MASTER THESIS “IT self-leadership: the way to adapt to a new IT system?”

(1)

MASTER THESIS

“IT self-leadership: the way to adapt to a new IT system?”

University of Groningen Faculty of Economics and Business

MSc. Business Administration Change Management 20 October 2016 TINYCE WASSENS Thomsonlaan 237 2565 JD ‘s Gravenhage y.t.wassens@student.rug.nl Student number: 2128012 Supervisor: dr. O.P. Roemeling Co-assessor: dr. Maris-de Bresser

(2)

ABSTRACT

Nowadays, healthcare organizations make large investments in information technologies (IT). However, IT is often not used to its full potential by users because they struggle to adapt to new IT systems. In this way, IT investments do not deliver the promised benefits for healthcare organizations. Therefore, this qualitative research explores how healthcare teams adapt to a new IT system. This study provides a deeper understanding of which motivators are important to individuals to engage in IT adaptation behaviors. It gives a more comprehensive conceptualization of intrinsic motivation, by exploring the concept of IT self-leadership, leading to a new research field. To get a deeper understanding of these phenomena, a multiple case study was conducted. Teams within two different hospitals tried to adapt to a new smartphone. The findings reveal that high IT self-leadership as an intrinsic motivator led to individuals engaging in exploitation and exploration-to-innovate behaviors. High IT self-leadership also indirectly influenced the IT adaptation on team level. So, IT self-self-leadership plays an important role in IT adaptation processes.

Keywords: IT adaptation behaviors, healthcare teams, information technologies, IT

(3)

1. INTRODUCTION

The attempt to provide equitable, safe and effective health services, while containing costs, is becoming a big struggle in the healthcare environment (Hughes, 2006). Information technologies (IT) are proclaimed as one of the solutions to these health challenges. However, healthcare teams often underperform in the adoption of these information technologies, not using the IT system to its fullest potential (Jasperson, Carter, & Zmud, 2005). Thereby, preventing the healthcare organizations retrieving the promised benefits from large investments in IT. So, using technology to its full potential remains a major challenge for healthcare organizations implementing information technologies.

Following the implementation of a new IT, users have to deal with big changes in their work environment and experience multiple expected and/or unexpected consequences (Boudreau & Robey, 2005; Morris & Venkatesh, 2010). Prior research has noted that users perform adaptation behaviors as an attempt to cope with new IT systems that resulted in changes and interruptions in their work (Bala & Venkatesh, 2015; Fugate, Kinicki, & Prussia, 2008). Bala and Venkatesh (2015) identify four IT adaptation behaviors which will be used in this research: exploration-to-innovate; exploitation; exploration-to-revert and avoidance. Despite the fact that user adaptation behaviors are widely accepted as key to understanding several important issues related to implementation and usage of IT in organizations, there is limited understanding of the topic (e.g. Pinsonneault & Beaudry, 2005; Jasperson, 2005).

(6)

organizations to benefit from IT investments, users have to proactively explore the IT system and discover innovative ways of applying the system to support their own task performance (Wang, Li, & Hsieh, 2011). According to a study of Li et al. (2013) intrinsic motivation is an important indicator for routine use and innovative use. Next to that, healthcare information technologies are often complex systems, which provide a wide variety of features for users to explore and appropriate, which significantly challenge users of such IT systems (Sykes, Venkatesh, & Gosain, 2009). However, information technology exploration is usually not specified in healthcare job descriptions and depends largely on initiatives from individual users (Karahanna, Agarwal, & Angst, 2006).

When individuals innovate and explore new IT systems on their own initiative, without a task description demanding this, it indicates a form of self-leadership in the field of IT. Where self-leadership is defined as the process of influencing or leading oneself without directions from task descriptions to enhance performance (Carmeli, Meitar, & Weisberg, 2006; Manz, 1986), IT self-leadership refers to the behavior of an individual or team to use, redesign or recombine IT systems in novel and creative ways to enhance performance, while there is no task description which ask for the use of this system. IT systems can include software or hardware, where both can contribute to self-leadership (Shinjeng, Zimmer, & Lee, 2014). However, the interchange between self-leadership and IT has not been studied. The concept of IT self-leadership can possibly provide a richer conceptualization of intrinsic motivation as an indicator for IT adaptation behavior. Therefore, IT self-leadership is approached in this research as a part of intrinsic motivation. Whilst, there are multiple studies linking self-leadership and innovative behavior, the possible connection between self-self-leadership and adaptation behaviors have had limit attention in the literature (See Appendix 1: systematic literature review). Hausschildt & Konradt (2012) found a positive relation between self-leadership and individual task and team member adaptivity and innovative behavior can be connected to the IT adaptation behavior of exploration-to-innovate.

(7)

can provide a richer conceptualization of intrinsic motivation regarding IT use. Managers can use these insights to facilitate IT self-leadership within their teams as a strategy to enhance team adaptation and thereby performance.

Therefore the research question of this study will be:

“ How does IT self-leadership play a role in the adaptation process to a new IT system in a healthcare context?”

Subquestions include:

• Why do users perform IT adaptation behaviors?

- What are motivators for team members to adapt to a new IT system? - What behaviors do team members perform to adapt to a new IT system? • How does IT self-leadership influence the team adaptation processes?

Figure 1 – Conceptual framework team adaptation

(8)

2. THEORETICAL FRAMEWORK

In this section, the different constructs of this research will be explained by means of a literature review. First, the concept of IT self-leadership will be introduced and explained. Next, a deeper understanding will be provided of team adaptation in a healthcare context.

2.1. IT self-leadership

2.1.1. Self-leadership

(9)

2.1.2. IT self-leadership

Individuals perform different IT behaviors, which influence the use of IT (Sun, 2012; Wang, Li, & Hsieh, 2011). These IT behaviors range from routine use to more high-level usage behaviors, like extended use (Jasperson et al., 2005). Both IT and self-leadership are used to influence behaviors, respectively as extrinsic and intrinsic motivators, and both facilitate individuals and teams to enhance organizational performance (Carmeli et al., 2006; Manz & Neck, 2004; McAfee & Brynjolfsson, 2008).

Where IT systems are used by individuals, while their task description is not asking for their usage, the link to self-leading behavior can be made (Hausschildt & Konradt, 2012). So, IT self-leadership can be defined as: the choice and behavior of an individual to use, redesign or recombine IT in novel ways to enhance their own performance, while there is no task description which asked for the use of this system (Manz, 1992; McAfee & Brynjolfsson, 2008). IT self-leadership refers to individuals using IT systems to direct and motivate themselves (Manz, 1986). Also, (Williams, 1997) suggested: “self-leadership emphasizes doing things for their intrinsic value (p. 141). Therefore, IT self-leadership in this research is approached as a part of intrinsic motivation. To explain IT self-leadership, IT will be combined with the cognitive and behavioral strategies of self-leadership. Therefore, the next strategies emerge: (1) IT behavioral focused strategies, (2) IT natural reward strategies and (3) IT constructive thought patterns strategies. Information technologies are added to existing strategies. Therefore, these strategies will be redefined taking into account that it is not clear if IT self-leading strategies refer to individuals being self-aware and self-motivated regarding their use of IT or if these strategies refer to individuals using IT to enhance their self-awareness and self-motivation.

2.1.3. IT self-leadership strategies

IT behavioral focused strategies (1) refer to enhancing self-awareness and improving goal behavior, by self-observing and observing others how to make use of the IT system. They also refer to the use of an IT system to enhance self-awareness and improve individual goal behavior, by self-observing and observing others.

(10)

At last, IT constructive thought pattern strategies (3) refer to creating focus, learning from the past and constructing own thoughts to use an IT. They also refer to the use of an IT to create focus, to learn from past experiences and store data to construct individual thoughts. IT self-leadership strategies are suggested, like the self-leading strategies, to be trained and facilitated to improve individual performance and innovativeness (Carmeli et al., 2006; Neck & Manz, 1996).

2.2. IT adaptation

2.2.1. Motivators IT adaptation

Motivators of adaptation are extrinsic or intrinsic in nature. Extrinsic motivation is associated with individuals perceiving tension and pressure, valuing the results rather than the process (Li et al., 2013). The most common extrinsic motivators in the literature are perceived usefulness and ease of use from the technology acceptance model (e.g. Legris, Ingham, & Collerette, 2003). Perceived usefulness is the degree to which a person believes that using a particular system would enhance his/her performance (Davis, 1989). The ease of use of the IT refers to the degree to which the user believes that using the IT system will be free of effort (Davis, 1989).

(11)

trust under the concept of intrinsic motivators. Trust in the IT system refers in this study to the subjective guarantee of the IT provider that the IT system will behave in a reliable way, as promised (Gefen, Karahanna, & Straub, 2003).

2.2.2. IT adaptation behaviors in a healthcare context

This study is based on the four IT adaptation behaviors suggested by Bala & Venkatesh (2015), these are: (1) exploration-to-innovate, (2) exploitation, (3) exploration-to-revert and (4) avoidance.

Exploration-to-innovate is here defined as the degree to which team members try to find, extend and/or change features of an information technology to accomplish his or her tasks in novel ways, in ways its use was not compulsory or introduced during the introduction of the IT system. Prior IT coping theories have suggested that some users will put more effort in exploring an IT to discover new features and ways of performing their work processes in novel, creative and improvised ways (Boudreau & Robey, 2005; Pinsonneault & Beaudry, 2005). Similar concepts of exploration-to-innovate in the literature include feature extension, feature exploration, infusion and emergent use of IT (Jasperson et al., 2005; Thatcher, McKnight, Baker, Arsal, & Roberts, 2011). Where those concepts often refer to the same behavior, they are used scattered in the literature. The four IT adaptation behaviors of Bala and Venkatesh (2015) cover those scattered concepts the best.

Exploitation behaviors refers to “the degree to which an employee uses a recommended set of features of an IT to perform his or her portfolio of tasks (Bala & Venkatesh, 2015, p. 161).” Users adopt a set of IT features that they learned in training sessions and/or from other colleagues or supervisors and use these features on an almost daily basis to accomplish work tasks. Similar concepts of exploitation in the literature include feature adoption, deep use and routine use of an IT (Jasperson et al., 2005; Thatcher et al., 2011). These concepts all refer to users using the IT system as an integrated part of their work routine.

(12)

Behavior of avoidance refers to the degree to which team members try not to use the IT system when performing his/her tasks (Bala & Venkatesh, 2015). Beaudry and Pinsonneault (2005) found that some users did not use an IT system at all, because users thought that they would be able to perform their tasks efficiently without using the IT. Avoidance of an IT system may happen when the user experiences a misfit between the technology and his/her work system (Bendoly & Cotteleer, 2008).

In Figure 2 a more detailed conceptual framework is included. This conceptual framework is used in this study as a guideline to structure thoughts and provides an overview of the relationships recognized.

(13)

3. METHODOLOGY

In this chapter, the research design, the case selection and case descriptions are presented. This is followed by a description of the data collection and how this data was analyzed. Additionally, the quality criteria controllability, reliability and validity are discussed.

3.1. Research design and research setting

The aim of this study is to gain a deeper understanding of how teams adapt to a new IT system in a healthcare context and how the concept of IT self-leadership plays a role in this process. Where we have limited understanding of these phenomena, the qualitative research approach, which provides rich information, is most appropriated for this research purpose (Yin, 2014). Mintzberg (1979) described, “Theory building seems to require rich description, the richness that comes from anecdote.” (p. 587). Qualitative research methods make it possible for participants to provide their own understanding of a situation in their own words and through their own experiences (Yin, 2014). The method used to explore the concepts of this study was the case study approach. The case study method allows to answer ‘how’ and ‘why’ questions, which is the case in this research (Yin, 2014). Case studies are also more likely to develop new theories and are characterized by focusing on understanding the dynamics and underlying mechanisms present within a single or multiple setting(s) (Eisenhardt, 1989). This study choose for a multiple case design, which enables to replicate findings across cases and increases external validity (Baxter & Jack, 2008). The steps of the theory building approach described by Eisenhardt (1989) are followed while carrying out this study, see table 1.

(14)

Table 1 – Research process

RESEARCH STEPS ACTIVITIES

1. Initial phase

- Searched for a literature gap;

- Developed possible constructs for research; - Developed research question and subquestions.

2. Selecting cases

- Selected multiple cases:

• One team of 4 nurses and their manager in a large academic hospital and two teams of 3 nurses and their managers in a large non-academic hospital, a total of 13 participants. - Cases were selected by literal replication:

• Selected teams that were known as adaptive, innovative and who took initiative towards IT, within the teams most adaptive and innovative team members were selected for the

interviews. 3. Crafting instruments and protocols

- Developed a protocol to approach team members for interviews;

- Developed an interview protocol and an observation protocol.

4. Entering the field

- Conducted 13 semi-structured interviews with team members and their managers.

- Observed each team for eight hours during a day shift.

5. Analyzing data

- Coded interview data and observation data with the help of Atlas.ti

- Data analysis:

• The analysis was related to the adaptation process of healthcare teams to a new IT system and the role of IT self-leadership in this

process.

• First a within case analysis was executed and thereafter a cross-case analysis.

6. Shaping hypotheses - Patterns were found

7. Enfolding literature - Compared findings of research with existing _literature 8. Reaching closure - Developed a conceptual framework and 2

(15)

A few hospitals in the Netherlands now use a new smartphone that support the work of nurses. This smartphone functions as a pager for medical and patient alarms and at the same time functions as a telephone and leaves room for multiple applications. The new smartphone replaces old pagers and supports nurses in prioritizing critical alarms, patient communication, patient monitoring and communication with colleagues. Nurses have the option to adjust settings in the smartphone their selves and use a range of functionalities and medical applications which are not mandatory to use, enabling nurses to perform different IT adaptation behaviors. The use of the smartphone should lead to benefits for the hospital in terms of efficiency, work process optimization, patient safety, nurse safety, reduced workload and a reduced amount of alarms. However, the implementation process of this new IT system turned out to be rather tough. ICT departments and management teams of the hospitals have received a lot of negative feedback and complaints about the new IT system and are trying to deal with this. It is interesting to see how some healthcare teams adapt more easily to the new smartphone, than others. It is relevant for the research question to see how these teams adapt to the new IT system and how IT self-leadership plays a role in this. For the hospitals and the managers of the healthcare teams it is interesting to see what make some teams more easily adapt to the new IT system and if this is something other teams can learn from.

3.2. Case selection and case descriptions

(16)

At the large academic hospital there were only two wards who used the new smartphone, after a meeting with the Advisor Quality of the hospital, one ward was selected as being adaptive to the new IT system. The advisor based her decision on how proactive the team was in trying to solve problems with the smartphone and the amount of ideas the nurses had to make the smartphone more of an added value for them. After another meeting with the Advisor Quality and the Manager of TEAM 1, to make sure this team was an adaptive team and willing to cooperate in this research, this case was selected. At the large non-academic hospital, in a meeting with the clinical physicist of the ward Medical Technology, three teams out of all the teams in the hospital were selected who showed most effort to adapt to the new IT system and were known as being innovative teams. The clinical physicist based the ‘adaptability’ of the teams on how proactive and self-managing teams are in trying to solve technical problems with the new IT system or/and were able to cope with misfits between the new IT system and their work processes. After a meeting with all managers of the three selected teams, two teams, TEAM 2 and TEAM 3, were most suitable and willing to cooperate in this research. A brief description of the selected cases of both hospitals will follow.

Case 1: Large academic hospital

(17)

of alarms have occurred. The new IT system has forced nurses to change their way of working and adapt themselves to the new situation.

Case 2: Large non-academic hospital

The second case is a team of the care unit of Hematological oncology consisting of 60 nurses in a large non-academic hospital. The entire hospital was moved to a new building in January 2016, were the new smartphones became mandatory to use. This team received a short explanation (10 min.) about the use of the smartphone. The team consists of two teams emerged together by the movement, one team had been working with only a simple pager, the other team was used to work with a pager and a simple mobile phone to make calls. Now they have to work with a smartphone, which is more complex in its use, but makes it for example possible to communicate with colleagues regardless their location within the ward. This team is working on a care unit were the work is quite routine, with no monitors attached to patients, so no medical alarms are involved. The main activities of the nurses are providing care to cancer patients, including patients in isolation rooms. There have been a lot of technical problems in the implementation process, like a poor WIFI range and ghost calls. The new IT system has forced nurses to actively use the smartphone in accepting and declining patient alarms and making calls, so they had to adapt themselves to this new situation where they have to interrupt their work processes.

Case 3: Large non-academic hospital

(18)

isolation rooms. There have been a lot of technical problems in the implementation process, like a poor WIFI range and ghost calls. The new IT system has forced nurses to actively use the smartphone in accepting and declining patient and medical alarms and using the phone as a communication tool. The team had to find ways to cope with the new situation that arose with using the new IT system.

3.3. Data collection

Within this case study, the data collection methods consisted of meetings, observations and semi-structured interviews. Meetings with the developer of the smartphone, included unstructured interviews and a demonstration of the new smartphone to understand why hospitals choose for this IT system, how the IT system works and how it is intended to use. Meetings with managers of the hospitals, including unstructured interviews, were used to select appropriate cases, as described under case selection. Appendix 2 contains a more detailed collection of methods used and the obtained information.

Observations were used to gain a better understanding of the actual use of the IT system in care processes and team processes involved, such as team collaboration and team communication. The observations were direct in nature, meaning that nurse’s behaviors and their interactions with the IT system were observed at the moment that it occurred, so the nurses were aware that the researcher was observing them. Three observations were conducted by shadowing different nurses during an eight-hour day shift for each team. A protocol was used while observing (Appendix 7).

(19)

All semi-structured interviews were conducted face-to-face. The interviews took between the 20-50 minutes, an average of 30 minutes. Eleven interviews were conducted one-on-one, one interview included three interviewees (team manager and two day coordinators) and one interview included an interrupter (nurse) who made some comments during the interview. The interviews with the nurses of the same team were compared to translate individual experiences into team level experiences. Table 2 presents an overview of the interviewees. All interviews were recorded and conducted in Dutch.

Table 2 - Interviewees

The topics of the interview were based on the theoretical framework. These topics were discussed during the meetings with the IT developer, the meeting with the Quality advisor and manager of TEAM1 of the large academic hospital and the meeting with the clinical physicist of the large non-academic hospital. Interview questions were based on discussions during these meetings. One interview with a nurse of TEAM1 was conducted to see how the interview questions covered the relevant constructs. On the basis of this interview, which is not included in this research, the interview questions were adjusted towards a final interview

INTERVIEWEES

HOSPITAL WARD TEAM FUNCTION RESPONDENT

Large academic hospital Obstetrics & Neonatology (Intensive care) Team 1 Manager _ERSOPH110 Nurse ERSOPH101 Nurse ERSOPH102 Nurse ERSOPH103 Nurse & Daycoördinator ERSOPH104 Large non-academic hospital Hematological oncology (Care unit) Team 2 Manager Daycoördinator Daycoördinator MSONC210a MSONC201b MSONC210c Nurse MSONC201 Nurse MSONC202 Nurse MSONC203 Cardiology

(Care unit) Team 3

Manager MSCARD310

Nurse MSCARD301

Nurse MSCARD302

(20)

protocol. This way of working ensured that all the relevant topics for this research were covered. In appendix 3 and 4 the interview protocols on team-level and management-level are included. The interviews started with some demographic questions, like “How old are you?” and “How long are you working in this team?”. Second, questions regarding the attitude towards the new IT system and effort towards adapting to the new IT system were explored. These questions included: “What is your attitude towards the new IT system?”, “What makes you different from your colleagues while adapting towards the new IT system?” and “How do you try to adjust your work process so it fits with the use of the new IT system?”. Questions followed regarding innovativeness of the team, including questions “Which ideas for

innovation has this team?”. To make a connection between adaptation behaviors and IT self-leadership, questions were asked about which efforts nurses had made regarding the use of the IT system in combination with questions of the IT self-leadership probing table, like “How do you use the IT system different then intended?”, “Why do you consciously think about what you’re doing when you use the smartphone?” and “How do you use the smartphone to set goals for yourself?”.

3.4. Data analysis

Interviews were recorded with the permission of the interviewees. The recorded data were transcribed into textual transcripts; these textual transcripts were coded. Also the notes of the observations were coded (Appendix 8). Coding is a process to summarize the amount of gathered data and organize these data (Miles & Huberman, 1994). It is not an precise science, but rather an interpretative act (Saldana, 2009). The start of the coding process is retrieving codes from the relevant literature. These so called deductive codes were complemented with inductive codes, which arose from the empirical data of the research. A codebook was made to include both deductive and inductive codes, their definitions and some example quotations (Appendix 9). The reason for a codebook is to structure the relevant data, this makes the process of finding patterns easier (Saldana, 2009). The researcher coded all transcripts and notes of observations three times, called intra-coding, in order to ensure a higher level of reliability (Miles & Huberman, 1994). Also, one transcript of each team was checked by a fellow thesis student, called “member-checking” by linking codes to quotations, this is a way of validating the findings (Saldana, 2009).

(21)

write-ups/descriptions of each case (Eisenhardt, 1989). Analyzing the data within cases was important to compare the answers of different team members, to get an answer on team-level. After the within-case analyses, there was searched for patterns between the data of the different teams during a cross-case analysis. According to Eisenhardt (1989) a cross-case analysis “will force investigators to go beyond initial impressions” (p. 541). Here the main constructs were compared among the different teams.

To get a clear answer on the research question, the data analyses were divided into two parts. The first part was used to explore on individual level which extrinsic and intrinsic motivators, including IT self-leadership lead to team members performing IT adaptation behaviors. The second part was used to explore how IT self-leadership plays a role in IT adaptation on a team level, taking into account factors that influence the IT adaptation process of teams.

3.5. Quality of research

To make sure this study draws verifiable and transparent conclusions, it was important to strive for inter-subjective agreement. This means there should be a consensus between the respondents who dealt with the research problem (van Aken et al., 2012). Controllability, reliability and validity are the most important quality criteria of research, as they provide the basis for inter-subjective agreement (Yin, 2014; van Aken, et al., 2012).

(22)

Table 3 – Ensuring reliability and validity of research

QUALITY CRITERIA HOW?

Reliability

1. Researcher’s bias

Using insights of other (master thesis) researchers, called ‘friendly strangers’ by meetings every two/three weeks. In this way no mechanisms or processes according the topic should be overlooked.

2. Instrument bias

Applied triangulation. The use of three different data collection methods, meetings, observations and semi-structured interviews, remedies the specific

shortcomings and biases of instruments individually (van Aken et al., 2012).

3. Respondents’ bias

Only nurses, who had sufficient knowledge about the IT system and worked with it right from the start, so were involved during the entire implementation process, were selected.

4. Situation bias

• Tried to avoid by holding the interviews in an quite room where nobody else was able to hear what was discussed;

• Participants were guaranteed that information of the interviews and observations was processed

anonymously, which reduces the likelihood of socially desirable answers and behavior.

Validity

1. Construct validity

• A review of the interview protocol by the thesis supervisor and a review of the observation protocol by an other researcher in the field of healthcare information technologies;

• Meetings with the Quality advisor of the large academic hospital and the Clinical Physicist of the large non-academic hospital were used to make sure all relevant topics were covered in the data collection methods.

2. Internal validity • Executed both within and cross-case analyses, _{searching for patterns;} • Member checking and intra-coding of the codebook;

3. External validity

(23)

4. FINDINGS

This chapter presents the findings of the three cases based on the information outcomes of the interviews and observations. First, the cases will be analyzed separately by a within-case analysis, followed by a comparison between the cases by a cross-case analysis, which includes the most remarkable findings. Finally, a conceptual framework is presented based on the findings.

4.1. Within-case analysis

Within this research, members from three different teams of two hospitals were observed and interviewed about their experiences with the new IT system. Comparing the different views of individual team members made it possible to find an answer at the team level. First, the most important and remarkable findings will be presented per team.

4.1.1. Findings CASE 1: Large academic hospital Extrinsic motivators leading to IT adaptation behaviors

Members of this team experienced some misalignment between the new information technology and their work process. They are used to only handle alarms of their own patients, now they receive and need to handle alarms of all patients. This misalignment between the new IT and the work system indirectly resulted in team members showing avoidance behavior. Indirectly, in the way that as a result of the misalignment team members experienced alarm fatigue, “So, when you get 136 alarms during your duty, yeah you just want to throw that thing [smartphone] away. But you know you are going to need it.. (ERSOPH102)”.

(24)

just switch it off. And than I take a look a bit later and I think ‘Oh the Delivery Room has called’, what turned out to be something really critical.” So, this alarm fatigue among team members decreased their job performance in the sense that they did not react adequately and in time to alarms anymore, decreasing their patients’ safety and quality of care. For this reason, alarm fatigue functioned as an strong extrinsic motivator for members of the team to engage in one or more of the three types of avoidance behaviors mentioned above.

For other team members, the alarm fatigue as an extrinsic motivator was a reason to engage in exploration-to-innovate behavior. They looked into the initial settings of the smartphone and concluded that the high amount of alarms partly was a result of strict limits for vital sign ranges within the IT system. Team members broadened some of these limits of ranges for vital signs by adjusting the settings, which resulted in a decrease in the amount of alarms. So, team members looked behind the initial settings of the IT system, engaging in IT exploration-to-innovate behavior, in an attempt to reduce causes of alarm fatigue and its effect on job performance.

(25)

perceive technical problems as a strong extrinsic motivator to engage in exploration-to-revert behavior, in the form of workarounds.

Nurses within this team perceived the smartphone as useful and of added value to their work process. They now had options to use functionalities which were previous not available to them. This created the ability to enhance their job performance by using these functionalities, like the option to make calls to enhance communication, ERSOPH102: “This smartphone you can entirely adjust to the rooms with the buddies along and that is not even the biggest advantage for me. The biggest advantage, the most big advantage for me is that you can use it to call.” So, perceived usefulness was a jointly extrinsic motivator for team members to engage in the exploitation behavior of routine use.

Some team members found the IT system easy to use, this made it easier for team members to use the smartphone as intended, engaging in exploitation behavior. However, at the same time some other team members complained about the amount of activities they had to undertake for accepting/declining an alarm, making it harder for them to use the IT system within their routines. Thus, the ease of use remained a moderate extrinsic motivator for team members to engage in routine use as exploitation behavior.

(26)

Figure 3 – CASE 1: Identified extrinsic motivators that led to IT adaptation behaviors

IT self-leadership as an intrinsic motivator leading to IT adaptation behaviors

IT self-leadership as an intrinsic motivator did really differentiate between team members of this team. Some team members did show almost no self-leading behavior regarding the IT system, were others were really self-aware in their IT use and self-motivated to adapt themselves to the new IT system.

(27)

engage in exploration-to-revert behavior more often, taking part in workarounds, and avoidance behavior. So, the use of IT natural reward strategies in an attempt to adapt to the new IT system differentiated between team members.

However, most team members used IT behavior-focused strategies of IT self-leadership to adapt to the new IT system. This happened in two ways. First, team members showed behavior that was focused on how to use the IT system. For example in concentrating themselves in the use of the IT system, thereby facilitating exploitation behavior by using the IT system as intended: “And by this I really have to take a moment and concentrate on what am I doing (ERSOPH101)”. Second, some team members used the IT system in itself, using optional functionalities, to influence their own behavior for example by setting goals for themselves with the help of a timer, ERSOPH102: “If I have to check something every once in a while on a patient. So, every two hours I have to do something, I just set the alarm clock.” Other nurses said they did not look beyond the introduced functionalities: “I look at what I need and I use that and I do not look further (ERSOPH103).” Based on the observations, team members actually frequently a lot used the calculator, the timer and the ‘pharmacotherapeutic compass’. All these applications were not compulsory to use and weren’t introduced in the training session, so the nurses explored the system themselves, thereby engaging in exploration-to-innovate behavior.

(28)

Concluding, high IT self-leadership among some team members functioned as an intrinsic motivator for these members to engage in IT adaptation behaviors, however some team members did not showed signs of IT self-leadership. Team members, who were really self-aware (high IT self-leadership) in their IT usage and adaptation behavior engaged more in exploitation and exploration-to-innovate behaviors. IT behavior-focused strategies of IT self-leadership were most common and frequently identified among members within this team and where most visible of influence on IT adaptation behaviors. Figure 4 gives an illustrative overview of how high IT self-leadership led to performing IT adaptation behaviors of team members within this team.

Figure 4 – CASE 1: High IT self-leadership as an intrinsic motivator leading to IT adaptation behaviors

Other intrinsic motivators leading to IT adaptation behaviors

Where the focus within this study is on IT self-leadership as an intrinsic motivator, also other intrinsic motivators who led to team members engaging in IT adaptation behaviors were identified and will now be discussed.

(29)

should be seen as an overall restraint in making effort as a team member in adapting to the IT system.

This resistance can partly be explained by the information technology self-efficacy (IT self-efficacy) of the team members, where age and prior experience with IT seemed to play an important role, ERSOPH110 explained: “You truly see differences among colleagues. And that definitely, what we discussed earlier has to do with the age category (ERSOPH110). Some nurses were not used to work with a smartphone, because they did not own one or because they had no prior experience in using one, “And for some older colleagues, they obviously are like what the hell do I got in my hands this time again? (ERSOPH110)”. Nurses, who did own a smartphone and had prior experience in using one, adapted more easily to the new IT system. They used the smartphone sooner as an integrated part of their work routines engaging in exploitation behavior, where this took more time for the other team members. A reason for this is that team members who did not have a lot of prior experience using smartphones were unsure about their capability to use the smartphone correctly. This restrained them to adapt to the change, ERSOPH110: “So, it results in a kind of unrest among colleagues who have the feeling that they are not really getting the system yet”. So, high IT self-efficacy of team members can be seen as an intrinsic motivator to perform exploitation behavior, like routine use, because the team member has the feeling he/she is capable of using the new IT system as intended and that this will bring pleasure to the work.

What did help nurses to get familiar with the IT system was just playing with it and trying different features, ERSOPH101: “..when I came here, I just tried and played along with this Myco [smartphone]. And it is just ideal.” IT playfulness functioned as an intrinsic motivator for performing IT adaptation behaviors, because team members who were curious and excited about the new IT system, believed this system could bring joy to their work. By exploring the smartphone in a playful way, they even found out about new functionalities (not compulsory IT use) or got ideas about new functionalities which would be useful, performing exploration-to-innovate behavior: “No, sometimes it is like you are drinking coffee with a group of colleagues. And than someone says like hey you also can make pictures with the Myco [smartphone] and look how this works. That is how it happens (ERSOPH102).”

(30)

is not bringing enjoyment into their work, but rather frustration. Therefore, team members have a higher tendency to perform avoidance and adaptation-to-revert behaviors. Figure 5 provides an overview of how other intrinsic motivators led to IT adaptation behaviors among team members.

Figure 5 – CASE 1: Other intrinsic motivators leading to IT adaptation behaviors

Other factors that influence the IT adaptation process on team level

Where the extrinsic motivators and intrinsic motivators within the team where more of an individual nature, other factors influenced the IT adaptation process, on a team-level.

(31)

how it was. So the colleagues who worked under her, they are not used to change at all (ERSOPH110).”

Also, the fact that the new IT system was not the only change for the team to cope with, impacted it’s ability as a team to adapt to the new smartphone, they moved to an entire new department: “But it is also really difficult to realize, because this new pager system, it was synchronically introduced, with everything was new. And too many new things is maybe, yeah maybe not good, right? (ERSOHP104)”.

Another characteristic of this team is that its ability to adapt to the new IT system is heavily influenced by group processes resulting in a negative attitude towards the system. The manager explains these processes as: “A lot of resistance, absolutely. So, they are not open to that [new IT system], they heavily influence each other. We are really suffering of group processes…and I noticed that everybody has a say about it, because they think that colleagues are expecting of them that they are going to say something and that makes it really difficult. We are definitely working on that (ERSOPH110).”

However, nurses who had a high IT self-leadership, were able to go beyond these group processes and did provide colleagues with peer support and for example learnt them ways how to engage in exploration-to-innovate behaviors to reduce alarm fatigue: “For example, I tried to stimulate people to adjust values, so certain alarms reduced, I tried to make people aware. Adjust the settings, so it produces less alarms.. (ERSOPH104).”

The implementation process had its influence on the ability of team members to adapt to change as well. The training in how to use the system was experienced by the team members as not sufficient, because only a small section of the team was able to follow the training: “We are here with 90 nurses and I think we only reached a group of twenty. Because we got only a few data of *** when we could possibly provided training and we should have had reached everybody, it is such an essential part, such an important system (ERSOPH110).”

(32)

So, other factors that influenced the adaptation process to the IT system as a team could within this case be divided into team factors (1), including group processes and team’s history with change, learning interventions (2), including feedback and peer support, implementation factors (3), including training and external factors (4), such as other changes the team had to deal with. Important to note is that peer support by team members who had high IT self-leadership skills enhanced the ability of the team to adapt to the new IT system.

Conclusion within-case analysis CASE 1

Concluding, within this case alarm fatigue and technical problems were strong extrinsic motivators for team members to engage in the less desirable IT adaptation behaviors of avoidance and exploration-to-revert. Perceived usefulness was a strong extrinsic motivator to engage in the more desirable IT adaptation behavior of exploitation. Team members who possessed IT self-leadership skills experienced more pleasure in engaging in the desirable IT adaptation behaviors of exploitation and exploration-to-innovate. Functioning as an intrinsic motivator, they were more self-motivated to adapt to the new IT system and more self-aware of their own IT use. Important was the capability of team members to motivate themselves in shifting their own perceptions away of the negative aspects of the IT system into the more rewarding aspects, part of IT natural reward strategies. Also, behavior-focused strategies were important, where team members focused themselves in how to use the IT system and/or used the IT system, for example a timer (an optional functionality), to set goals for themselves. Other important intrinsic motivators for team members to engage in IT adaptation behavior were prior experience with IT, IT playfulness and trust team members had in the IT system. Respectively, leading to the IT adaptation behaviors of exploitation, exploration-to-innovate and a higher tendency to engage in exploration-to-revert and avoidance. Important factors that influenced the ability of the team to adapt to the new IT system were team’s history with change as a restraint and peer support as an facilitator. Especially peer support provided by team members who had high IT self-leadership skills, resulted in more efforts of the team to engage in exploitation and exploration-to-innovate behaviors.

4.1.2. CASE 2: Large non-academic hospital

Extrinsic motivators leading to IT adaptation behaviors

(33)

process. For some nurses the misalignment between the new IT and their work system made them modify their procedures. They tried to find ways to adapt their work procedures when using the IT system, MSONC202: “ Sometimes I’m at isolation and then I put the Myco in the gate and leave the door a bit open. Than, I do not have to pull it out of my jacket, so I just pull of my hand glove and than. Otherwise, I have to pull it out with my dirty hand glove and then.”.

Where nurses were still getting used to the IT system, they often pushed the wrong button, causing unnecessary alarm escalations. Nurses became tired of all those alarms influencing their work performance, where alarm fatigue became an extrinsic motivator, for them to engage in workarounds. Nurses did not accept or decline alarms anymore, made the decision with each other to only handle your own patient alarms. This resulted in even more alarm escalations and alarm fatigue.

Also, technical failures, including poor WIFI connection, wrong location detection and alarms not coming through, caused a big problem among nurses in their adaptation to the IT system, because this factors directly influenced their job performance. The poor WIFI connection caused workarounds and an actual adaptation of the resources of the department, because nurses prefer calling with a landline phone, to prevent disruptions in calls, So, the management of the team decided to add extra landlines to the department: “We got extra landlines, so people can also be here in the office and in the multifunctional rooms. People just choose to call with a landline during for example a family conversation, because it [Myco] is not convenient (MSONC210a).”

Team members do see advantages of the IT system in the sense that they have access to functionalities they had not before, like an option to call security, but they do not per se perceive these functionalities of added value, MSONC202: “I’m also not negative about the Myco. However, a mobile phone and a pager were also been enough.” So the perceived usefulness by nurses is an average extrinsic motivator.

(34)

do their jobs, being an extrinsic motivator to engage in exploration-to-revert behavior, in the form of workarounds. Figure 6 gives an illustrative overview of how extrinsic motivators within this team led to different types of IT adaptation behaviors.

Figure 6 - CASE 2: Identified extrinsic motivators that led to IT adaptation behaviors

IT self-leadership as an intrinsic motivator did differentiate between team members of this team. Not all nurses showed IT self-leadership skills, but most team members were self-aware about their IT use and adaptation to the new IT system.

(35)

smartphone: “More like I have to keep my focus, I always have to take a close look. If colleagues are not responding to an alarm, then I should not get that alarm myself, however I’m constantly checking to make sure it is not an alarm of one of my own patients. I’m always really conscious with that (MSONC202).” This fostered routine use among team members, performing the IT adaptation behavior of exploitation. Second, some team members used clues for themselves about how to use the IT system, facilitating routine use: “If I have late duty, I always keep a note with all my patients and I write on it which nurse has which Myco [smartphone] (MSONC203)”. Third, nurses also used the IT system in itself as a clue, for example by using the timer to remind themselves to provide medication. Or using the calculator to calculate the amount of medication for patients. The timer and calculator are not compulsory functionalities to use for nurses and are not introduced as such during the training. However, some team members found pleasure and satisfaction in trying new things and looking behind the initial functionalities, therefore they engaged in exploration-to-innovate behavior while adapting themselves to the IT system.

Some members of the team had the ability to improve their own belief systems, incorporating IT constructive thought pattern strategies, MSONC202: “Absolutely, I am thinking more positive about it now than first. Yes, I am able to shake that [negative feeling about smartphone] off.” They pushed themselves in taking a fresh look to the IT system and its usefulness after using it for some time, because they get satisfied of overcoming difficulties with the smartphone. This capability could not be linked to a specific type of IT adaptation behavior, but was a facilitator for adapting to the new IT system in general. It also was of influence on the team process of IT adaptation. Nurses who had the capability to reassess how they thought about the smartphone over time, also influenced the perceptions about the IT system of other team members, through feedback moments and peer support.

(36)

led to performing IT adaptation behaviors or facilitated overall team adaptation (dashed

lines).

Figure 7 - CASE 2: High IT self-leadership as an intrinsic motivator leading to IT adaptation behaviors

The ability to adapt to the new IT system differed among team members, MSONC210a: “It really differs on an individual level. It is also not like older people find this [adaptation] harder. I do not notice that at all.” This difference within the team can be explained by the prior experience with IT team members had, which make some nurses with less experience feeling that they were less capable of using the system: “I do think that others may be had a harder time with that, who are not really used to a smartphone or do not have one themselves. But because it are only a few functions, is it not that hard (MSONC201).” Prior experience with IT facilitated team members in facilitating in exploitation behavior, using the IT system in their work routine.

(37)

adaptation behavior, MSONC210a: “I notice that there is no trust, the trust in the system has reduced. You have to trust on it blindly and you have to make use of it easily… You know what. Something get accepted if it functions well. Simple as that.”

There was a high tendency of the nurses to interact with the IT spontaneously and imaginatively, most nurses played along with the smartphone because they were curious and excited about its use: “Yes, I think just a bit playfully. Just doing. Yes, I practiced and tried with it a lot and I looked into it to see what functions were on it (MSONC203).” This sometimes resulted in nurses using IT functionalities which were not compulsory to use, like the calculator, timer and photo function, they explored the smartphone on their own: “Yeah, the timer and I also look into the phone book if I need certain numbers, so I look into that. Sometimes I add a new number if I think that will convenient (MSONC202).“ They were also excited about thinking of new functionalities which could make their work process more easy and joyable.

Figure 8 gives an illustrative overview how other intrinsic motivators led to IT adaptation behaviors within this team.

Figure 8 - CASE 2: Other intrinsic motivators leading to IT adaptation behaviors

Other factors that influence the IT adaptation process

(38)

course bring complaints forward. And we are been really involved and have taken immediate action and raised questions, when it did not work for us (MSONC210a).”

Due to all kind of problems, like technical failures and alarm fatigue along the introduction of the IT system, the managers have now the tendency to bring back the old situation in the department, preventing nurses the chance to get adapted to the IT system: “This afternoon we have an appointment with *** also with the goal, to get it more established as we had before (MSONC210a).”

Team members do provide each other with peer support in coping with the new IT system, MSONC202: “And we always can go to each other, within the team we help each other and we can also always go to the team lead.”. The team has built feedback moments into the day in the form of time-outs, to facilitate the process of nurses getting used to the IT system and the other changes in their work processes.

The new IT system was namely not the only change for the nurses, it came along with the movement of the entire hospital to a new building, so everything is new: “And of course I already had the irritation of a new hospital and I get that this system is entirely built for this. However, I thought and a new hospital, and a new system. And than it did not even work, that was the biggest issue (MSONC202).”

The team in this case is an emergence of two teams of the old hospital. One group of the team was already used to working with a pager and a mobile phone, the other group was only used to an pager. This separation can also be made in terms of the ability of the nurses to adapt to the IT system, for one group its functionalities were more new than for the other part, so this group was more struggling to adapt: “I think that has to do with different things. Before we had two teams, oncology and hematology, they were already used to work with mobile phones, that they could call each other, we did not had that at all (MSONC203).” However, they were also more exited about the new IT system and perceived it as more useful than the group who already worked with a pager, MSONC203: “Before you just went physically looking for someone, but then the walking distances were less. So, because of the new building, I think you need something like that.”

(39)

4.1.3. CASE 3: Large non-academic hospital

Extrinsic motivators leading to IT adaptation behaviors

Within this team a possible misfit between the IT and the work system was not mentioned frequently, however some team members had the feeling they had to use their hands to much in using the system, while they rather use their hands for providing care.

This team had to deal with a lot of technical problems, which restrained the nurses in adapting to the IT system, the manager explained the technical problems, MSONC310: “We have had so many things, we had ghost alarms, false alarms, alarms which were handled but kept going, I can go on forever. We had error messages or that the complete WIFI system switched off..” Poor WIFI range hindered communication between team members, therefor they used a landline phone to communicate instead of the smartphone, engaging in exploration-to-revert behavior.

Alarm fatigue caused by these problems resulted in nurses trying not to use the system anymore by simply ignoring it. To reduce the amount of alarms, nurses adapt their work to the new IT system, for example by paying more attention to the cardiac monitoring screens: “.. I have screens here. There I have my patients on screen and I walk by frequently, so I have my patient visibly on screen as well, that reduces my filters with alarms, my alarm behavior (MSCARD301).” Another manner in which the team has tried to cope with the amount of alarms the new IT system produced is by adjusting the resources of the department, they split the department, so escalations went over less smartphones: “Yeah, it [the department] is split in two. That it is possible is great, but that it is necessary is a pity. But we can not fine-tune the system enough to not do that (MSONC310).”

Most nurses within the team perceived the new IT system as useful, in the sense that all the functionalities are integrated in one device and that they now can make use of a buddy system, enhancing patient safety. However, due to the sensitivity of electronic equipment that is used to monitor heart rhythms and coupled to the smartphone, a lot of unnecessary alarms are produced, which lead to frustration: “All these escalations. Because if for example one patients’ electronic is getting loose, than the alarm goes everywhere tulululu, than I think hmm.. And if it is something serious, I do not mind. But it is nothing serious. I mean, it is only one electronic, and I have vision, so that is too crazy (MSCARD303).”, and a decrease in exploitation behavior.

(40)

be taken, this became clear during the observation. The frustration about this is restraining nurses in adapting to the new IT system. Team members experienced more frustration about the system while they find it a difficult system to use. The biggest complaint is about the amount of proceedings necessary to use the system as intended: “And you need an amount of proceedings for that. You choose or declining or accepting and then you get another pop-up window to close. That is a triplicate of activities needed (MSCARD301).” Another complaint is that nurses experience difficulties with making calls, because alarms are coming through, the alarms overrule the conversation, to deal with this nurses prefer to use the simple mobile phones for making important calls, MSCARD302: “And sometimes you get frustrated by all the alarms coming through while making phone calls. You actually should have a ‘gripje’ [simple mobile phone], but we don’t have a lot of these, so you should search one of these and call with those instead.” Figure 9 gives an illustrative overview of the extrinsic motivators within this team leading to IT adaptation behaviors.

(41)

IT self-leadership as an intrinsic motivator differentiated among members of this team. Some nurses showed more IT self-leading behavior than others. However, most nurses within this team were highly aware of their own behavior regarding the use of the IT system, regardless if this was positive or negative to them.

Most team members did incorporate in IT behavior-focused strategies as an attempt to adapt themselves to the new smartphone. These strategies included that team members focused themselves in the use of the IT system, because they wanted to learn how to use it as intended and make it part of their routine, engaging in exploitation behavior: “In the morning with the alarm values, you really have to focus, because otherwise you get a lot of alarms on your Myco [smartphone] that are unnecessary if you do nothing with them, then I will say you have to change the settings (MSCARD302).” This was also a reason for some nurses to perform exploration-to-innovate behavior, adjusting settings within the smartphone to make the IT system more pleasant for themselves to work with. Some team members used the IT system itself, using not compulsory functionalities, as a clue to influence their own work behavior. For example by using the timer function, engaging in exploration-to-innovate behavior.

Some team members made use of IT constructive pattern strategies, in the sense of mental imagination, which let to exploitation behavior as routine use: “Yes, I think in pictures. I am also a picture thinker. It is more like if I now do this, than I have to push towards that and I should not forget to close it there. That is how it goes with me (MSCARD302).” It seems to satisfy these team members when they are able to use the IT system as intended, willing to put effort in adapting to the new situation. IT natural reward strategies were not visible within this team.

(42)

exploitation behavior. Figure 10 provides an illustrative overview of how high IT self-leadership of team members led to these team members performing IT adaptation behaviors.

Figure 10 – CASE 3: High IT self-leadership as an intrinsic motivator leading to IT adaptation behaviors

Due to the technical failures of the IT system, team members lost their trust in the system, what made it harder for them to actually adapt to the system: “Then, the system was also not that good. But I still have that the alarm did not came through or that it is not working. So, I do not have a lot of trust [in the system] (MSCARD303).”

In this team the people with less experience with IT are the ones who are more struggling in adapting to the IT system: “But no the older ones are more complaining about it, they have more trouble getting used to it (MSCARD310).”

(43)

function. Figure 11 gives an illustrative overview of how other intrinsic motivators led to different IT adaptation behaviors.

Figure 11 – CASE 3: Other intrinsic motivators leading to IT adaptation behaviors

Other factors influencing the IT adaptation process

Different factors where of influence on the adaptation process of the team. Nurses themselves are really active in problem-solving and are exploring the system: “I am busy with seeking for possibilities to do things different. Which sounds can be eliminated, what can be reduced, because that is what is driving me crazy (MSCARD303).” This active and independent problem-solving is supported by the manager, MSCARD310: “I am really of own responsibility, I steer more coaching wise then that am taking the lead… And sometimes they go to the ICT or medical technology themselves, they make things discussable, before me even knowing it.” So, the team is looking for ways to adapt to the new IT system more easily.

(44)

to them that they have to adjust their alarm values, because otherwise everybody get those alarms all the time.”

During the implementation process of the new IT system, the nurses received a quite intensive training: “We did it somewhat more elaborated. That has to do with the MOS [medical pager system]. So, we trained and educated all employees for a day here in the new building, on every new aspect around the telemetery and monitoring and the VOS [nurse pager system] and MOS. So, we provided more training than the rest (MSCARD310).”

However, the movement of the entire hospital to a new building made it harder for nurses to adapt to a new IT system, next to all these other changes: “In the beginning it was hard of course. But that is because everything was new (MSCARD302).”

4.2. CROSS-CASE ANALYSIS

The aim of this study is to find out how healthcare teams try to adapt to a new IT system and which role IT self-leadership plays in this process. A cross-case analysis is conducted, in order to analyze the similarities and differences between the teams. The purpose of this comparison is to lay out the combination of factors that may have contributed to the team’s adaptation to the new IT system.

4.2.1. IT adaptation behaviors

(45)

were coupled to the smartphone, causing alarm fatigue. But also the wide variety of technical problems, constraint all the teams of using the IT system as intended. Especially in TEAM1 the avoidance of the IT system was high, for example by turning off the entire IT system, in TEAM3 nurses also tried to ignore the IT system, by simply paying no attention to the alarms anymore. Both TEAM2 an TEAM3 put a lot of effort in adapting their work procedures to better fit the new IT system and also invested in adjusting resources of the department to better fit the new IT system, for example by separating the department in two sub departments and adding more landlines to the department. Table 4 includes all kinds of IT adaptation behaviors, team members of the different team performed.

TEAM 1 TEAM 2 TEAM 3

Exploration-to-innovate

• Ideas to add new functionalities to IT system; • Not compulsory IT use; • Adjusting initial settings of the IT system

Exploitation • Routine use; • Intended use • Routine use; • Intended use • Partly routine use; • Partly using IT system as intended

Exploration-to-revert • Workarounds • Workarounds • Workarounds

Avoidance • Decrease volume of alarms; • Removing alarms automatically without looking;

• Turning off IT system

* No efforts identified • Not paying attention to alarms anymore

Adapting work system to new IT system