ROLE CHANGE: CONTRIBUTIONS OF INDIVIDUAL AND TEAM COPING ACTIVITIES

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ROLE CHANGE: CONTRIBUTIONS OF INDIVIDUAL AND TEAM COPING ACTIVITIES

A study on the influence of individual and team coping mechanisms to external pressure on role change for general practitioners in elderly health care

Master thesis, MscBA, specialization Change Management University of Groningen, Faculty of Economics and Business

August, 2013

I. Klingenberg

2222159

Achter de muur 36, 9711 PR Groningen, The Netherlands

Phone: +31 6 11125969

Email: i.klingenberg.1@student.rug.nl

Supervisor

Dr. M.A.G. van Offenbeek

Second evaluator

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Abstract

This research focuses on the contributions of job crafting and boundary work to role change. The research was performed under a sample of 29 GPs throughout the Netherlands, using in-depth interviews and questionnaires. These GPs all experienced external pressures through changing orientations in treating elderly patients. In this setting, it was found that job crafting can result in a new role, the subtraction of duties and rights of a role and role expansion. Also, it was found that boundary work can both result in role expansion and new roles, but also creates the conditions under which role change coming about through different processes can be negotiated successfully. Therefore, it was concluded that both mechanisms as a way in coping with external pressures have relevant contributions to role change. Through understanding these mechanisms, this research hopes to contribute tools and insights for GPs in dealing with external pressures and clarifies how agency and pro-activity can impact role change.

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1. Introduction

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“All the world is a stage, all the men and women merely players. They have their exits and entrances; each man in his time plays many parts.”

William Shakespeare –

The role a person has in society has been the topic of much debate throughout history and has always been subject to change, as shown by the quote from Shakespeare’s As you like it. Role change has recently become a relevant subject for general practitioners (GPs) in the Netherlands, as this group of professionals experiences external pressures in treating elderly patients. As GPs have a high degree autonomy in their daily operations, each individual handles these external pressures differently. Through coping differently with these pressures, role change might occur in different ways. However, it is important for this group of professionals to take on consistent roles, leading to discussions on GP roles. Therefore, how GPs cope with external pressures and how this affects role change is interesting to analyze. Results of such a research have the potential to aid GPs in better understanding their own efforts and how these affect their different roles in elderly healthcare. Furthermore, this research also has the potential to ways to better fulfill roles as prescribed by the National Association of General practitioners (NHG) regarding elderly healthcare.

1.1 Introduction to the research

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6 individual incorporates more responsibilities and activities into their role (Grant & Hoffmann, 2011). Early work on professional roles has assumed that roles were static in nature (Grant & Hoffman, 2011), but more recent studies have shown that individuals often exercise agency and pro-activity in modifying their role definitions (Grant & Ashford, 2008; Ilgen & Hollenbeck, 1991; Morrison, 1994; Nicholson, 1984; Parker et al., 1997; Wrzesniewski & Dutton, 2001). Also, it has been shown that roles can change based on shared expectations and are communicated from a sender to a receiver in a social context, in which not only individual definitions are important. Therefore, team mechanisms can also be the focal point of agency and pro-activity (Katz & Kahn, 1966) and in studying role change team dynamics and team level mechanisms are important too.

One of these social contexts in which roles play an important part is a multidisciplinary team of a GP practice. Through social discourse within these teams, roles can also be subject to change and team coping mechanisms also come into play. This research will set out to analyze whether and how individual level and team level activities performed by GPs in coping with external pressures fit within the current theory on role change and role expansion. Also, it seeks to gain understanding into how the coping processes on both the individual and team level can contribute to or influence role change and role expansion. The research will be performed within the sector of general practitioners (GPs) providing care for elderly patients within the Netherlands.

1.2 Study context

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7 region in the Netherlands. In this case, GPs cooperated with a large health care insurer to set up a project in which the role of the GP is meant to be proactive towards vulnerable elderly patients, visiting them at home and monitoring them through questionnaires. These tasks were not included in the treatment of patients in the past, and require a different approach to the patient by the GP. On the individual level these activities are considered “job crafting”, which include changing task boundaries, changing cognitive task boundaries and changing relational boundaries and is used to increase control over job and work meaning (Wrzesniewski & Dutton, 2001). On the group level these activities are considered “boundary work”, which is used to increase team performance and provide psychological safety by establishing and maintaining boundaries, and managing interactions across those boundaries (Faraj & Yan, 2009). Starting this project is an example of how GPs are actively redefining the boundaries of their work on a team level, thus affecting their roles through this redefining. Such boundary work activities are showing how GPs are currently coping with external pressures in the healthcare sector. However, by reconstructing these boundaries, tasks and perceptions of their daily activities, the role of GPs can also be subjected to change.

1.3 Research question

Therefore, this research will attempt to analyze how job crafting and boundary work activities contribute role change. Therefore, the goal of this research is to answer the following research question:

How are individual and team coping mechanisms, in terms of job crafting and boundary work activities respectively, perceived to contribute to role change under conditions of external pressure?

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8 The first sub question to be answered is concerned with role change coming about through job crafting activities. Job crafting activities are displayed on the individual level and are concerned with the task boundaries, cognitive task boundaries and relational boundaries. Because past research has shown that both agency and pro-activity has been important in modifying role definitions, job crafting activities are thought to contribute to role change. This leads to the following sub question: How do job crafting activities contribute to role change?

The second sub question is concerned with role change coming about through boundary work activities. Boundary work activities are displayed on a team level and are concerned with establishing mutual team boundaries and managing interactions across these boundaries. Boundary work is a process used to increase team performance, provide psychological safety for its members and can be used in response to, or anticipation of, disruptive forces within the environment in order to protect the team. Because of these factors, boundary work activities are thought to contribute to role change. This leads to the following sub question: How do boundary work activities contribute to role change?

By answering these questions, the process resulting in role change is further clarified. The research will give insight in the processes of job crafting and boundary work as mechanisms to cope with external pressures, and how these processes contribute to role change. This view on role change in relation to coping with external pressures is rarely discussed in academic literature, thus through this research new insights into role change and how role change comes about are obtained. Finally, through this clarification, a deeper understanding of role change of GPs in the Netherlands can be obtained as well. This will aid GPs in shaping their own roles and enables them to cope with the current external pressures more effectively, resulting in less negative effects on their psychological well-being.

1.4 Practical relevance and contributions

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2. Theory

This chapter will describe the concepts of the research based on existing literature. It will start out by describing the concept of role change and how this comes about. Then it will describe the concepts of job crafting and boundary work and how these activities have the potential to influence role change.

2.1 Role and role change

In order to understand role change, it is important to understand what constitutes a role. Classical role theory formulates a social role as a constellation of responsibilities and expectations for action embedded in a social position (Callero, 1994; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964; Lieberman, 1956). Building on this concept of social role, Turner (1990) defines four different types of roles: basic roles, structural status roles, functional group roles and value roles. In these types, the structural status role is concerned with occupational roles that are related to position, office or status in an organizational setting. In this research the role of GPs with regard to treating elderly patients and their position within the practice is analyzed, thus it seeks out the structural status role of GPs. Therefore, a role is considered to be the constellation of responsibilities and expectations for actions embedded within the social context of an occupational position, in this case the position of the GP in the GP-patient-practice context.

Understanding what defines a role, it becomes clear how to define role change. Turner (1990) defines role change as “a change in the shared conception and execution of typical role performance and boundaries”, clearly distinguishing it from role transition or reallocation. Before role change will take place, certain pressures will have to be present to initiate this process. Pressures for role change can have different sources as it can arise from a misfit between person and role in regard to functionality, tenability or representational character of the role. Also it can arise from changes in roles of other significant parties, or it can arise from changes in the environing social structure (Turner, 1990). One example of this is the increase of market orientation in the healthcare sector in the Netherlands. These pressures can form an impetus for role change, and through coping with these pressures in different ways, different types of role change can be the result. Role change as an outcome exists in the form of (Turner, 1990):

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11 3. More or less power or prestige associated with a role or;

4. Fewer or more duties or rights of a role.

In order to be considered successful, the process through which role change came about has to meet certain criteria (Turner, 1990). The new role has to have a more favorable benefit/cost ratio then the old role, there has to be a degree of autonomy in establishing the new role, all incumbents of the role have to be unified in the desire for role change, there has to be a client demand for the role change, a cultural credibility for the new role has to exist and finally institutional support has to be attained, such as legal acceptance (Turner, 1990). If these conditions are met, individuals are more likely to successfully negotiate the new role and it will be accepted more easily within a specific social context.

A more specific type of role change, more recently discussed in research, is “role expansion”. This occurs when individuals choose to include more responsibilities into their personal definitions of their roles, treating these responsibilities as expectations rather than discretionary activities (Morrison, 1994; Parker et al., 1997). In this case a clear distinction is made from extra-role behavior. Role expansion can also come about through a process of dyadic communication, but has two distinct conditions that make role expansion a separate addition to the traditional role change theory(Grant & Hoffman, 2011). Role expansion focuses on the individual change in view on a role and requires engagement in the new role over time instead of a single act.

The final condition of role expansion is related to role change theory, as role expansion also includes adding responsibilities instead of substituting existing responsibilities (Grant & Hoffman, 2011). Because of these conditions, this research will use the theory on role expansion as the fifth type of role change, describing quantitative additions to a role more detailed. Concluding, successful role change is considered an outcome of different processes in a social context resulting in:

1. A new role; 2. A dissolved role;

3. More or less power or prestige associated with a role; 4. Fewer duties and rights of a role or;

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12 In order to successfully negotiate role change, different conditions have to be met in order to gain acceptance in their respective social contexts. As these social contexts are often exposed to external pressures, the process of successful role change is subject to different activities of individuals in coping with external pressures, one of them being job crafting.

2.2 Job crafting

In the social context of an organization, individuals are exposed to external pressures and seek ways cope with these pressures. They seek to increase control over job and work meaning, fulfill the need for positive self-image and fulfill the need for human connection with others (Wrzesniewski & Dutton, 2001). These needs are fulfilled through actions described as job crafting. Job crafting calls individuals to anticipate and create changes in the way of work on the basis of increases in uncertainty and dynamism (Grant & Parker, 2009). These reflection activities can help them cope with ongoing changes (Petrou, Demerouti, Peeters, Schaufeli & Hetland, 2012) and can therefore be considered an advantage during change (Van den Heuvel, Demerouti, Bakker & Schaufeli, 2010). Finally, an important effect of job crafting is an increase in readiness to change (Lyons, 2008). Because of these effects of job crafting on individual needs, it is considered a coping mechanism in this research.

Job crafting describes how individuals can actively change tasks, cognitive tasks and/or relational boundaries of their work (Wrzesniewski & Dutton, 2001; Berg, Wrzesniewski & Dutton, 2010). Firstly, through job crafting the task boundaries of a job can be altered. Task boundaries encompass all activities a person is involved in when performing a job (Wrzesniewski & Dutton, 2001). Through job crafting individuals seek to change the number, scope, or type of job tasks done at work. These aspects are all part of a role, as defined earlier in this research. Therefore, the process of changing task boundaries strongly relates to the process of creating new roles, dissolving old roles and role expansion.

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13 are based on the engagement of the individual over time and the change views on a job does not constitute an entirely new job.

Thirdly, through job crafting relational boundaries within the social context of a job can be altered. Relational boundaries are the people a person works with and/or the nature of the interaction with these people (Wrzesniewski & Dutton, 2001). Through job crafting, individuals can change the quality and/or amount of interactions with others at work. They can often decide how frequently they want to interact with others on their jobs and also have great influence in the quality of these interactions (Wrzesniewski & Dutton, 2001). This process is related to the loss or gain in power or prestige of a role and the social context in which role change can be negotiated, thus the process itself. Role expansion, for example, comes about through dyadic communication, and as job crafting influences the interactions on the job and the quality of these interactions, job crafting can influence the process of role expansion.

Finally, it is important to note that job crafting will often occur in the context of prescribed jobs of individuals. These jobs are frequently marked by prescribed tasks, expectations, and positions in the organizational hierarchy, which will limit opportunities to actively engage in job crafting activities. Important factors influencing the potential for job crafting are autonomy and discretion in choosing an own course of action (Berg, Wrzesniewski & Dutton, 2010). This overlaps with the conditions required for role change, as successful negotiation of a new role is also based on the degree of autonomy in which this new role was constructed, similar to job crafting.

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14 chooses how to deal with external pressures. Thus, job crafting focuses on the individual level of coping with external pressures. The example also clarifies how job crafting is related to role change theory, as they both hinge on interaction in social contexts and are concerned with the established duties and rights of a role, or the individually attributed responsibilities of a role. As the current research is also concerned with the social context of teams, team dynamics are also important with regard to role change. Although some research has shown that job crafting is sometimes performed within informal groups of employees (Brown & Duguid, 1991; Orlikowski, 1996), we focus on the formal context of teams. Therefore, team boundary work will be used as the mechanism to cope with external pressures on a team level. 2.3 Team boundary work

As not only individual GPs, but also the teams in which GPs operate within their practices are exposed to external pressures, it becomes important to analyze the potential for role change that can come about through coping activities of a team. The increase of uncertainty and dynamism also influences teams, affecting their process of defining reality (Lamont & Molnár, 2002). One the tools used by teams to agree upon these definitions of reality are symbolic boundaries. These are an essential medium through which people acquire status and monopolize resources (Lamont & Molnár, 2002). By having clear boundaries in the status and the resources teams in which GPs operate, the role of GPs is co-defined. However, in light of the pressures on these teams, team boundaries can be altered in order to meet the expectations of society, this process is considered team boundary work. Team boundary work is a process used to increase team performance, provide psychological safety for its members and can be used in response to, or anticipation of, disruptive forces within the environment in order to protect the team (Yan & Louis, 1999; Faraj & Yan, 2009). Because of these effects of team boundary work, it is considered a coping mechanism in this research.

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15 used to gain access to expertise not present in the team (Marrone, 2010; Faraj & Yan, 2009). Boundary spanning consists of several specific activities, including building relationships, scouting for information and persuading others to support the team’s work (Druskat & Wheeler, 2003; Marrone, 2010). Also it includes representing the team to outside stakeholders, coordinating task activities with other groups and seeking information from outside experts (Marrone, 2010).

Secondly, boundary buffering activities are outward-facing activities which are used as a strategy of disengagement in order to close the team off from exposure to the environment, strengthen its barriers against external interference and create a protected internal atmosphere for the members (Faraj & Yan, 2009). Activities include the use of formal strategies and procedures, informal codes and norms for deflecting and managing external demands on team members and the control of quality and quantity of inputs entering the team by “sentries and guards” (Ancona & Caldwell, 1988; Yan & Louis, 1999; Yan & Faraj 2009).

Finally, boundary reinforcement activities are inward-facing activities which are used in order to reduce resource leakage, increase intra-team integration and commitment and facilitate team work (Ancona & Caldwell, 1988; Yan & Louis, 1999; Faraj & Yan, 2009). Activities include setting team boundaries internally, reclaiming boundaries through increasing member awareness of boundaries and sharpening team identity (Yan & Faraj, 2009). Another way of reinforcing team boundaries is through coordinating mechanisms within teams, as these enhance interactions among participants in a work process (Gittell, 2002). Boundary spanners, team meetings and work routines are potential coordinating mechanisms, in which team meetings become increasingly effective under conditions of high uncertainty (Gittell, 2002). For this reason, team meetings are included as a process in which team boundaries are reinforced with regard to GP teams in practices.

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16 Therefore, the relation between role change and team boundary work is such that it can possibly directly result in role change, or it may facilitate role change through different processes. By changing team boundaries in order to cope with external pressures, and creating awareness of these boundaries through a process of boundary reinforcement, team coping activities can initiate or result in role change.

To conclude, teams can perform team boundary work activities in order to increase team performance, provide psychological safety for its members and helps to handle disruptive forces in the environment. Team boundaries can be spanned, buffered or reinforced in order to cope with external pressure. These activities are also strongly related to role change theory, as they both hinge on interactions within a social context and performing reflective actions in order to gain acceptance of team members to the fulfilling of roles, even if these change, within a team.

2.4 Conclusions

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3. Methods

As stated, this study aims to investigate if and how job crafting and boundary work activities contribute to role change. Based on described existing literature, it is expected that these two activities can lead to role change. This section will cover the methodology used. First, the participants of this study and way of sampling are described. Secondly, the data collection method is explained. Finally, the process of analyzing the resulting data will be described.

Empirical research was performed under 29 different GPs located in the Netherlands. The empirical research used a research method aimed at qualitative data analyses of interviews held with GPs, and a quantitative questionnaire. These interviews were conducted at a previous stage during a post-doctoral research at the University of Groningen and were offered to the researcher to perform analyses based on the developed framework of this research. The questionnaire was performed during the interviews and was filled in by the GP. All questionnaire data will be used descriptively to complement the findings that have come up during the analyses of the interviews.

3.1 Participants

In order to obtain a high degree in variation in GPs, they have been selected based size of the practice, the location of the practice, their tenure as a GP, their age and their gender. Table 1 provides the general characteristics of this group.

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19 We assume all the participants are faced with the same external pressures based on the reorganizations in the healthcare sector in the Netherlands. As table 1 shows, there is a variety found among GPs in tenure, age and operating FTE. Due to the nature of this sample, it is representative of the GP population in the Netherlands and the results of this research might be generalized, although further testing would be required.

3.2 Data collection method

In total, 29 in-depth interviews and questionnaire were conducted. Whenever a GP was interviewed, they would be presented with a questionnaire during the interview as well. Questionnaire results will be used as a descriptive support of the findings that came up during the analyses of the interviews. Therefore, the in-depth interviews are the main data source used for this research. As stated, these interviews were conducted at a previous stage offered to the researcher to perform analyses.

The interviews were conducted in a semi-structured way, following a specific structure and contained the following phases:

1. Introduction phase 2. Role identity

3. Organization of care and activities, includes questionnaire 4. Role identity change

5. Closing phase

During the introduction phase the structure of the interview was explained and how the resulting data would be used. Any questions a participant had would be answered and the conditions of the interview were understood and agreed upon by the participant.

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20 During the phase on organization of care and activities participants were asked to described thoughts and ideas with regard to the organization of elderly patient care within their own practice, but also in a wider context. The participant would be asked to rate different situations to assess how often certain activities were performed by the participant. After having rating several activities the interviewer would prompt the participant to explain reasons and motives on why the participant would participate in some activities, but not in others. Also, participants were asked if they recognized any important events or turning points which encouraged them to change their daily activities.

During the phase on role identity change, participants were asked if they would assess their roles in treating elderly patients has changed over the past years. The participant would be prompted about tasks, responsibilities and reasons they may have for changing their roles in providing care for elderly patients. Finally, they would be asked about their competencies and if they felt they needed to expand their set of competencies with regard to elderly patient healthcare through, for example, schooling.

Finally, the closing phase of the interview would provide the participant the possibility to add any important information or discuss subjects that had not come up during the interview itself. Any questions the participant might have had afterwards would be answered and confirmation of the goal of the interview would be given again. Also, all the interviews lasted for about sixty minutes and were held voluntarily. The data was recorded and then transcribed and made available for this study. Interviews were held in Dutch and transcriptions were also made in Dutch. All interviews were held face-to-face and one-on-one, making sure they would be held in similar settings as much as possible.

As shown through the interview guide, the topics that were discussed were closely related to the topics and the framework of this research. Therefore, these interviews provide a fitting source of information to this research. During the interviews, participants further prompted in order to gain more information or insight into a specific topic. As the participants were regarded to be knowledgeable about the topics discussed and are academically schooled, topics were presented in an academic fashion and rephrasing of the subjects was often not necessary.

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21 specific activity related to team boundary work and offered a scale to which the participant would evaluate the degree to which he or she would engage in the activity. Assessments would range from “yes, a lot” to “No and never considered”. In some instances the participant did not have the option to perform certain activities, in which case the answer “inapplicable” would be used.

Further data based on the framework presented in this research was not deemed necessary. The interviews discussed relevant subjects for this research and the questionnaire was concerned with team boundary activities specifically, providing very detailed information on this part of the framework as well. Furthermore, the GPs were often prompted about their vision and ideas on certain roles or activities during the interviews. These individual views and ideas on roles offer enough insight into the variables presented in the framework.

3.3 Data analysis

In order to analyze the interviews, the previously developed transcripts were used. Based on the theoretical framework, the initial coding scheme was developed which was used to analyze the specific transcript. This coding scheme can be found in appendix B, and mostly consists of deducted codes, with the exception of "no role change". This code was added inductively, as it during analysis relations between "no role change" and job crafting and boundary work showed interesting findings. These were attained using the strategy for development of inductive coding (Hennink et al. 2010), which include reading and rereading data to identify explicit and more subtle codes, focuses on the participants‘ words instead of the question of the interviewer, moving back and forth between different transcripts and finally distinguishing returning issues as a significant code.

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22 that in some cases items were not illustrated by the GP and only an indication was given on the scale. However, in other cases GPs would use examples or describe situations where the specific activity was performed or how they perceived these activities to be affecting their current roles. In these cases, not only the statistical analysis of the questionnaire was interesting, but also quantitative analyses of these omissions became interesting. However, because not all activities were discussed in great length, finding proper examples of each activity without overlapping with the results section was impossible.

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4. Results

This chapter describes the findings based on the interviews and the questionnaire. First, the findings concerning role change will be described using all the data of the interviews and be substantiated by questionnaire results. Then, the contribution of job crafting to role change will be described based on interview data as well. Finally, the influence of team boundary work activities on role change will be explained through the questionnaire results.

4.1 Role change

As shown in table 2 below, GPs rated the perceived change in role from "not at all" (1) to "to a high degree" (7).

Table 2

Descriptive statistics of evaluation on role change by GPs

Perceived role change # of GPs

Not at all 1 0 2 0 3 1 Somewhat 4 4 4,5 1 5 2 5,5 3 6 7 To a high degree 7 11 Total 29

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24 GP to have changed with regard to treating elderly patients. However, this GP did show instances of job crafting and team boundary work, as he explained how tasks were performed differently within their practice and how this affected his views on his own tasks. The three types of role change that were found most frequently will be clarified in this paragraph. Table 3 displays all the different types of role change, a description of the type of role change, how many GPs mentioned this type of role change in the interview and an example of such a finding.

Table 3

Findings on role change

Type of role change Description # of GPs Example

New roles

The addition of a specific role that was previously not

fulfilled by the GP which includes different tasks compared to other roles.

16/29

“Ik had vandaag een diabeet , die heb ik nu ingesteld samen met een praktijkondersteuner( ...) uiteindelijk moet je als huisarts als een soort manager er staan . Je weet van niks meer,

niks meer iets.” - SCH6

Dissolved role

Removing a role with distinct tasks and responsibilities which is not

needed to be performed by the GP.

5/29

“soms lijkt het wel of je uh meer, uh kijk, dat je vroeger meer een ‘doener’ was en dat ik tegenwoordig vaker ‘briefjes zit

te ondertekenen” - SCH2

Subtracted duties/rights

Removing tasks, responsibilities and activities

from a specific role, thus still performing this role but

with limited tasks and responsibilities.

19/29

“De praktijkondersteuners nemen veel van de taken rond chronische ziekte over hè....” -

DEV2

Power/prestige lost/gained

Increase or decrease in perceived status or power in

relation to other stakeholders.

8/29

“Ja, ik merk toch wel meer dat de jongeren kritischer zijn en meer zelf de regie willen hebben

en de ouderen wat meer, wat makkelijker aannemen wat de

dokter zegt” - GP10

Expanded role

Including more tasks and responsibilities in a specific role and enacting these tasks and responsibilities actively.

29/29

“de zorg is wat grootschaliger geworden waardoor je duidelijker moet vastleggen .. iedereen die daar komt ook weet

wat er afgesproken (is)” - GP4

Unchanged role

Performing a role the same way as before and not adding responsibilities or

tasks to the role.

10/29

“nou de rol is misschien niet eens zo erg veranderd, maar wel

het werk wat je ermee hebt. Er zijn gewoon meer ouderen, meer

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25 4.1.1 New roles

In several instances, GPs noted that in addition to their respective roles, new roles have been negotiated. In these cases GPs had often restructured their practice and delegated tasks to “practice supportive carers” (POH). The Dutch government in their demand for more market orientation has established possibilities to hire additional workers, in the form of POH's specifically for a group of patients. In the past this was done for, for example, assisting with the treatment of patients with diabetes, but in recent years these specialized workers have also been made available for treating elderly patients. This was introduced in order to meet rising demand surrounding the elderly healthcare. These additional staff members can become responsible for fulfilling most of the care towards elderly patients and would be able to meet the higher demands of these patients, when comparing them to younger patients.

However, this also meant an additional role as a supervisor of these workers for the GPs, as they would maintain medical responsibility for patients. This increase in supervision of workers, instead of treating patients directly led to a new role: employee manager. A clear case of this is displayed in the quote to the left. In this example, the GP had introduced the POH within the past years, and acknowledged a new role was added. Another type of role change is also closely related to the delegation of tasks and the introduction of these POH's.

4.1.2 Subtracted duties and rights

GPs had also negotiated the subtraction of duties and rights in the traditional role of a GP through delegating tasks. If a POH was active within a practice, GPs always noted that their role in treating elderly patients involved less tasks, as most of the treatment was done by the POH. This would free up more time for them to be concerned with other issues, e.g. management. The most important finding was that these GPs did not consider these treatment tasks to be part of their role anymore, thus successfully subtracted the duty of having to treat these type of patients from their role.

“is ook meer dus overzicht ... managen zeg maar leiden

kijken of het wel goed gaat. ... Maar dat is gewoon uh

dan ben je dus meer manager”

- GP2

“De praktijkondersteuners nemen veel van de taken rond

chronische ziekte over hè. Hart- vaatziekten, COPD en

diabetes dat zijn daar zijn veel gedelegeerde taken bij”

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26 In other instances, GPs also mentioned a different subtraction of rights to their role. In three cases, GPs FRIES1, SCH6 and SCH5, it was mentioned that the “care” aspect in treating elderly healthcare patients by nursing homes or homecare used to be fulfilled in cooperation with the GP. However, because nursing homes often have specialists for elderly patients these days and the influence of homecare has increased drastically over the past years , the GPs role fewer rights, and duties, then before. This shows that in the social context of nursing homes, home care and treating elderly patients, the role of GPs has been negotiated to change by subtracting specific duties and rights of the GP role.

Also, two of the GPs, GP4 and GP5, noted that the role of the GP no longer contained the duty of visiting people in their homes and provide “social calls”. Some of the GPs related this to the current “Zeitgeist”, and would still provide it every now and then because they considered themselves to be a more traditional GP. However, multiple GPs noted that having to visit patients in their homes in light of a more social visit, instead of a pure medical visit, was not part of the GP role anymore.

Finally, one GP, R2, mentioned that a pilot was held transferring the task of screening patients to the 2nd line care, which would free up more time for GPs as well. This is a clear case in which fewer duties for the GP were negotiated, but not successfully as the GP in question stated that this project had failed as it did not achieve its desired goals of cost reduction and increased efficiency. This subtraction of tasks only made the process in treating elderly patients more burdensome, and it was concluded that this task should not be delegated to the 2nd line. This was further confirmed by findings from other interviews, in which the GP had actually taken on more tasks that used to be performed by 2nd line care. So instead of subtracting duties from the role of GPs as the pilot was set out to do, it enabled role expansion for the GP. This role expansion, and all other forms of role expansion, will be described in the last section.

“Vroeger deden we dat als dokter zelf, dan moest je

overal voor visites heen, en

dat vroegen ze dan zelf.”

-GP5

“ja, dat is met name het zorgaspect in het verzorgingshuis was het zorgonderdeel wat daar geleverd wordt ook vaak een punt waar de huisarts

naar gevraagd werd. Maar dat wordt nu

gedaan door een verpleeghuisarts of de specialist ouderenzorg"

-FRIES1

“We hebben net meegewerkt aan het project

waarbij de screening door de 2e lijn werd gedaan. Daar kwam niks uit voort. Daar

hadden we eigenlijk alleen maar last van.”

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27 4.1.3 Expanded role

As shown, almost every GP acknowledged that their role had changed over the years. Much of this role change constituted of role expansion. Role expansion is the addition of duties and rights to a role which are enacted by an individual over time. Many of the GPs noted that they had increased their duties within their roles by becoming more pro-active in seeking out elderly patients. The goal of changing this approach to treating elderly patients is to be more preventive of disease and be able to signal potential problems in the treatment process earlier. The quote on the left illustrates this specific type of role expansion. This came during nearly all interviews, as most GPs had, to some extent, begun working more pro-actively in order to be able to provide more preventive treatments next to their original treatments, which is also shown in table 3, as all the GPs have mentioned role expansion in their interviews.

Another type of role expansion also came up during the interviews. Many GPs talked about expanding their role through applying more protocols in their role and work in a more structured, pre-scripted fashion. This led to doing more administrative tasks, communicating more, i.e. more regularly and with an increased number of parties. The goal of this was to apply more structure in the exchange of information, in order to be able to process this information more adequately through the growing system of healthcare. This also meant the GP had become more of a coordinator in the process for providing the right treatment for elderly patients, as the number of parties involved in the process has increased over time. This was considered by different GPs to be a new way of working and the related activities to this role were being incorporated into their tasks, constituting role expansion.

A third type of role expansion was concerned with the tasks a GP could perform in his or her practice. GPs showed that new technology had made it possible for them to expand their possibilities for diagnoses that were only accessible through hospitals in the past. Examples of this were cardiograms and lung functionality diagnosis, which could be done effortlessly Ja, je kijkt en daar

wordt je ook voor uitgenodigd natuurlijk vaak veel meer preventief (...) zeker bij ouderen, bij de oudere groep,

is natuurlijk veel belangrijker geworden. Dus preventie, het voorkomen van.. “ - GP7

“de zorg is wat grootschaliger geworden waardoor je duidelijker moet vastleggen vroeger als je een

probleem patiënt had ik 8 collega’s en daar deden we de diensten mee en daar sprak ik nee maar nu doen we met de hele stad dienst dus dan moet ik gewoon als ik iets wil vastleggen thuis vastgelegd hebben zodat

iedereen die daar komt ook weet wat er afgesproken (is)”

(28)

28 inside a GP practice these days, and were also performed in these practices instead of in the hospital. The shows how GPs expanded their role and incorporated more responsibilities that in the past were located somewhere else in the process of treating patients.

Finally, in some instances the role of the GP had changed from being employed within a practice, to owning the practice itself. An example of this is given in the quote on the left. This is a regular process in The Netherlands, in which practices are passed on from one GP to another after retirement, or are constructed in a partnership fashion. In these cases, the GP reported that they had also expanded their role with more responsibilities and had enacted these responsibilities over time as well. Therefore, this must be considered a form of role expansion too. However, as this system in organizing the general practitioners will most likely not change in the future, this type of role expansion is less interesting for this research.

4.1.4 Unchanged role

Having described all the changes the role of GPs has gone through over the past years, it is important to note one different view on the role of the GP in The Netherlands. Even though questionnaire results shown all GPs evaluating their roles as having changed, qualitative analysis of certain interviews suggested the contrary. In order to analyze the influence of job crafting and boundary work activities on role change, these activities also have to be described for those GPs not experiencing role change and compared with GPs who do experience role change. Therefore these findings are included in this research as well.

In eight instances, GPs DEV1, DEV2, DEV3, GP4, R4, R6, SCH6, and SCH7, it was mentioned that the role of the GP had not changed over the years. Some signals are given for having to work in a more structured fashion, but these are marginalized by the GP in saying that this does not really constitute a role change for him or her as such. One of these examples is giving in the quote below.

“nou de rol is misschien niet eens zo erg veranderd, maar wel het werk wat je ermee hebt. (...) En er zijn meer instellingen waar je mee samenwerkt, of meer mensen. Dus het kost gewoon meer tijd, maar of de rol nou zo

anders is geworden (...) dat zou ik geloof ik niet zo zeggen”

- DEV3

(29)

29 The quote of GP DEV3 also explains the evaluation for rating role change higher than “not at all”, even though their role had not actually changed: they experienced an increase in bureaucratization and frequency of tasks , but they also felt that this had not actually changed their role as such. This also signals the importance of job crafting activities in role change and the way both processes interact, as individual perceptions of the boundaries of tasks, cognitive tasks and relational boundaries can result in role change. The above example shows how the individual perception of the GP role has not changed, and therefore actual role change remains absent.

As stated, in order to analyze the influence or contributions of job crafting and boundary work activities to these types of role change one should gain insight in the existence of these activities in cases where role change is both present and absent. The next section will describe all the findings on the job crafting activities in light of role change and how these were displayed by the GPs.

4.2 Job crafting

The first sub question this research set out to answer is concerned with job crafting activities: How do job crafting activities contribute to role change?. As described within the theoretical framework, job crafting activities take place in three different forms: changing task boundaries, changing cognitive task boundaries and changing relational boundaries. Through gaining insight in these activities and how these are performed by GPs, this research attempts to seek further insight into the contributions of job crafting on role change. During the interviews all of these activities came up in multiple ways which will be described in the following section. Table 4 displays types of job crafting, a description of the activity, the number of GPs mentioning this activity in the interview and an example of such an activity.

Table 4

Findings on job crafting activities

Type of job crafting Description # of GPs Example

Changing task boundaries

Altering either the perceptions on or the execution of the number of tasks, the scope of the tasks or the type of job

performed.

29/29

“we hebben een praktijkondersteuner en (...) dat zal toch wel een groot deel op hem toch ook neerkomen, (...) die delegeerde functie ook

(30)

30

Changing cognitive task boundaries

Altering the perceptions on the job as a contribution to a whole or

a specific part of a process.

29/29

“Die zorg buiten mij is ook beter georganiseerd (...) waardoor je er meer tijd aan besteed, omdat

het ook meer kan opleveren.” - GP5

Changing relational boundaries

Altering the number or quality of interactions

related to the job.

29/29

"Wat op bepaalde momenten is het gewoon

heel veel visites (...) En dat dan de kwaliteit minder wordt” - GP9

4.2.1 Changing task boundaries

Table 4 surprisingly shows all GPs were actively changing the boundaries of their tasks. In multiple instances the GP was questioned about tasks included in their roles with regard to specific situations. These situations were based on either different types of patients, different social contexts (such as working with people inside a practice or working with people outside a practice) and some situations were brought up by the GPs themselves.

One of the most interesting findings is that GPs tend to alter the boundaries of their tasks based on the type of patient, i.e. they include more or fewer tasks when treating elderly patients in comparison to treating younger patients. GPs DEV1, DEV3, DEV4, GP4, GP5, GP6, GP7, GP9, GP10, R1, R2, R4, R5, SCH1, SCH2, SCH3,

SCH4, SCH5, SCH6, SCH7 and TEX1 tended to view the scope of their tasks and the type of their tasks differently between different groups of patients. In the example on the right, the GP explains how terminal care becomes part of their job when treating frail patients, something he does not consider when treating younger, more vital patients. Furthermore, GPs associated their tasks in relation to elderly patients to be more coaching and directing. They felt that with relatively younger, more vital, patients their tasks should be

less directing and controlling, whereas with elderly patients these tasks should be included much more. Finally, the scope of the tasks would also differ with elderly people, as, for example, GPs would often include communication with family as a part of their job. This type of changing task boundaries has led to the expansion of the GP role, as by including these tasks and enacting them, GPs took on more duties in treating elderly patients.

“nou ja kijk oudere mensen staan dichter bij de dood dan

jongere mensen dus vandaar dat een onderdeel is hè dus de

terminale zorg dus de het zorgen dat mensen goed dood

gaan dat hoort bij ouderenzorg”

(31)

31 Furthermore, changing task boundaries was also found in the light of second line care. GPs DEV1, DEV2, DEV4, FRIES1, GP3, GP6, GP7, GP8, GP9, SCH5, SCH6, SCH7 explained how they changed task boundaries with regard to second line care. As described earlier, the health care sector has become much larger in size and has increased in different parties involved treating patients. In some instances, GPs showed activities with regard to their tasks involving communication with second line care, in many cases specialists and hospitals. Most GPs constructed the interactions between these parties as being passive in nature when viewed from the position of the GP. However, in several instances GPs were actively redefining the scope of their task and the type of job they had in this process. They would suggest that there was potential for the GP to become much more pro active in these interactions as well and to “seize control” in this process and become more directing in providing care for patients. One of these examples is shown in the quote on the previous page. This process of changing task boundaries and its enactment by GPs also led to an expanded role in these cases.

Thirdly, GPs GP2, SCH2 and TEX1 reported that they had changed the boundaries of their own tasks in light of restructuring the practice as through hiring additional POH's and increasing bureaucracy. As described in the section of "new role", several GPs experienced a new role in the form of a manager role. In these cases, GPs also reported changing the boundaries of their tasks through applying protocol and including more managerial tasks in performing their jobs. So in these cases, the role change had initiated the process of job crafting, resulting in changes in task boundaries of GPs as needed for fulfilling the new role.

Finally, GPs DEV2, GP4, GP5, GP6, SCH3, SCH4, SCH6 and TEX1 reported that their tasks would also have to include being more of a “coach” to patients. Examples were given in which patients would be much better informed about diseases and treatment then they would have been in the past. Based on this experience, GPs had altered the boundaries of their tasks. In these instances, GPs felt their tasks were more focused on guiding a “...met de 2e , nou

met de geriatrie, de internisten. En daar zou je heel

proactief in kunnen zijn door er

achteraan te bellen.”

- GP3

“Want ja, dan kun je er ook nog weleens voorbij gaan schieten

omdat als je langzamerhand meer werkt in de papieren dan in de patiënten te gaan stoppen. ” - SCH2

“De coach rol wordt steeds groter ook voor jeugdigen trouwens hoor - die vinden van

alles op internet, (...) maar als je het dan wilt implementeren of voor jezelf toepassen dan komen er heel vaak vragen”

(32)

32 patient in their choice for treatment and how to best handle the disease, as compared to having the GP make the choice for treatment. This often led to cases where GPs had expanded their roles with tasks such as assisting patients in the process of choosing specific treatments and elucidating findings made by patients about certain diseases and conditions.

To conclude, GPs are very active in redefining their task boundaries. These changes are made for various reasons, such as different types of patients, changes in societal expectations and restructuring practices. These changes in tasks then lead to role change for GPs, as clarified by the "elderly vs. young patient type" example. However, results show that this job crafting activity can also be performed to cope with a role change that comes about through societal expectations, as explained through the "coaching" example. Therefore, it is concluded that changing task boundaries can either lead to role change, role expansion, or can be done in light of a new role.

4.2.2 Changing cognitive task boundaries

Also, all of the GPs reported that they were active in changing the cognitive boundaries of their tasks. One of these changes is concerned with the view on their tasks in light of the growing healthcare sector in the Netherlands. GPs GP2, GP4, GP5, GP7, GP8, GP9, R1, R2, R4, SCH3, SCH5 and SCH6 reported that they were relating their jobs more to a larger part of the chain involved in treating patients instead of viewing their job as a separate job. The change in the healthcare sector had made GPs reevaluate their tasks in such a way that they would more often relate their tasks to a process of treating elderly patients, whereas in the past they had perceived their task as being more closed off from other parts of this care chain. Interesting however is, that both ways of thinking about their job were described as a holistic way of working, suggesting that this boundary had not changed . The quote on the left illustrates this changing of cognitive task boundaries.

“Die zorg buiten mij is ook beter georganiseerd (...) waardoor je er meer tijd aan besteed, omdat het ook

meer kan opleveren.”

(33)

33 Another instance in which GPs showed that they changed their cognitive task boundaries based on the type of patient, in a similar fashion as changing the task boundaries. These classifications would be based on the age of patient, young or elderly, but also on the symptoms of patients. In cases of elderly patients, GPs tended to perceive their tasks to be performed in a broader context when compared to younger or healthier patients. For example, at least GPs DEV1, FRIES1, GP6, R1, R4 and SCH1 reported how they believed that working in a more pro active fashion would benefit the quality of care provided for elderly patients. One of these examples is given by the quote on the left. In this instance, the tasks included by GP R1 would be based on the patient as a whole, whether or not the patient could still take care of himself and if the patient could remain at home. These considerations would not come into play for GPs normally, but in the case of elderly patients they did and influenced the cognitive task boundaries set by the GP. Furthermore, when ranging elderly patients from very active and low in vulnerability, to highly inactive and very vulnerable, GPs would not only include more and different tasks in their role, they would also perceive the treatment of the patient as much more significant and their role would contribute more to a “whole”. These changes in cognitive task boundaries then led to role expansion, as providing a more wholesome and pro-active treatment for elderly patients, the role of the GP became more guiding and directing. Therefore, changing cognitive task boundaries can result in role expansion for GPs.

4.2.3 Changing relational boundaries

All of the GPs also reported that they were active in changing the relational boundaries of their job. As described, this includes changing the quality or frequency of interactions with others related to the job. Two distinct types of changing relational boundaries were identified with regard to GPs and their treatment of elderly patients.

First, GPs tended to alter relational boundaries based on the type of patient, in similar fashion as described for changing task and changing cognitive task boundaries. Based on this distinction, GPs often changed both the quality and the frequency of the interactions they performed. All GPs, except GP4, GP8, R3, R6, and SCH2 gave examples of how they actively redefined the number of interactions with the patient in order to meet increasing

“...Maar kwaliteit van leven staat heel erg voorop. En ik vind bij

ouderenzorg dat je gewoon heel proactief moet zijn hè. Dus niet hè, dat je vooruit moet kijken, ook met de ouderen. Om te kijken hoe je kunt zorgen

dat ze zo lang mogelijk goed blijven functioneren.”

(34)

34 demands of these patients, or in order to meet the demands of the

changes in the healthcare sector. One of these examples is illustrated by the quote provided on the right.

In this case SCH1 describes how the interaction should change from being more reactive to being more proactive in treating elderly patients. This illustrates how the boundaries of the quality of the interaction have changed in the perception of the GP. This redefinition of quality of interaction is strongly related to role change, as by having the

perception that treating elderly should be done in a more pro active fashion, this role was eventually enacted by the GP in question. This constitutes as the role expansion on pro activity as described earlier and shows how changing relational boundaries can lead to role change.

Another instance in which GPs would alter the boundaries of the relations in their job was with regard to healthcare professionals involved in the care process. Many GPs gave examples of how the growing health care sector has influenced their views on the quality and frequency of interactions required with colleagues or specialists from second line care, in order to provide adequate care for patients. Patients often have numerous specialists available in second line care, which requires a lot of communication. This increase in communication was handled by the GP, through increasing both quality and frequency of interactions. GPs took on a more guiding function for the patient, in order to manage the flow of information and assist or direct the patient to the best care available. Therefore, it is concluded that changing relational boundaries can result in role expansion.

Concluding, to answer the sub question this section was set out to answer, job crafting has important contributions to role change. Job crafting activities can directly lead to a new role for GPs and it can lead to having an expanded role. Furthermore, it can assist in dealing with instituted role change of subtracted duties and rights or a new role, as altering individual boundaries afterwards has shown to help individuals in accepting fewer duties and rights. Finally, through the example of unchanged roles, the contributions of job crafting on role change become even apparent. When GP displayed very limited amounts of job crafting activities, this individual often showed no, or only limited signs that they perceived the role of the GP had changed.

“En bij de ouderen ga je proactief er

naar toe. En je probeert te helpen met definiëren wat voor ze problemen waar ze tegenaan

lopen”

(35)

35

4.3 Team boundary work

The first sub question this research set out to answer is concerned with boundary work activities: How do boundary work activities contribute to role change? As described within the theoretical framework, team boundary work activities can take place in many different ways. During the interviews all of these activities were gauged using a questionnaire asking the participant to rate their perceptions on certain activities. Firstly, in table 5, on the next page, all types of team boundary work that were performed by at least 50 percent of the GPs and was rated at either 1 “Ja, veel” or 2 “Ja, enigzins” are provided.

Table 5

Findings on boundary work activities

Type of boundary work Description # of GPs Example

Task redistribution or delegation/differentiation

Degree to which participant viewed himself to be involved with delegating or redistributing tasks

within the team

24/29

"ja, dat hebben we wel enigszins door de POH’s, we hebben diabetes POH’s, zorg POH’s en COPD POH’s, maar

nog niet zoveel".- GP1

Agreements with regard to task distribution and specialization

Degree to which participant viewed himself to be involved with making agreements to the distribution and

specialization within the team

16/29

"onderlinge taken – ja, dat is wel enigszins, omdat ik dus dat

“Dijkhuis” doe; dus ja, enigszins" - DEV3

Arranging additional carers externally

Degree to which participant viewed himself to be involved with obtaining more expertise in the

process of treating an elderly patient externally from practice

20/29

"AL: uhm en uhm ja dus uh dus bijvoorbeeld soort van

aanvullende zorg GP: ja nou ja dat is die

wijkzuster dus" - GP4

Clearly carrying out role to patients/family

Degree to which participant viewed himself to be involved with clearly communicating and performing the role he/she needs to fulfill with

regard to patient or family

16/29

"- nou ja, dat is altijd zo. Oh op die manier, ja, ja, wat haalbaar

is. Ja, dat vind ik wel, dat probeer ik wel goed te doen." -

R2 Clearly carrying out role

to others in care process

Degree to which participant viewed himself to be involved with clearly communicating and performing the role he/she needs to fulfill with regard to other medical experts

active in the process

18/29

" GP: En helder uitdragen naar andere belanghebbenden. Ja,

dat doen we wel. AL: En dan tijdens die overleggen of bijeenkomsten?

GP: Ja." - DEV4

Making agreements with all stakeholders in practice with regard to responsibilities

Degree to which participant viewed himself to be involved with making

agreements with external stakeholders about responsibilities

concerning the treatment of an elderly patient

15/29

"het is wel zo dat ik in elk geval met de collega in mijn dorp uh hè wel duidelijk moet afspreken dat we dat een beetje op elkaar

afstemmen hè, dat we met dezelfde

verantwoordelijkheden"

(36)

36

Formal multidisciplinary consultation outside of practice

Degree to which participant viewed himself to be involved with organizing formal multidisciplinary

consultations with stakeholders outside of the practice

16/29

"Dat, ik heb dat wel eens gedaan, bijvoorbeeld met die mevrouw, ben ik ook een keer

naar zo’n MDO geweest, multidisciplinair overleg van het verzorgingshuis en zo, dus incidenteel komt dat wel voor" -

GP10 Informal

multidisciplinary consultation inside practice

Degree to which participant viewed himself to be involved with

organizing informal multidisciplinary consultations with

stakeholders inside the practice

15/29

"ja, informeel overleg is er altijd hè. Dat is gewoon elke dag hè, dus dat is dat gebeurd

ook best veel hè. (...) Is meer ‘ad hoc overleg’ - dat zul je daar ook wel wat meer mee bedoelen denk ik." - SCH2

Exchanging

views/experiences inside practice

Degree to which participant viewed himself to be involved with informally exchanging views and

experiences concerning elderly patient treatments

17/29

"Nou ja, nummer 9 doen we wel eens (...) Willen we speciale projecten gaan doen eh? Willen

we een project doen polifarmacie, of willen we een project doen om die mensen

75-plus allemaal in kaart te brengen" - GP7

Putting effort into obtaining additional resources for

instruments/protocols

Degree to which participant viewed himself to be involved with obtaining additional resources for

treating elderly patients better

17/29

"ja daar is allemaal geld voor.

(...) geaccrediteerd dus dat betekent dat ik transparante kwaliteitzorg lever en daar is

extra geld voor. Moet je wel aanvragen dus en in een inspanning is het." - GP4

Following courses or training regarding elderly healthcare

Degree to which participant viewed himself to be involved with following courses, training sessions

or congresses that are specifically concerned with elderly patient

treatment

16/29

"ja, dat gebeurt in zijn algemeenheid wel veel meer bij huisartsen(...) het NHG congres hè ging over ouderen. (…) dat

was 2 jaar geleden"

- R2 Encouraging others to

follow courses or training with regard to elderly healthcare

Degree to which participant viewed himself to be involved with encouraging others to follow

courses, training sessions or congresses that are specifically

concerned with elderly patient treatment

18/29

"dat ja, ik denk dat ik dat wel doe. Iedereen mag ook alle nascholing volgen die ze willen

hier, dus dat (...) er wordt redelijk wat nageschoold door

de anderen ook." - SCH3

ROLE CHANGE: CONTRIBUTIONS OF INDIVIDUAL AND TEAM COPING ACTIVITIES

Abstract

Contents

1. Introduction

2. Theory

3. Methods

4. Results