

Formal Formal communication is the exchange of messages via communication channels that are recognized officially by the organization. Instruction and information are passed downward and upward along these channels. (Anderson & Narus, 1984).

Business meeting, Presentations

Informal Informal communication is that which remains when rules and hierarchies, as ways of coordinating activities, are eliminated and is spontaneous, interactive and rich (Kraut, Fish, Root & Chalfonte, 1990).

Casual conversations within the organization

2.3 Behavior (readiness and resistance)

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Resistance to change is probably the best-known attitude toward change. However, literature provides a large amount of different definitions, without one clear definition that stands out (Bouckenooghe, 2010).

Management literature suggests that resistance often greets change and that managers must be aware of the reasons why people resist change and the strategies for overcoming this resistance (Curtis & White, 2002). Some authors view resistance as any set of intentions and actions that slows down or hinders the implementation of change (Pardo del Val & Fuentes, 2003). Others view resistance as part of a process that fosters learning among organizational participants (Msweli-Mbanga & Potwana, 2006).

Most articles reviewed by Bouckenooghe (2010) mention resistance as the intentional/behavioral component as a driving force behind maintaining the status quo, and hindering successful implementation of change. This definition will also be adopted for this study. However, Ford, Ford and D’Amelio (2008) argue that change recipients’ reactions to change are not necessarily dysfunctional obstacles or liabilities to successful change. On the contrary, recipient reactions can have value for the existence, engagement, and strength of a change, serving as an asset and a resource in its implementation and successful accomplishment (Knowles & Linn, 2004).

Piderit (2000) adds that resistance to change can be viewed as a multidimensional attitude towards change, which consists of affective, cognitive, and behavioral components. These three components are depending on each other but are not necessary in line, since some sources of resistance have a stronger impact on recipients’ feelings, while others have stronger impact on recipients’ thoughts or behaviors (Oreg, 2006).

Landaeta et al. (2008) claim that that there are sources of resistance to change that are specific only to the healthcare sector. Curtis and White (2002) provide eight reasons for individual resistance among nurses in particular. They argue that resistance to change of nurses has to do with: Increased stress, self-interest, denial, personality, lack of understanding, trust and ownership, different assessments or perceptions, motivation and uncertainty.

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Klein (1996) argues that, many change models provide suggestions for developing an effective communication strategy as a means of avoiding resistance.

Next to the resistance avoidance, communication can also aid by increasing readiness for change (Wackerbarth, McGladrey & Fanucchi, 2015). According to Bouckenooghe (2010) the most adopted definition of readiness is the definition of Armenakis, Harris and Mossholder (1993, p. 681): “Readiness is defined as ‘an organizational members’ beliefs, attitudes and intentions regarding the extent to which changes are needed and the organization’s capacity to successfully make those changes.” However, this paper will use a different definition provided by Holt, Armenakis, Field and Harris (2007, p. 235): “Individual readiness for change reflects the extent to which an individual or individuals are cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo.” Vakola (2013) adds that readiness to change has a strong impact on many decisions in a change process such as planning, implementation, communication and institutionalization.

Table 2 provides an overview of the definitions of both behavior types and shows examples of these behaviors.

Table 2 Type of Behavior

Definition Examples

Resistance “The intentional/behavioral component as a driving force behind maintaining the status quo, and hindering successful implementation of change.” (Bouckenooghe, 2010)

Complaining about change.

Readiness “Individual readiness for change reflects the extent to which an individual or individuals are cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo.” (Holt et al., 2007)

Persuasive

communication with regard to the change, active participation

Since the role of behaviors, such as resistance to change and readiness for change, when striving for integration appear to be underdeveloped in the current literature, this paper will identify whether the medical personnel in this particular case will either resist or show readiness for more integration between departments and how this display can facilitate interdepartmental integration.

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Moreover, literature suggests that behavior can be part of overall communication (Matos Marques Simoes & Esposito, 2014). However, it has also been argued that communication can help with creating readiness for change (Wackerbarth, McGladrey & Fanucchi, 2015) and offer a solution in changing (unwanted) behavior of organizational members (Giangreco & Peccei, 2005). Curtis and White (2002) add that change often evokes resistance with regard to nurses and that managers must be aware of the reasons why people resist change and create strategies for overcoming this resistance. Studies have shown that in general, organizational members’ values do not have to consistent with and can even be in opposition to the goals of the organization (Padovani, Orelli & Young, 2014). But especially in healthcare is the discrepancy between the agenda of clinical professionals and non-clinical managers evident (Kitchener, 1999; Weick, 1976; Young & Saltman, 1985). This behavior of clinicians, is an issue of great importance in change efforts in healthcare organizations according to Padovani, Orelli and Young (2014) and thus a potential factor in relation to improving integration. Therefore, this paper will study both communication and behavior with regard to the facilitation of integration.

3. METHODOLOGY

The methodology section will first describe the research method. Next, the case overview and selection will be elaborated. Thirdly, the data collection procedure will be explained. This paragraph will be finalized by the data analyses process.

3.1 Research method

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A single case study was used as research method for this research paper. The choice for using a single case study stems from the fact that healthcare organizations are recognized as complex organizations (Drupsteen, van der Vaart & van Donk, 2013) and in order to gain an in depth understanding in a real live unique setting, a case study is a desirable research method (Eisenhardt, 1989). Moreover, one particular case was selected due to its unique character. The case focuses on an organization that is a result of a merger. As a consequence, hospital staff members have been forced to switch between departments and locations and were prone to many changes in the recent years. On top of that, The organization in question is in the middle of a major relocation process. Stake (2000) asserts that single case studies allow a more precise in depth understanding of the circumstances in which the phenomena occurred and therefore tend to make them more reliable than multiple case studies. Van Aken, Berends and van der Bij (2012) argue that case studies will lead to the development of theories.

3.2 Case overview and selection

The organization where the case study was conducted is a hospital in the province of Groningen in the Netherlands. This Dutch organization was a result of a merger between two previous existing hospitals, where medical care was provided to the residents of the eastern and northern parts of Groningen in the Netherlands. Moreover, the organization had two locations from where medical care was provided. As a consequence of the merger, hospital staff has been subject to many changes in the recent years and many staff members switched between departments or jobs. Furthermore, the organization was in the process of a major relocation at the time of this study.

Within this big change context, the emergency department (ED) and their integration with various other departments of the hospital was the focal point of this case study. The analysis of documents recovered from the organization revealed an overview of patient flows. Based on this information, the researcher identified and selected the departments with the highest patient flows from the emergency department, because logically these departments have to work together more and will therefore benefit more from a potential increase in integration and collaboration. In total, two clinical departments were selected as well as a department that functions between the aforementioned departments in the patient flow process (see figure 1).

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14 Figure 1: overview of selected departments

3.3 Data collection

Eisenhardt (1989) states that a qualitative approach should make use of flexible data collection methods in order to grasp features in unique cases. In all their variety, interviews are a valuable qualitative method (Westbrook, 1994). Weber (1990) characterized interviewing as a research method that uses a set of procedures to make valid inferences from text and the flexibility of the interviewing technique allows the investigator to probe, to clarify, and to create new questions based on what has already been heard. This technique has also been used for this research paper, where semi-structured interviews have been conducted (see Appendix I). The questions in the interviews were created by the researcher focused at the specific aim of this study. To increase validity, concepts and definitions were derived from literature. The organization provided the researcher with a contact person who could help identify possible respondents in the organization and plan the interviews with the respondents for this study. The contact person from the organization provided the researcher with a list of possible respondents for the interviews. However, in order to create a good (valid/reliable) sample, the investigator had the opportunity to select the desired respondents for this research.

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In total, 13 respondents were interviewed individually at one of the two locations of the organization. The interviews took place in a room of their choice, with the aim of making them feel at ease so they would talk freely. The sample consisted of 10 women and 3 men. The spread among departments was shown in table 3 and the differentiation of functions was depicted in table 4. Moreover, the descriptive statistics were presented in table 5. These descriptives give a general view about the sample used in this study. Table 3 Table 4 Department N Function N Emergency 2 Head of department 3 Emergency/ A* 2 Head nurse 2

A 3 Emergency nurse 2 B 3 Nurse 3 C 3 Physician assistant 1 Total 13 Physician 1 *some respondents work for both departments Team leader 1 Total 13

Table 5 –Descriptives (in years)

Minimum Average Maximum

Age 29 45 57

Work experience in current function

1,5 13 30

Total relevant work experience

1,5 22 40

Employment at the organization

0,375 18 40

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In order to make the participant feel comfortable, the interviewer assured that the input from the respondents was confidential and would only provide data for this particular research. Furthermore, all data used in this study were anonymized to ensure ethical integrity. Moreover, participants were asked to sign a form of informed consent. No participants objected to recording the interviews and the duration of the interviews varied between 24 and 53 minutes. Moreover, the interviewer made use of direct and indirect probing techniques such as neutral verbal expressions and mirroring techniques (Mack et al., 2005). According to Louise Bariball and While (1994) probing can be an invaluable tool for ensuring reliability of the data, because it allowed for the clarification of interesting and relevant issues raised by the respondents (Hutchinson & Skodal-Wilson 1992), it provided opportunities to explore sensitive issues (Nay-Brock 1984; Treece & Treece 1986), it can elicit valuable and complete information (Gordon 1975; Austin 1981; Bailey 1987), it enabled the interviewer to explore and clarify inconsistencies within respondents’ accounts and could help respondents recall information for questions involving memory (Smith 1992).

Each interview started off with a personal introduction, followed by an explanation of the procedure. Next, the researcher asked the respondents to sign a consent form and asked if they would first answer some questions to be able to make descriptives (see table 5). A pilot interview has taken place to make sure that the interview protocol was accurate. The questions in this protocol were of an open ended nature (see Appendix I). The interview protocol was slightly altered as result of the pilot interview. Next to the interviews, the researcher also used documents provided by the organization and wrote memos during the interviews. The use of multiple sources of data is referred to as data triangulation which makes any finding or conclusion in this case study likely to be much more convincing and accurate (Dubé & Paré, 2003).

3.4 Data analysis

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This study made use of both deductive (top-down) and inductive (bottom-up) coding approaches. Deductive codes were borrowed from literature (see table 1 and 2). The inductive codes on the other hand, were derived from the data of the transcribed interviews. The inductive coding process allowed new important concepts to emerge from the transcribed interview data, next to the concepts deemed important according to the literature review. During the data analysis process a second researcher was asked to analyze some interview transcripts. This triangulation of researchers was used in order to increase the validity of this study as argued by Flick (2009). Furthermore, Flick (2009) also argues that when different researchers are employed, biases resulting from the researcher as a person can be detected and minimized.

4. RESULTS

In this section, the results of this study will be presented. The consecutive focus is on the concepts of integration, restraining forces, communication and behavior and discuss our main findings. Lastly, a summary of the findings is provided and a framework is presented.

4.1 Integration

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18 4.2 Restraining forces

The main reason for problems in relation to the integration of departments stem from ‘busyness’ in one or more departments.

Throughout this study, busyness refers to an increased workload for organizational members because the number of patients demanding care is close to, or higher than the amount of care employees can supply at that time. This restraining force is illustrated by a department head who says: “But there are problems when things do not go as smoothly and that has to do with busyness.” [ICBR100]. A similar point is made by another respondent stating: “You notice that things derail more when both departments are very busy.” [ICBR101]. The results reveal that all respondents recognize that busyness is a restraining force for integration and mentioned responses similar to these previous comments.

Another restraining force for integration between departments is a lack of trust due to experiences from the past. One example is depicted by a nurse who describes: “You notice that because there have been many changes, people from other departments are sick of changing.” [ICBR124]. Other respondents have mentioned examples of behavior that lead up to difficulties integrating departments. A head nurse illustrates such an example: “In the past, not only at our department, there have been colleagues who claimed that it was very busy and needed help even though that was not the case. That makes people doubt.” [ICBR120]. A head nurse reports a similar story: “There have been disappointments back and forth. Let call it that way. Because of that, people are prejudiced.” [ICBR101]. These experiences have created a negative culture for the implementation of integration. The presence of this culture is expressed by a nurse’s response: “…It is more of a problem regarding culture, I think.” [ICBR122]. Moreover, a department head argues that this culture has a negative effect: “I think that the whole organization has to make a switch in culture.” [ICBR102].

Lastly, the results show that the existence of department A, which is a fairly new department, has a positive effect on the degree of integration between departments. An employee of the nursing department states: “The presence of department A is just very pleasant for our department.” [ICBR110]. Employees from the emergency department report a similar effect: “I do think that things run more smoothly and that throughput towards department A is quicker than towards nursing departments.” [ICBR121].

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This section describes the findings with regard to communication. First, it discusses which forms of communication have been found. Second, the results concerning the planning department and capacity planning are depicted.

The planning department is included because most of the communication between departments is about the transfer of patients and the planning department has an impact on this communication. Followed by tact and understanding and coordination results.

The results regarding communication show that most communication of organizational members is done in a synchronous fashion. This is illustrated by multiple respondents, for example, a nurse from a nursing department states: “Most communication is by telephone.” [ICBR102], another nurse from department A reports: “It is often by phone, so we call.” [ICBR124], a team manager argues: “Beforehand I try to reach everyone verbally.” [ICBR150] and a head nurse: “By phone, I call people.” [ICBR111]. However, examples of asynchronous communication are also present even though they are much less frequent in the data. A head nurse mentioned: “A lot of communication is done by email.” [ICBR110]. Although most employees claim that synchronous communication is dominant, they also argued that changes in communication could facilitate integration. These possible changes are discussed in the following paragraphs. The first changes that facilitate integration relate to the role of the planning department.

During the day a planning department acts as a mediator and coordinator between the emergency department and the other departments for the allocation of patients and beds. Some respondents state that the planning department has a positive role in the process towards integration because their mediating role enables them to communicate tactfully. This is illustrated by the head of a nursing department: “Look, when the planning bureau works between departments, they know what we need and can also keep peace.” [ICBR101]. However, according to other respondents the planning department hinders patient flow and integration. An emergency nurse argued: “I think that is an obstacle in this organization, because that means a lot of calls back and forth while one call could have sufficed. Then I have had four in-, or outbound calls, while I could have arranged things much faster with a head nurse of that particular department.” [ICBR123]. Furthermore, the respondent claims that a decrease in communication will be helpful as it is faster and less interruptive: “And you are constantly interrupted during your work.” [ICBR123].

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The use of synchronous communication is useful in this case because of the quick response time. However, the way of synchronous communication is in doubt. The reason for communicating by telephone is obvious, but it could prove beneficent to have the people responsible for the capacity planning and allocation of patients and beds on location, so face to face communication is possible. One of the respondents stated: “I have noticed that when it is very difficult, or tedious and you have to take the role of the planning bureau which occasionally happens in time of crisis, you can just walk back and forth to talk to people and then there is always a good solution to be found. While that is harder to achieve by telephone. So what I would like to see is that there is someone during the day at this location with the job to coordinate everything.” [ICBR100].

Moreover, a department head reported that moving around the work floor makes it easier to accurately determine the amount of beds available: “I walk around in the hospital sometimes because I want to know what the real capacity is. That is another thing, sometimes we really do not know that.” [ICBR102]. Therefore, having people on the work floor, with the ability to move from one department to another and engage in face to face communication while determining the available capacity is desirable. This way, capacity planning and coordination can be optimized and better solutions can be found according to the respondent. There is less room for mistakes (not reporting the availability of a bed) and miscommunication when planning is done by employees who are on the location where the allocation and planning actually takes place. Ultimately, this can result in a decrease in patient throughput times, a shorter length of stay for patients and better overall quality of care.

Another way of reducing the amount of communication is by the use of an information system. A department head stated: “We very much try to steer towards putting information clearly in our computer system. Because we have a wonderful patient system, that we do not use optimally. We, as department B, are busy to put that in our system, so when a patient is discharged the emergency department can see that as well.” [ICBR101]. This means it can prove useful to increase the use of asynchronous communication at the expense of synchronous communication in specific areas. A switch between synchronous communication and asynchronous communication can especially be beneficial in the aforementioned communication about capacity between departments.

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The analysis shows that such an information system is present in the organization. However, the organization is not using the system to its full potential because employees are not consistently registering changes in capacity. This is illustrated by a nurse who reported: “Xcare is our program wherein people can faultlessly see how many beds there are. But if people do not register the admissions and discharges then it is of no use. That is something we have run into for several years.” [ICBR123]. This person also mentioned possible implications for the planning department when the information system is used to its potential by stating: “No, the changes in capacity are not updated well. If everybody would do that correctly, the whole planning department would not be necessary because we would know exactly where beds are available.” [ICBR123]. The information system can thus be used to communicate knowledge about capacity in a more efficient way. As a consequence, the number of (unnecessary) interruptions caused by a reduction in redundant synchronous communication decreases as well as the time needed to communicate. These factors will contribute to the efficiency of the communication in general, which results in time savings that can be used to treat patients. Thus the information system could pose an opportunity for increasing integration and the quality of care (see figure 2).

Figure 2

Figure 2 illustrates that the presence of an information system can reduce the amount of redundant (synchronous) communication, which causes a decrease in the amount of interruptions for hospital personnel, who can then use this increase in time to provide care for their patients. Consequently, the length of stay of patients may decline resulting in a decreased patient throughput time.

4.3.1 Tact and understanding

When studying the interview data about communication, it becomes evident that a new concept arises that has an influence on integration. Instead of looking at types of communication, this concept, labelled ‘tact’ is not a type of communication, but rather how messages are framed by people with regard to linguistic usage and intonation. The importance of tactful communication is highlighted by one of the nurses who claims: “The only thing I can think of is that the tone determines the music. That is most important of all. So friendliness is number one of course.” [ICBR123].

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This is illustrated by a respondent of department A reporting: “The communication becomes more curtly and sometimes there is no communication at all.” [ICBR150]. Moreover, the use of untactful is likely to evoke resistance as portrayed by a nurse reporting: “Well, it evokes resistance. If you call a lot, like I have a patient and he needs to be picked up now, the department will immediately start resisting.” and “I am very aware that giving curt answers usually fosters resistance.” [ICBR121].

When this happens, departments show resistance by keeping their foot down and are less motivated to put in extra effort to receive patients from the emergency department in times of increased work pressure.

The results indicate that synchronous communication, and face-to-face communication in particular, can augment the use of tactful communication, a head of department states: “...but I am very aware of the way I ask things of departments. I also know that it can occasionally help just to walk downstairs and talk face-to-face.’’ [ICBR101] and a nurse reports: “Yes and to be able to see each other as well. So not all communication is by phone. Just walk to the department and discuss things. Then you can be more responsive to emotion. By explaining and looking we will find a good solution.” [ICBR124]. This indicates that face to face communication is preferable over other forms of synchronous communication because it assists in being responsive to emotion, which increased the tact of communication.

Although organizations in the healthcare sector rely on protocols and regulations for ensuring the quality of patient care, it is striking that the results indicate that tactful communication is still an issue with regard to integration. Despite the fact that untactful communication mostly occurs in times of increased work pressure, it is still a fundamental requirement for integration that is lacking and therefore should receive attention.

Tactful communication is likely induced by another concept found in the data, namely understanding. Understanding refers to a person's state in which he or she comprehends the position, situation and/or way of working of other individuals that are not part of the same department. The importance of this concept is highlighted by the following quote from a respondent: “Understanding what happens at other departments is most important of all in my opinion.” [ICBR150]. Furthermore, a nurse described that understanding is lacking: “...but I do not know if we, as nursing department, are always aware of what happens over there and the other way around. The emergency department does not always know what is going on at the nursing department and vice versa.” [ICBR110].

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Therefore, an increased understanding could indirectly have a positive influence on integration of departments, because it increases tactful communication and this communication in turn affects integration. A head nurse expressed this positive influence by saying: “And what works beneficial? Well, being able to comprehend each other.” [ICBR111].

More understanding is likely to increase the use of tactful communication between employees because their knowledge of the processes of others makes them empathize.

Since a nurse mentioned: “I think you can get more insight in each other’s jobs and when you know who someone else is and how they do their job you will create understanding. Communication will improve if you know each other better.” [ICBR122]. Furthermore, by becoming more tactful, employees will find overall communication easier and/or more pleasurable which in turn, facilitates integration (see figure 3).

Figure 3

Next, the question arises; how can understanding be fostered? The analysis points out that understanding among employees can be increased in this setting by letting employees voluntarily work or help at other departments in the patient flow chain for a day. A nurse from one of the nursing departments stated: “Having an open mind about each other I think. And I think that you should walk along with another department to find out how things really work in practice.” [ICBR120]. Furthermore, a different nurse argued that meetings with members of other departments proved useful: “We have had meetings with department A to discuss bottlenecks. That turned out to be very helpful, also because it gave insight in how things work for others, why those things matter to them. It was a very enlightening conversation and afterwards you notice that things are going better, that the collaboration runs more smoothly.” [ICBR121]. Another respondent adds that an increase in the number of conversations between organizational members can also aid in creating understanding by stating: “In any case, having conversations with each other and then you see that there is more understanding for each other.” [ICBR150].

4.3.2 Coordination

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[ICBR110]. Currently all clinical departments have assigned a head nurse to coordinate employees and patient transfers for their particular department. However, the emergency department employs another system where emergency nurses use job rotation and as a result, the assignment of a head nurse differs from day to day. Although the concept of job rotation has many benefits, such as reduced boredom and monotony and reduced absenteeism for example (Triggs & King, 2000), in this case the benefits of having a fixed head nurse could outweigh the gains from job rotation in respect to integration. The first potential benefit of a fixed head nurse is that it limits the amount of emergency department personnel communicating with the nursing departments. A head nurse reported on this issue by saying: “At the emergency department it works like this, then this person calls and then another. That is obstructive. Because if one person just called and another calls next for the same patient, that is not really conducive.” [ICBR111]. In line with this opinion a department head states: “They work with three people at the emergency room and they alternately think; I will call that department. Good intentions, but it disturbs a lot.” [ICBR101]. Not only can this decrease in the amount of people leave less room for redundancy and disturbance, but it can also encourage the use of tactful communication. The importance of having a fixed head nurse at the emergency department is depicted by a head nurse, who claims: “Because of that, all communication is done with one person and that person gives feedback to the team. That is especially useful in late shifts.” [ICBR110]. This reduction of redundancy can also save time which can then be used to treat patients and reduce their length of stay which is illustrated by a quote from a respondent from the nursing department: “If they keep calling because they need beds, that means that I have to pick up the phone every time. Then I do not have time for my other responsibilities.” [ICBR122].

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25 4.4 Behavior

This section shows the results with regard to behavior as a facilitator of integration. 4.4.1 Resistance and readiness

Respondents showed signs of both resistance and readiness behavior. During the interviews, they voiced that there have been acts of resistance in the past: “In the past, not only at our department, there have been colleagues who claimed that it was very busy and needed help even though that was not the case. That makes people doubt.” [ICBR120]. A nurse adds that many changes over the years have made it difficult for people to change resulting in resistance: “You notice that because there have been many changes, people from other departments are sick of changing.” [ICBR124].

Furthermore, some of these resistance behaviors have not fully disappeared according to some respondents: “When a department says; ‘we do not have places available’, even though they actually have. That they are trying to create a time out for themselves.’’ [ICBR101]. In line with this a nurse argues: “The emergency department calls sometimes claiming to have too little beds available and that they have to get rid of a patient. Then we go over there and 4 beds are empty. Then we do not see the urgency, so we feel cheated.” [ICBR122]. These results indicate that nurses act to fulfill their own interests. Especially the latter quote reveals that this behavior is detrimental for the degree of trust. Another cause is the amount of communication, portrayed by a nurse who mentions: “If you call a lot, like: ‘I have a patient and he needs to be picked up’, then the department will immediately resist.” [ICBR121]. The lack of trust and the redundant amount of communication negatively influences integration.

On the other hand, a respondent expressed a sense of collective readiness: “No, no, that readiness is present.” [ICBR120]. The most evident display of readiness behavior is described by a head nurse arguing: “Look, it is important that leaders set a good example, that doctors set a good example and that leaders with a higher position than department heads set a good example. Everybody can show each other how to have a normal conversation.” [ICBR102]. This result shows that readiness behavior can have a positive effect on tactful communication, which can facilitate integration.

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In conclusion, the presence of both resistance and readiness behavior was found. Moreover, resistance does have negative implications for trust between workers from different departments that in turn has a negative impact on integration.

4.4.2 Flexible protocol adherence

The organization has rules and regulations that employees follow in their line of work. These rules and regulations are necessary for ensuring good care. A head nurse stated: “But if people act according to the rules then I do not foresee many problems.” [ICBR110]. However, in times of high work pressure, tradeoffs between protocol adherence and patient flow become evident. Multiple respondents voiced the need for more flexibility among co-workers from other departments regarding the use of protocols. A doctor from the emergency department reported: “So, that flexibility has to be there as well, not everything has to be ready at all times.” [ICBR130].

Problems occur due to the fact that some policies of the different departments coincide with one another in times of increased workload. A statement of a respondent from department A illustrates this: “We want to stick to regulations as much as possible, but sometimes it has to be handled with flexibility from both sides.” [ICBR 150].

Furthermore, this flexibility is lacking according to one of the respondents who argued: “That flexibility is missing sometimes at department A, to deviate from that protocol. And that is occasionally very useful in practice.” [ICBR140]. The same respondent added: “The rules should become more flexible and employees need to learn how to be more flexible.” [ICBR140]. By acknowledging the aforementioned tradeoff organizational members can start focusing on patient flow. The focus on increasing patient flow can result in decreasing throughput times, that can be beneficial for the integration of departments. As a consequence, more communication is needed to align the interests and priorities of employees in the form of mutual agreements to allow them to engage in flexible behavior in times of busyness for the benefit of the entire process.

4.4.3 Top down, bottom up

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Empowerment is on the agenda of managers in the organization, which is a good thing because empowerment is likely to be especially important in complex and dynamic settings such as hospitals (Laschinger et al., 2009; Purdy et al., 2010). In this case, the self-determination aspect of empowerment, which is the sense of autonomy in initiating and regulating actions regarding decisions such as work methods, pace, and effort as argued by Bell and Staw (1989) should be the focal point of attention. First, self-determination can aid the process of integration as it fosters flexible protocol adherence of people in difficult situations caused by high work pressure and helps people to come up with creative solutions. Second, empowerment may enable employees to organize meetings themselves where they can discuss problems that might have arisen during their work both within departments but also between departments, thus improving communication. Such propositions are also provided by a respondent who claims: “If you run into something that you dislike, you have to address that issue. As long as you do not do that, you will not be able to fix the problem. You have also have to make an effort yourself.” [ICBR111].

Changes with regard to determination have the potential to increase communication (by self-organized meetings for example), understanding and ultimately integration between departments.

4.4 Summary of the results

In summary, the results show that communication and behavior can both facilitate integration in specific ways. An overview of the research results is depicted as a framework (see figure 4). The following paragraph will explain the reasoning behind this framework. The influence of on integration communication is discussed first, followed by the influence of behavior.

Communication can facilitate integration in two main forms, either by creating or enhancing tactful communication or by improving throughput times of patients. The first way, tactful communication, can be achieved in several ways, namely understanding (through cross departmental meetings, internships and more conversations), an increase in face to face communication and having a fixed coordinator at the emergency department.

The second way, decreasing throughput time of patients, can be accomplished by implementing an information system or once more by assigning a fixed coordinator at the emergency department. Both of these suggestions will reduce the amount of redundant communication, which causes a decrease in the amount of interruptions for hospital personnel, who can then use this increase in time to treat their patients. As a consequence, the length of stay of patients may decline resulting in a decreased patient throughput time.

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Flexible protocol adherence can improve throughput times because a tradeoff between protocol adherence and throughput time was identified. By allowing employees to deviate from certain protocols in time of need for the benefit of patient flow, throughput times can be decreased.

The last form of behavior that can be leveraged is empowerment. Empowerment can help employees with the aforementioned protocol adherence flexibility. Next to that, it can stimulate organizational member to organize (cross departmental) meetings, internships at other departments and the amount of conversations for themselves and others. As mentioned in the paragraph above, this will facilitate integration as well.

Beside all the possible facilitators of integration, the findings also suggest that integration is restrained by busyness and culture. The dotted line indicates that these concepts negatively influence integration. Moreover, resistance behavior enables the existing negative organizational culture of distrust to last.

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5. DISCUSSION

This section discusses the research findings. First, a summary of the results of this study will be given. Second, these findings will be linked to existing literature theoretical implications paragraph. Third, the managerial implications are presented. Lastly, the limitations of this study receive attention, as well as directions for future research.

The aim of this study is to gain a deeper understanding about the facilitators of integration in a change context. In that respect two concepts have been identified that could possibly facilitate integration, namely communication and behavior. This paragraph will provide a summary of the findings based on the concepts mentioned above to answer the research question: “How can communication and behavior of employees facilitate interdepartmental integration in a healthcare context.”

Findings suggest that both communication and behavior can facilitate integration in different ways. Communication can facilitate integration through more interdepartmental meetings, internships for employees at other departments of the same patient flow process in the organization and more conversations between members of different departments. These findings lead to more understanding, which in turn increases the amount of tactful communication.

Furthermore, more face to face communication can also increase the use of tactful communication. This has a positive influence on integration.

The second way how communication can facilitate integration is a switch from synchronous communication to asynchronous communication by means of an information system, which reduces the amount of redundant and interrupting communication. This will ultimately lead to decreased throughput times for patients, benefitting integration.

Lastly, communication can facilitate integration by the assignment of a fixed coordinator (at the emergency department). This finding facilitates integration because it increases tactful communication and a decrease in redundant interruptive communication.

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Besides facilitators of integration, the findings also show restraining forces of integration. These forces are busyness and culture.

These results of this overview will have theoretical and managerial implications. The next paragraph explains how the findings of this study can be linked with existing literature, followed by a paragraph discussing the implications for management.

5.1 Theoretical implications

This paragraph discusses the findings of this study and provide a link with existing literature.

The results indicated that there was little integration between departments and that the departments mostly functioned independently. This means that the notion that most hospital departments function independently found in literature (Lega & DePietro, 2005) held true is this study. Ahgren and Axelsson (2005) and Burns and Pauly (2002) argued that interaction may not be necessary or beneficial in all contexts. In this particular case however, findings showed that the need for integration is present and that the organization would benefit from more integration. How communication and behavior can facilitate that need for integration is discussed in the next paragraphs.

According to the findings, most communication is done in a synchronous fashion in this study. Both the advantages and disadvantages mentioned in literature of this type of communication became apparent in this study. The results show that synchronous communication is preferred over asynchronous communication in most cases because of the immediate response it requires, which is in line with statements of Coiera (2006) who argued that when messages are urgent, synchronous communication is preferable. However, the negative consequences of synchronous communication have also been mentioned.

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Literature suggests that there is a clear distinction between formal communication and informal communication (Pagell, 2004). In this study however, almost no separation of the two types of communication became apparent. But, it could be that the organizational members are not aware that these types are different as well as their possible effects on integration. It is also likely that there was a discrepancy between the definitions of the researcher and the interpretations of both of these communication types. Therefore, results did not show an impact of either formal or informal communication as facilitators of integration. Literature suggests that informal communication is difficult to achieve, so changing should start with formal communication, as that is easier to achieve (Pagell, 2004).

The findings showed that both resistance and readiness behavior was present in this research. Literature about resistance behavior is divided, because some scholars argue that resistance should be avoided and that resistance has negative effects. However, other authors state that resistance can also have a positive effect on change (Knowles & Linn, 2004; Ford, Ford and D’Amelio (2008) Msweli-Mbanga & Potwana, 2006).

In this study, resistance is viewed as negative, and something that does not generate positive outcomes. Therefore, in this case, resistance reaffirms the claims of (Bouckenooghe (2010) and Pardo del Val and Fuentes (2003).

Curtis and White (2002) provide eight reasons for individual resistance among nurses. They argue that resistance to change of nurses has to do with: Increased stress, self-interest, denial, personality, lack of understanding, trust and ownership, different assessments or perceptions, motivation and uncertainty. In this study, some of these reasons of resistance among nurses become visible: Increased stress due to busyness, self-interest to create a time out for themselves, lack of understanding between nurses of different departments and trust due to past experiences. The other reasons for resistance have not been found in this case. However, this study does show causes of these reasons. Increased stress is caused by busyness and trust issues take shape because of past experiences. However, the most evident display of resistance according to Kitchener (1999), Weick (1976) and Young and Saltman (1985), the contradicting agenda of physicians in relation to non-clinical managers was not found in this research. A new finding is that readiness behavior can have a positive effect on tactful communication through the use of given good examples, which can facilitate integration.

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By using communication as one of the concepts for this research, this study also adds to the need for in depth communication studies in hospitals as argued by Rabøl et al. (2011). Furthermore, this research paper shows that communication is indeed a key enabler for integration, confirming the findings of Pagell (2004), but in a different context.

Beside types of communication and behavior that were derived from literature, other possible findings that can facilitate integration were also identified. Integration can be facilitated by communication through understanding, tactful communication, coordination and the use of an information system for the planning of capacity. Behavior can facilitate integration by setting examples, the empowerment of employees and flexible protocol adherence. The framework created as a result of these findings can contribute to literature.

Based on these findings and the framework, two propositions are created that make a contribution to literature.

Proposition 1: Coordination positively influences integration through an increase in the use of tactful communication.

Proposition 2: Face to face communication between organizational members of different departments working on the same process positively influences integration through an increase in tactful communication

5.2 Managerial implications

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33 5.3 Limitations and future research

This research faces several limitations that provide directions for future research and interpretation of the research outcome.

The first limitation regards the research strategy used in this study. As mentioned in the methodology section, this study adopted a single case study research design because of the unique context of the organization. This means that data was collected at several departments of one organization. However, this implies that as a consequence, the results of this paper lack generalizability. In order to increase generalizability, future research can focus on conducting similar research among other organizations. The second limitation is based on the limited selection of departments. Only a few departments that received most of the patients of the ED were considered in this study. Therefore, results could differ among other departments. Future research can include other departments in their studies to increase generalizability of the results. Furthermore, one of the selected departments titled ‘department A’ is a relatively new department, which means that not all processes have become routine and much aligning still had to take place. However, department A had to be taken into account in this study, as it has an influence on integration. The results indeed revealed this positive influence.

The selection method of respondents poses a third limitation. All respondents were identified by employees of the organization, either by information received from a contact person or by snowball sampling. Increasing the risk for bias because employees of the organization could provide the researcher with potential respondents that share the same beliefs, opinions or thoughts as themselves. However, this selection method was chosen because the researcher lacked the knowledge about which organizational members had a clear view about the concepts of interest, integration, communication and behavior. Furthermore, the contact person did not work specifically for one of the departments mentioned in this study and the researcher still had the opportunity to select respondents based on a list of potential respondents received from the contact person.

A fourth limitation concerns that the study is based on qualitative data only. Even though these data provide an image of the case, the results are not grounded with statistical numbers. Future research can focus on increasing reliability by statistically testing the findings. Moreover, a mixed method case study that uses both qualitative data and quantitative data as described by Yin (1981) can increase the reliability of this research outcome.

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In doing so, some professions were only interviewed once, even though there is a possibility that other respondents with the same profession would come up with totally different answers. In line with this, research can make efforts to make sure that certain professions are represented more than in this study. Lastly, the concepts formal and informal communication were used in this study. But, it appears a likely possibility that there was a discrepancy between the definitions of the researcher and the interpretations of both of these communication types among the respondents. This refers to problems with validity. Because validity cannot be ensured, little inferences can be made with regard to these concepts.

6. CONCLUSION

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Communication and behavior as facilitators of integration: a single case study