‘As if they are on a different island or something!’
Strategies used by new entrants to a new profession to bridge faultlines in
inter-professional teams during innovation adoption
Joint Master Thesis
MSc Business Administration Health and Strategic Innovation Management University of Groningen
Faculty of Economics and Business
Date: 05-04-2020
Word Count: 10521 (including abstract) Supervisor: drs. N. Renting Second assessor: dr. J.D. van der Bij
Written by
Abstract
Context. Although the influence of faultlines on team performance is demonstrated in a
considerable number of studies, the influence of faultlines on innovation adoption remains undertheorized. Insights into the relationship may be beneficial for healthcare teams, as innovation adoption within the healthcare sector is perceived as difficult due to the
professional nature of healthcare teams. In order to reduce the negative influence of faultlines, a new professional with overlapping domains can serve as a broker. The value of the broker to close the professional gap is recognized, although it remains uncertain which strategies will be used. Moreover, it remains uncertain whether these strategies will have an impact on innovation adoption.
Objectives. The aim of this study is to explore the relationship between faultlines and
innovation adoption. In addition, this study aims to provide insight into the potential of a new professional to bridge professional faultlines and thus promote the innovation adoption.
Methods. I conducted a triple case study within one academic hospital focused on three
innovation projects carried out by a hospitalist in training. 15 semi-structured interviews were conducted with members of healthcare teams and formed the input for the data analysing process. A realist review approach is applied to identify the causal mechanisms, in combination with the context leading to the outcomes of the innovation projects.
Results. The results of this study point in the positive direction of a new professional as a
knowledge broker under circumstances of moderately strong knowledge and professional faultlines. On the other hand, this study also shows that under circumstances of strong hierarchical and professional faultlines a new professional is unable to be a broker between faultline groups. When no faultlines are identified, the hospitalist is able to execute the project with associated organizing and leading functions.
Conclusions. The role of the hospitalists offers an opportunity to bridge the professional
1. Introduction
Regardless of whether or not a healthcare innovation is supported by empirical evidence, innovation adoption remains uncertain (Fleuren et al., 2014). Research points in the direction of the complicated character of healthcare teams as an explanation, given their tendency to split up into professional subgroups (Ferlie et al., 2005). These subgroups, for example nurses and specialists, have the potential to operate independently and block innovations (Ferlie et al., 2005), and can be identified as the so-called phenomenon of faultlines (Lau & Murnighan, 1998). Faultlines in the literature are referred to as dividing a group into subgroups based on one or more attributes (e.g. age, profession, work experience) (Lau & Murnighan, 1998). The effect of faultlines on team performance is often negatively documented. For example, Thatcher & Patel (2012) showed that activated faultlines can lead to conflicts, inhibit the elaboration of information and reduce team performance. Moreover, activated faultlines can result in an ‘’us vs. them’’ thinking within groups, making it challenging to survive within a dynamic environment (Lotan, 2019). Although there is a well-established understanding of the influence of faultlines on several team outcomes, little is currently known about the relationship between faultlines and innovation. In order to reduce the innovation adoption uncertainty in the healthcare sector, this study explores the influence of faultlines on innovation adoption.
To explore the above-mentioned relationship, healthcare teams are considered as a suitable unit of analysis. Healthcare teams have the character to be highly professional, due to long-term traditions of well-developed professional boundaries that tend to dominate (Fitzgerald, 2008). Because of this professional character, professional subgroups are often formed within healthcare teams (Liao et al., 2015), which implies the potential existence of faultlines. Prior research that focuses on innovation adoption within healthcare teams explains several barriers, such as a lack of time for healthcare professionals to change their routines (Byers et al., 2017), professionals who fail to see the relative advantage of the innovation (Rogers, 1995) and have the conviction that change is against the professional culture (Luxford et al., 2011). However, there is only limited reference in the literature to the influence of fault lines on innovation adoption.
social system on innovation adoption but do not address the influence of certain subgroups within a social system. In addition, while research reveals that faultlines are negatively influencing innovative team performance (Xie et al., 2015; Homan et al, 2007; Kunze & Leicht-Deobald (2014)), relationship in which faultlines influence innovation adoption remains underexplored. To address this academic gap, this study aims to explore the relationship in which faultines influence innovation adoption within the healthcare context.
Reducing the negative effect of faultlines and bridging the gap between subgroups can be assigned as a task for the hospitalist. The hospitalist is a new generalist practitioner who focuses on increasing the quality of care by, for example, initiating healthcare innovations. Based on the overlapping professional domains with both specialists and nurses, the hospitalist is identified as a suitable broker between subgroups (van Offenbeek, 2004). Therefore, the hospitalist is in the position to bridge faultlines and, because of that, can aid the adoption of healthcare innovations. Although the role of the hospitalist as a broker between professional subgroups has been recognized (van Eijk, 2013), it remains unknown how exactly the hospitalist can reduce the negative effect of faultlines. Moreover, it remains uncertain how certain strategies impact innovation adoption.
In order to get a better picture of the hitherto undervalued role of the hospitalist as a broker, I will follow a realist review method (Pawson & Tilley, 1997). This method is found to be suitable to determine what works, how it works and under what circumstances. Trough the combination of faultlines theory and the realist review method, I aim to provide insight into the role of a new professional during innovation projects and the possibility to bridge faultlines to aid innovation adoption. By specifically focussing on the role of the hospitalist as a new professional, I aim to answer the following research question:
Under conditions of faultlines (context), what is the role of a new professional during innovation projects, and how effective are these strategies (mechanism) on innovation adoption (outcome) within teams?
2. Literature Review
Using ‘innovation’ and ‘healthcare’ together to search for academic literature, a large number of articles will become available. Despite the comprehensive amount of literature on healthcare innovations, there remains a clear distinguishing line between the academic field of innovation and that of healthcare (Ilinca et al., 2012). This seems remarkable, since both fields can learn a lot from each other. On the one hand, the healthcare field can gain knowledge about innovation adoption to stimulate innovation adoption. On the other hand, innovation literature overlooks the influence of faultlines on innovation adoption. By bringing together the innovation and healthcare field, this study aims to provide insights for both fields. This chapter starts by defining what innovation in healthcare means to have some background information. I will then follow the order of the CMO configuration of the realist review method by explaining the context of the healthcare teams followed-up with the explanation of faultlines. After that, I will shed a light on the task of the hospitalist as the mechanism that is followed by the concluding part about innovation adoption as the outcome.
2.1 Healthcare innovation
To improve the quality and safety of the care delivery process as well as making the healthcare system more efficient and cost-effective, healthcare organizations make use of innovations (Höög et al., 2013). Innovation is a buzzword within the healthcare sector, but it is still difficult to define what it exactly means (Kimble & Massoud, 2017). In the innovation literature, innovation is often defined as ‘an idea, practice, or object that is perceived as new by an individual or another unit of adoption’ (Rogers, 2003, p. 990). While in other sectors innovation is often related to making profit, within the healthcare sector, it is seen as a common way to improve the quality of the care delivery processes (Lee et al., 2009).
and cost and time savings, innovation literature generally pays more attention to product innovations (Piening & Salge, 2014; Hervas-Oliver et al., 2014; Un & Asakawa, 2015). In line with the goal of the healthcare sector to continuously improve the quality of their care processes, I will bridge to between the healthcare literature and the innovation literature and contribute to a better understanding of process innovations. By doing this, this study will aid in the process to close to gap between the best medical advice and the delivered care (Kyratsis et al., 2012)
2.2 Context: Healthcare Teams
Literature describes healthcare teams as the composition of multiple professionals who are brought together by requirement to deliver a complete healthcare cycle (Sicotte et al., 1993; Fitzgerald, 2008). In order to deliver the best possible care, healthcare team members are characterized as highly dependent on each other, which requires not only that they are a skilled practitioner of their discipline, but also that they are good team players (Fitzgerald, 2008). Compared to teams from other sectors, healthcare teams are more dynamic because they often change of team members, work together for a short period of time and have to integrate team members with different professional cultures (Manser, 2009). In addition, healthcare teams must be able to cope with the rapid developments in the sector (Leipzig et al., 2002) and provide safe care, which makes good collaboration a prerequisite (Leggat, 2007; Schmutz et al., 2019).
2.1.2 The influence of Faultlines
Diversity within teams refers to the extent to which there are similarities and differences between team members and appears to have both positive and negative effects on team performance (van Knipperberg et al., 2010). While some authors argue that diversity contributes to a better team performance as a source of information, knowledge and expertise (Harrison & Klein, 2007), others argue that too much diversity will lead to an increase in team conflict (Homan et al., 2007). In 1998, Lau & Murnighan expanded the diversity thinking and introduced the phenomenon of faultlines. Faultlines are defined as hypothetical lines splitting a group into relatively homogeneous subgroups based on one or multiple attributes (Lau & Murnighan, 2005). Those attributes were originally demographically based (e.g. gender, age, ethnicity), but nowadays research based on functional background, educational background, status disparity, and organizational background is also included in the faultline literature (Meister et al., 2019).
Since it is almost unfeasible for teams to consist of different individuals having the same attributes, every team has the potential to split up into faultline subgroups. In line with this conviction, Thatcher & Patel (2012) recognize that faultlines can be dormant (not perceived by the subgroups) or active (when group members actually perceive subgroups based on attributes). Dormant faultlines can be converted into activated faultlines as a result of a specific event, for example organizational change (Meyer et al., 2015). Meister and colleagues (2019) also reveal that the impact of faultlines often changes over time and can be seen as a dynamic concept rather than a stable state. So, while a dormant faultline can be activated as a result of an event at a certain point in time, the impact of that specific faultline can change afterwards.
The current literature describes mixed findings regarding the influence of faultlines. For example, Richard et al. (2019) found that educational faultlines negatively influence strategic change decisions, while task related faultlines positively influences strategic change. Moreover, faultlines can lead to a risk of colliding, leading to conflicts, and disintegration within teams (Bahargam et al., 2019). This stems from the tendency of faultline subgroups to stay with their own subgroup members, as they have the same values, scripts and assumptions and promote communication with own subgroup members (Lau & Murnighan, 2005). On the other hand, faultline groups have the potential to be effective when team performance consists of divisible tasks (Lau & Murnighan, 2005). In addition, Gibson & Vermeulen (2003) state that teams with moderately subgroups learned more, compared with groups with no or strong subgroups. While the influence of faultlines on team performance is demonstrated in a number of studies, innovation literature exploring the impact on innovation adoption has not been explored yet.
2.3 Mechanism: The role of a new professional
In response to healthcare capacity and continuity problems, several hospitals in the Netherlands have introduced the hospitalist. The hospitalist is a general doctor who is specialized in improving the quality of the care delivery process and focuses more on the patients’ domain than on a speciality (Kathan-Selck & van Offenbeek, 2011; van Offenbeek, 2004). Within the Dutch healthcare setting, the hospitalist is described as: ‘the connecting factor in the
multidisciplinary medical setting. The hospitalist works effectively with medical specialists but also with other care professionals, such as nurses, nursing specialists and physician assistants, and with non-caregivers, e.g. hospital managers’ (SOZG, 2012, p. 2). On the one hand, the
hospitalist supervises and coordinates the nurses and on the other hand takes over the general tasks of the specialists. Furthermore, administrative tasks and quality improvement projects aiming to improve the care delivery processes are also examples of the range of tasks of the hospitalist (van Offenbeek et al., 2018).
hospitalists often act in an environment with professionals who are unfamiliar with the precise functioning of the hospitalist and may feel that the hospitalist is threatening their profession. The job description of the hospitalist describes that a hospitalist should be a team player, a coordinator, collaborator and a knowledge contributor (VVZG, 2020). To date, however, there is a lack of practical insights into the performance of the hospitalist.
In their faultlines literature review, Thatcher & Patel (2012) briefly shed a light on the influence of a new member entrant within faultline-based subgroups. Results show that when there is a change in the team composition, the level and the strength of the faultline may change significantly. A new entrant potentially changes the characteristics of a team, the evenness of subgroups, and the number of subgroups and may result in different faultline groups. In response, Mäs et al. (2013) studied the influence of certain actors within groups with demographically overlapping attributes, defined as crisscrossing actors. Those crisscrossing actors can function as a bridge between multiple subgroups based on their shared attributes. The authors found significant evidence referring to the positive effect that crisscrossing actors can have to overcome polarization within faultline teams, even in teams with strong faultlines. Considering the ‘in-between’ character of the hospitalist, the hospitalist can act as a crisscrossing actor between the professional groups of nurses and medical specialist. However, more empirical results should provide insights into the effect of new member joining within existing faultline-based teams (Thatcher & Patel, 2012)
2.4 Outcome: Innovation Adoption
Rogers (1995, p.2) defines innovation adoption as: ‘the process through which an individual or
other decision-making unit passes from first knowledge of an innovation, to forming an attitude toward the innovation, to a decision to adopt or reject, to implementation of the new idea, and to confirmation of this decision.’ Due to the popularity of innovation adoption as a research
suggest multiple steps of the process, innovation adoption is often conceptualized as one single event phenomenon (Damanpour & Schneider, 2006).
According to Cooper (1999) there are two sets of success factors for innovation adoption: ‘doing the right projects’ and ‘doing projects right’. Ideally, combining those two sets will in the end lead to innovation adoption. Although this simplified perspective, innovation adoption is often considered as a highly complex process. Complexity arises from many different factors. For example, Solomons & Spross (2011) reveal that a lack of time and lack of awareness among adopters lead to nonadoption. In addition, Shea et al. (2018) argue that quality improvement projects developed bottom-up (from within practice) are earlier adopted. The same authors also suggest that there should be synergy between top-down mandates and internally derived priorities to achieve change.
Within the innovation literature, a well-known innovation adoption theory is the innovation of diffusion theory of Rogers (1995). This theory describes innovation diffusion as a process whereby an innovation is communicated amongst members of a social system through channels over time. The author argues that the structure of the social system influences innovation adoption (Rogers, 2003). According to Rogers, there are five innovation characteristics that explain the adoption decision: first, the innovation must have a relative advantage from the point of view of the adopters (e.g. effectiveness, cost-effectiveness). Second, the innovations should be compatible with the values, norms and perceived needs of the intended adopters. Third, the complexity of the innovation must be relatively low, because simple innovations have a greater possibility of being adopted (Denis et al., 2002). Fourth, if it is possible to experiment with the innovation, innovations are more easily adopted, described as innovation triability. Finally, the benefits of the innovation should be observable for the innovation adopters.
3. Methods
3.1 Conceptual Orientation
In order to analyse the role of the hospitalist during innovation projects, a realist review approach was chosen as a suitable conceptual stance. Realism is a philosophy of science that is positioned between positivism and relativism (Rycroft-Malone et al., 2010). Based on this position, the approach acknowledges the existence of a ‘real world’ that is interpreted through the inputs of people (Pawson et al., 2005). The method evaluates ‘what works for whom in what circumstances and in what respects, and how’. In order to explain a particular intervention out of observed data, the realist approach proposes that the observed outcomes (O) are the result of mechanisms (M) and this causal process is formed by the social context (C) in which they occur (Pawson & Tilley, 1997). Following the sequence of the ‘CMO’ configuration (see Fig. 1 for an example), a context (C) can refer to a certain setting in which the intervention took place, but can also include cultural norms, existing social networks, or an organization or culture. Mechanisms (M) are defined as forces that closely interact with the context in order to come to outcomes (O), referring to a change due to the intervention. The outcomes can either be intended or unintended, proximal, intermediate or final (Kirsh et al., 2017).
3.2 Case site and participants
The UMCG is one of the largest Dutch hospitals in the Netherlands with approximately 12,000 employees. Given their mission to use knowledge to innovate care (Mission and Vision UMCG, 2020), the UMCG was identified as a suitable unit of analysis to gain insights on innovations. The main pillars of the UMCG consist of patient care, science and research, and education. Furthermore, the UMCG was one of the four Dutch hospitals that started training hospitalists.
Based on the project documentation of the innovation projects we received prior to the interviews, relevant project participants were identified based on purposive sampling (Etikan, 2016). To define the healthcare teams, we included individuals who participated in the project, but because of the high turnover of team members also professionals who were familiar with the project or were affected by the project were included. These participants were all invited by e-mail by a PhD candidate (LHM). As the projects took place in 2016 & 2017, we added the project documents to the e-mails to make sure that the respondents were aware of the existence of the projects in advance of the interviews. In order to get a more reliable picture of the innovations, we interviewed respondents with different positions within the hospital and different functions during the project. An overview of the respondents is shown in table 1.
Case Department Occupation Gender Interview
duration in minutes
DELI Surgical Quality Officer F 52
DELI Surgical Quality Officer F 68
DELI Surgical Head of nursing M 54
DELI Surgical Nurse F 18
TRANS IVZ Head of nursing F 35
TRANS Surgical Quality Officer M 56
TRANS INU Nurse F 29
TRANS Hospitalist in training F 54
TRANS INU Room doctor M 9
TRANS ICU Chef de Clinique M 30
DONA Hospitalist in training F 62
DONA Nephrology Transplantation Coordinator F 35
DONA Nephrology Quality Officer F 37
DONA Surgical Quality Officer F 24
DONA Surgical Programme Director
hospitalists in training
M 61
3.3 Project definitions
This study analysed three innovation projects carried out by hospitalists in training at the UMCG. As part of their final six months of training, the hospitalists had to develop, launch and implement a quality improvement project aimed at the quality and safety of the patient within their own clinical setting (Stichting Opleiding Ziekenhuis Geneeskunde, 2012).
The inclusion criteria for this study were that all projects had been completed, so that the adoption phase was well advanced, and effectiveness could be determined. Moreover, all the innovation projects were selected on the basis of their process-related nature. This meant that there had to be a change in the way the team members worked together due to the implementation of the innovations. Below I will present a summary of the three projects.
Delirium prevention in frail elderly (DELI). This project took place at the Vascular surgery
and Hepato-Pancreato-Biliary surgery and liver transplantation nursing ward. This project was the first to be carried out by a hospitalist in training within the UMCG and started in April 2016 and ended in October 2016. The motivation to start this project was because of a fatal accident with a patient, which could be possibly be prevented by using the Delirium Observation Screening Scale form (DOSS). The DOSS form is an observation tool for the recognition of the phenomena of delirium and are intended for patients aged 65 and older, as the potential risk group for developing delirium. Based on the results of a clinical audit in 2014, it appeared that the DOSS forms were not consistently tracked by the nurses and room doctor: DOSS forms were used only in 1/3 of the patients at risk. Although following the DOSS forms are nursing activities, the room doctor is responsible for whether the patient has the potential to develop delirium or not. The aim of the innovation project was to increase the use of the DOSS forms in order to improve subsequent delirium prevention actions. Recommendations at the end of the innovation project consist of team education about delirium, measuring the use of DOSS-forms by nurses, use the DOSS digitally instead on paper, increase the awareness within the team about delirium and give team members feedback if DOSS forms were not used.
Patient transfer from the Intensive Care Unit (ICU) to the Intensive Nursing Unit (INU) (TRANS). This project started in July 2016 and ended in December 2016 at the Intensive
communicate well with the ICU physician about the transfer and the details regarding the condition of the patients. Based on the existing agreements at the start of the project, the transfer was considered to be sub-optimal, resulting in unclarities about the care needs and medical prescriptions. Therefore, the aim of the project was to adjust the appointments in order to improve transfer. Points for improvement in the working arrangements are threefold. First, the nurse can consulate the responsible room doctor about the upcoming transfer of the patient. Second, the ICU is responsible for the patient, which is described in the ICU letter. This one is in force until the assistant physician has seen the patient and worked out the medical policy. This policy should be made before the end of the day shift of the nurse. Third, The ICU bears responsibility for the patient until discharge from the ICU to INU.
Kidney donation during life (DONA). This project was aimed to improve the current care
delivery process focussing on the patients who donated their kidney and took place in the nephrology department. Based on the ISO1 certificates the hospital received that previous year, the department aimed to get better insights about the experiences of the living donors. Through a so-called ‘mirror-meeting’, the hospitalist gave the healthcare professionals information about past experiences of the donors. As a result, care process improvements were formulated. Compared with the two other cases, the actual process of the project was really different. The mirror-meeting was a concept the hospital was already familiar with, so the hospitalist task was to organize the meeting and formulate improvement steps in collaboration with the healthcare professionals. All the healthcare professionals were interested in the patient experiences’ and therefore supportive towards the project and the hospitalist. The project identified areas for improvement based on the information that the patients received before and after the donation, the time of admission of the patients was rearranged, and the donor coordinators involved in the process were advised to collaborate with the surgeons to reduce the waiting times of the patients before the donation took place.
3.4 Data Collection
other four, and we exchanged transcripts of the interviews. Prior to the interviews we compared our interview protocols to ensure that the questions of both protocols were asked during the interviews. We used the UMCG as the location where the interviews were conducted to get more contextual background of the projects and for practical reasons, because all respondents were working during the interviews. An exception to this were the 2 interviews with the hospitalists that were conducted via Skype because they were working abroad at that time (department boxes left white in table 1).
For the initial interviews (n=5), we followed a visualization technique in order to overcome one-to-one interview challenges, for example, a lack of memory about the projects (Comi et al., 2014). Visualization techniques proved to be a suitable tool because it can serve as a means of eliciting deeper answers trough cognitive stimulation to the respondent. Moreover, it was used to provide an image that represented the team as the unit of analysis. After the initial interviews using this technique, I decided to abandon the visualization technique, because during the interviews it was experienced as a distraction than as a supporting tool for the respondent. Due to this, explicit data from the visualization technique has been omitted for the data analysis process.
3.4.1 Semi-structured interviews
During the interviews an interview protocol was used as a guideline to get information about the project from the respondents. The protocol was used in order to explore the role of the hospitalist in training during the projects. In addition, questions were asked about the role and influence of the healthcare team members, as well as questions about the implementation of the improvement actions. Because the interview protocol served as a guideline, response questions were asked on the basis of the respondents’ answers, which were not included in the interview protocol. During the first part of the interview, broad, open questions were asked to the respondents: ‘Can you tell me something about the project?’. More in-depth questions based on the literature were asked afterwards: ‘To what extent did you experience the influence of
different professionals or professional subgroups during the project?’. Also, based on earlier
interviews we asked respondents to give their opinion about findings: ‘We heard that the other
department is quite hierarchical and difficult to approach, what is your opinion about that?’.
3.4.2 Secondary data
An additional task during the projects for the hospitalists was to write a document about the project. The document comprised of a literature review about the topic, the data collection method(s), results, recommendations and a reflection on the project. For this study, these project documents were used to gain more contextual insights into the projects prior to the interviews. They also served as a useful tool to improve the quality of the interviews and to compare the intentions of the projects with the results achieved.
3.5 Data analysis
After verbatim transcription of the interviews, I converted the transcripts into Atlas.ti 8.1.3 for coding. In addition, a short memo was written per interview and per case. The memos served as a memory aid for myself, to understand what kind of data was collected and what information was still missing, what I could ask the following respondents.
When following the CMO configuration, the first analysing step was to initially code the transcripts in terms of phrases of sentences related to contexts (C), mechanism (M) and outcomes (O). During this first step, the data was analysed on the basis of attention of the outcome of interest (Byng et al., 2005). Phrases were coded if they were identified as concepts that could possibly answer the research question. In the second step, CMO codes were grouped according a certain category. For example, the following context code was first defined as ‘experienced differences between different types of professionals’: ‘We said very clearly; this
is a nursing intensive care, not a medical one. You can still see that they find that very difficult.’ (Jaap, Head of nursing), after which it was added to the category ‘professional faultlines’. The
criteria for classifying a phrase as context was that it described something that existed prior to the innovation project. This often referred to the state of the care process or the culture of the department. Mechanisms rereferred to actions or activities of the hospitalist during the process of the project. A phrase was coded as an outcome if it illustrated a change based on the mechanisms.
and 25 outcomes codes. After the second step, the data was grouped in 3 mechanism topics, 4 context topics and 4 outcome topics.
3.6 Operationalization of faultlines
The identification of faultlines deserves attention based on the variety of operationalizations in the current faultline literature. In table 1, an overview of the relevant definitions is provided used for the operationalization of the relevant concept out of the obtained data.
Concept Definition
(Potential) Faultline Hypothetical lines splitting a group into groups based on one or multiple attributes (Lau & Murnighan, 1998)
(Potential) Faultline strength The degree of alignment of individual attributes of team members.
This means that a strong faultline indicates that the alignment of attributes among team members results in homogeneous subgroups, whilst a weaker faultline indicates that the attributes are loosely aligned (Meister et al., 2019). When the differences between subgroups had a major impact on a team outcome, for example on collaboration, the faultline was identified as strong.
Dormant Faultline Potential faultlines indicating the differences between individuals, but not directly resulting in subgroup formation.
Activate Faultline When a dormant faultline becomes active. This activation process can be influenced by a certain trigger, such as a change in working routines.
Faultline type A common category of attributes that underlie possible faultlines (Carton & Cummings, 2012). For example, profession, gender, education.
Table 2: relevant definitions (Retrieved from Meister et al., 2019)
3.7 Ethical considerations
4. Results
In this chapter I will first provide a theoretical case description that sheds light on the identified faultline(s) per case and on the strategies of the hospitalist in training during the projects. Subsequently, I will discuss the effectiveness of those strategies on innovation adoption. As a result, the found CMO-configurations will be presented in table 3. After that, I will further elaborate on the patterns, differences and similarities based on the cross-case analysis.
4.1 Within case analysis 4.1.1 DELI
The fatal accident that led to the start of this project revealed the differences within the healthcare team to the surface. In terms of knowledge about delirium, the team members experienced differences between room doctors and the nurses, which created a knowledge-based faultline. This is illustrated by the fragment below, which explains how the room doctor and nurses worked together in recognizing delirium in patients before the start of the project:
‘Delirium patients have many good moments, but also many bad moments. And during the bad moments the nurses see much more of the patient than what the doctor sees. So, the doctor needs the nurses there for those observations. And then at a certain moment you can't say as a doctor; no, delirium, that it is not the case!’ (Jaap, Head of nursing)
While before the fatal accident this knowledge-based faultline between the room doctors and nurses was experienced as dormant, the faultline became active due to the accident that caused the start of the project. Of course, respondents pointed to the severity of the accident, but in essence it was emphasized as something necessary to improve the care process and to reduce the knowledge gap between the room doctors and nurses. The following fragment illustrates that improvement of the care delivery process was needed:
‘This was, of course, a dramatic incident. But it was the reason to do something. Anyway, that's been going on for years. That we hadn't quite got that piece right in the care chain.’ ‘Sometimes you just need something to get everything listed’ (Loes, Nurse)
knowledge-based faultlines and shows how nurses and room doctors were separate groups with regard to the lessons they received about delirium:
‘We as nurses have had lessons about this subject before. We noticed at some point and we have mentioned that; that those education lessons seemed to become ''nursing parties''. While it's actually a multidisciplinary event. That is often the case with these kinds of things, everyone who's worried about it, except the doctor himself. While, of course, it's a joint responsibility to share that with each other.’ (Jaap, Head of nursing)
The analysis showed that the hospitalist in training performed teaching tasks to her fellow room doctors about delirium. As a result of the teaching tasks, the shared understanding of delirium among nurses and room doctors has improved, resulting in better team collaboration. The hospitalist in training was able to perform the teaching strategy because she was familiar with both the nurses and the room doctors. This was because during the project the hospitalist in training performed the function of room doctor and hospitalist at the same time. The fragment below describes the teaching role:
‘The hospitalist has also given training to the doctors.’ ‘They do understand the art of explaining it well to the nurses and fellow room doctors and to the supervisors, so of the image, like a delirium.’ (Ina, Quality Officer)
Due to the task of the hospitalist as a successful broker, innovation adoption was realized. The DOSS-forms were used more consistently, the level of knowledge within the healthcare team had become more balanced and subsequently the collaboration between the nurses and room doctors improved. This is illustrated with the fragment below, in which the nurse explains the difference in collaboration over time:
‘We are now much more involved in the delirium prevention chain. And you can also see for example, that delirium cases suddenly happened to us three years ago. Then a patient came back from surgery, and he got delirium. And then you're actually a little too late. So, if you can do all your surgery preventively, the doctors are already involved. So, they know they have to ask geriatrics right away. So that's just the care chain, and that's where the doctors come in as well. So, the care cycle goes on and on.’ (Loes, Nurse)
4.1.2 TRANS
the two departments, collaboration was necessary. Although the project was recognized as important by both departments, strong professional differences hindered the achievement of the project goal. Several attempts by the hospitalist in training to contact the ICA did not receive a response and due to time constraints of the project, the hospitalist in training decided to continue without the involvement of the ICA. In the fragment below, the hospitalist in training explains the perceived barriers:
‘Then I also tried to make contact with the IC. Because it's actually a project you have to do together. Only the IC here is so big and so cumbersome and so overcrowded. At a certain point I kept trying to contact the IC and it didn't work for a meter.’ ‘That was a stumbling block’
The professional faultlines the hospitalist in training experienced did not come as a surprise. The surgeons of the ICA were described as professionals who are mainly interested in ‘surgical’ tasks, such as doing medical interventions, with a sceptical view towards innovation projects. This is illustrated by the fragment below, in which the hospitalist in training explains the way surgeons think about innovation projects:
‘And of course, you became a surgeon because you love surgery and stuff like that. And then this project is another task in addition to the many tasks they have to perform. That's not really something they're excited about’
The respondents also reflected on the differences with the ICA surgeons as a cultural phenomenon within the hospital. It was indicated that surgeons are considered to be higher in hierarchy compared to professionals of other departments. The hospitalist explained that these hierarchical faultlines formed a barrier when approaching the ICA. Moreover, as the hospitalist in training explains in the fragment below, her pioneering position was also perceived as a barrier, as she was not seen as a 'full-fledged' doctor:
‘UMCG is quite hierarchical in that. And the IC is really ''the IC'', really the kingdom. And you were ''only'' an ANIOS2. That was always what you thought; I have to email someone I don't
know; I don't know even what he looks like at. You couldn't talk with someone either. That was a real threshold for me. Everyone said; yes, he's very nice. But if you can't make contact with someone...’
Because of the project, the dormant professional and hierarchical faultlines became active. However, it was also illustrated as something that confirmed the already existing vision of the way the ICA professionals thought about the other professionals:
‘It has always been like this, the IC is really a loose kingdom, a loose pillar. As a room doctor you have very little contact with them, you hear very little from them.’ (Gerda, Hospitalist in training)
As the above-mentioned fragments illustrate, the hospitalist in training tried to organize and to get in contact with the ICA. However, the strategies were not effective which resulted in nonadoption of the innovation. The hospitalist in training mentioned that the way in which the subject of the project initially evolved had significance impact on the process of the project. This was because the subject of the project resulted arose from her personal frustrations and there was no shared sense of urgency about the project. In the end the professional and hierarchical faultlines between her as a hospitalist in training and surgeons of the ICA were perceived as too strong.
4.1.3 DONA
In this case, the faultlines remained dormant and were not activated by the project. Although the hospitalist in training carried out the project in a different healthcare team than she was than she was accustomed to working in, no faultlines were experienced. Explanations why no faultlines were identified referred to the characteristics of the project and the way in which the subject of the project was formed. The project arose from the desire to get more information about the living donation patients, and there was support for the project from the perspective of the healthcare team. However, there was no real sense of urgency to innovate, the project was seen more as a valuable extra that could potentially improve the care processes. In addition, the size of the people involved in the project was limited and the hospitalist did not need to collaborate with large professional groups.
The hospitalist in training explained that it was easier for her to carry out the project because she did not work within the healthcare team and was unfamiliar with the team members. She stated that giving feedback to the healthcare team to improve their care system was felt to be comfortable because she was not personally involved in the healthcare team. In the fragment below, she refers to this:
‘And that didn't make it hard for me to tell them what needed to be improved.’ (Lotte, Hospitalist in training)
Because there was no influence of faultlines experienced during this case, the hospitalist in training was able to perform the tasks which were required from her. Based on the character of the project, she explained that the tasks were mainly organizationally related. The fragment below provides as an example of how the hospitalist in training experienced her organizing role:
‘That you had to call the patients, arrange the parking allowance, the people all received a VVV voucher for their participation. I remember that I also asked via-via and wondered who I should be with. Although you actually think yes, people may have to say they could arrange it and knew how to do it. So also, all kinds of small things that I thought; I had to do it all by myself.’ (Lotte, hospitalist)
The outcomes of the project were perceived as valuable insights for the healthcare team. Based on the information provided by the hospitalist in training, practical improvements have been made to the care delivery process. For example, a survey has been developed, as the fragment below illustrates:
4.2 Cross-case analysis
In the previous section I developed the CMO configurations per case. In this section I will integrate the results of the three cases by discussing the identified patterns as well as the differences and similarities. As a result, I developed the model shown in figure 2, which is explained below.
The three cases I studied showed the complexity of the phenomenon of faultlines. The DELI case serves as an example of knowledge and professional faultlines, while I found professional and hierarchical faultlines in the TRANS case. In addition to those two polar cases, no emergent faultlines were identified in the DONA case. The two faultline cases showed both that the innovation projects triggered the activation of faultlines. However, the effect of the activation of the faultlines was the opposite. While the activation with the DELI case was experienced as necessary to change leading to support of the healthcare team, the activation of the TRANS faultlines led to a collaboration constrains of the healthcare team.
Also, the strength of the identified faultlines differed between the DELI and the TRANS case. The knowledge differences between the room doctors and nurses created a moderately strong faultline between the two professional groups. These faultlines were labelled as moderately strong because the two faultline groups shared the attribute that they were working within the same department, instead of divided over two departments. With the TRANS case the professional faultline was identified as strong, based on the differences between both the professionals and the departments.
On the basis of the data analysed, an additional factor was considered important to include in figure 2. The collaboration constrains and support for the project were both moderated by a sense of urgency for the project. The hospitalist in training of the TRANS case explained that there was no sense of urgency for her project due to the fact that there was no real problem, but more a problem she experienced personally. This is explained with the fragment below:
a real problem, like with the projects of my hospitalist colleagues’ (Gerda, Hospitalist in training)
Considering the roles of the hospitalists in training, several similarities were found. All the hospitalists in training described that they were assigned as the project leader and had to organize the process of the project. Leading and organizing the project consisted of tasks such as organizing meetings, measuring current care processes to identify the improvement possibilities, writing the paper associated with the project and giving the final presentation. What emerged from the data was that the roles the hospitalists in training had to fulfil were perceived as challenging. Respondents stated that the hospitalists’ pioneering position influenced the difficulties encountered in performing the roles. The data showed that both the hospitalists in training and the healthcare teams found the role of the hospitalist difficult to define. This barrier is described with the fragment below, explaining the pioneering position of the hospitalist:
‘As a hospitalist, that's a new position here, you're a little in between doctors. And nurse specialists who already have their role a little bit, like; this is what you do, and that is clear. But, of course, the hospitalist was new, and she had to pioneer a little. And she found that very difficult because she didn't have any sparring partners.’ (Pien, Nurse).
Overall, two of the innovation projects can be labelled as adopted. Result showed that the DOSS forms of the DONA case were used more because of the project, with unintended outcomes of better team collaboration and an increase in knowledge. Knowledge-based faultlines and professional faultlines also weakened as a result of the strategies of the hospitalist in training, especially as a knowledge broker. In the quote below, the changed situation in terms of collaboration is explained:
‘While it is, of course, a joint responsibility to share that with each other. I think that's changed, and for the better.’ (Jaap, Head of nursing)
‘Everyone was actually very excited to go on and do things with the projects after it ended. To make improvements and adjustments, to really get the actions out of it. (Lotte, Hospitalist in training case)
On the other hand, the TRANS case was labelled as nonadopted by the respondents. As below fragment explains, patient transfer problems are until date still a problem:
5. Discussion & Conclusion
5.1 Principal findings and meaning
This study originated from the need to gain insights into the role of faultlines on innovation adoption. This study has shown that, in the studied cases, faultlines indeed can have an impact on innovation adoption. In line with the study of Ferlie et al. (2005) the findings suggest that, especially with strong influence of activated hierarchical and professional faultlines innovations can be blocked. Moreover, I was interested in how a new professional possibly can act as a broker between faultline subgroups, how this happens and what the impact is on innovation adoption. By following a realist method, I found that under circumstances of moderately strong professional- and knowledge-based faultlines, it was possible to break through those faultlines when the new professional followed the strategy of the knowledge broker. With this finding it should be taken into account that the knowledge teaching strategy was effective under circumstances of a supportive healthcare team context and a strong sense of urgency for the innovation. On the other hand, strong, professional and hierarchical faultlines were unable to break through under conditions of a low sense of urgency. Under these circumstances, the identified organizing and leading strategies were experienced as ineffective. When the new professional experienced dormant faultlines, the results showed that the leading and organizing strategies were perceived as effective, leading to innovation adoption.
5.2 Theoretical interpretation
profession. Second, preliminary innovation literature largely underestimates the influence of faultlines on innovation adoption. Scholars acknowledge the fact that innovation adoption is influenced by a social system (Rogers, 1962; Kelman, 1958), however, they do not address the influence of faultlines within a team. Therefore, this study enriches the innovation adoption literature by offering an explanation.
5.3 Strengths & Limitations
Prior faultline studies explored the influence of faultlines by using pre-defined subgroups in a laboratory setting (Choi & Sy, 2010). This means that faultline researchers often utilize an experimental format, in which faultline groups are created instead of naturally evolve (Gover & Duxbury, 2012). In this study I took a different approach, by exploring the influence of faultlines using a qualitative research method. By using this data collection method, I was able to illustrate the influence of faultlines close to the reality.
Several limitations of this study should be noted as well. First, the choice to examine the role of the hospitalists in training only within one hospital might constrain the generalizability of the outcomes. The results of the three cases are validated within this specific setting, although the transfer of the results of this study to other settings may not be guaranteed.
Secondly, I experienced a recall bias during the interviews. Because all the projects were carried out in 2016 and 2017 almost every respondent mentioned that they had problems with remembering specific events. In line with this, the context-mechanism-outcome configuration might be affected by other events after the project ended. On the other hand, because the projects have been finished a long time ago, I was able to assess the long-term effectiveness of the projects.
Third, as the realist approach relies on the interpretation of one researcher, differences would possible occur when the data is re-analysed by someone else, therefore a possibly researcher bias might occur.
5.4 Implication for practice
Furthermore, this study’s findings may be of practical value for the educational program of hospitals to become a hospitalist. In order to safeguard the quality of the programme and the effectiveness of the projects carried out by the hospitalists in training, supervisors must be aware of the possible difficulties the hospitalist may encounter during their project, especially in establishing contacts with other professionals as a pioneer. To solve this, hospitalists in training can be mediated during the project if they need to get in contact with other professionals. In addition, the findings serve as a practical guide for the hospitalists in training providing information about their role within the established professional healthcare setting.
5.5 Future Research
Further research in other hospitals is encouraged to increase the understanding of the role of the hospitalists in training during innovation projects. In order to get a better answer, innovation projects should be studied with outcomes which are more quantifiable than based on opinions of respondents. In addition, the innovation projects investigated must have been completed, but not too long ago to avoid a recall bias. Otherwise the dynamic environment of healthcare can influence outcomes.
Second, for this study I was unable to collect demographic data of the healthcare teams. This offers an additional avenue for further research, because by adding demographic data, a more comprehensive picture of the influence of faultlines on innovation adoption can be drawn. Third, whilst the innovation projects in this study were part of the training of hospitalists, I encourage future research on innovation projects of graduate hospitalists. This would contribute to create a better understanding of the role of the hospitalist and in defining the role of the hospitalist in the professional healthcare setting.
5.6 Conclusions
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