Participation towards acceptance: a cross case
analysis
Master thesis
University of Groningen
Abstract
Introduction
In the past years, several hospitals and other healthcare providers in the Netherlands have either gone bankrupt or are struggling with financial issues (Groenendijk, 2018). These events underline a need for change in healthcare environments, and the importance of organizational improvement (Poksinska, 2010). According to authors Van Aij & Rapsaniotis, (2017), healthcare providers are looking for ways to improve the way of working in hospitals, managers are looking for management techniques used in other sectors. One of the better known techniques is lean, a process improvement approach with a strong focus on adding value for customers
The need for change in healthcare organizations and the growing adoption of lean methods in those organizations resulted in an increasing amount of studies in the field of lean in healthcare. Literature reviews from: Mazzocato, et al. (2010), Poksinska (2010) and Leggat et al. (2015) show that although hospitals are trying to implement lean, the interventions are still lacking. Notwithstanding, healthcare providers appear to adapt their way of working by holding on to the effective methods, and by combining them with new methods that are more efficient (Feldman & Pentland, 2003). An important underlying element in lean manufacturing is kaizen (Brunet & New, 2003). Kaizen is defined as continuing improvement involving everyone, from management to workers (Suárez-Barraza et al. 2011). Lean thus involves continuous improvement and to do so, this requires change. That change is involved is also visible in the definition of Brooks (1993), he says that kaizen means ‘change for the good’.
There is an abundance of literature about change in organizations (Goltz, 2018). Particularly much is written about the unfreezing stage of Lewins change model and the participants actions in that stage (Schein, 1985). Many of these studies look at the negatives found within that stage. To name a few, Ford and Ford (2010), Ford, Ford, and D’Amelio (2008) and Rafferty, Jimmieson, and Achilles (2013). These studies all state that employee resistances that occurs within the stage of unfreezing is the main reason that the change project fails. The implementation of lean in healthcare organizations involves change. As a result of these changed ways of working, employees experience difficulty and pressure, while adapting to the new situation (Kanfer & Ackerman, 1989). Helping the employees with adapting to this new situation can be done by letting them participate in the change. Employees’ involvement in the communication process promotes dialogue and input, which prepares them to accept change (Helpap, 2016). Therefore this study aims to fill the gap of looking at participation and the positive effect it has on the acceptance of a change.
The main determinant of a change projects success is the response of the change recipients towards the change project (Oreg et al., 2011). That is the reason this studies aims at the recipients and their reactions towards the change initiative. There are many ways in which the recipients can respond to the change, more than just acceptance or resistance (George & Jones, 2001). Furthermore does neither resistance nor acceptance from the change recipient guarantee a certain outcome from a change project (Oreg et al., 2018). For example can resistance be a contributor and a resource to the change project due to the fact that the change is discussed, and potential problems are named (Ford et al., 2008). Whereas blind acceptance misses these potential problems, and those might arrive when the project is implemented resulting in a failure of the project (Oreg et al., 2011). However only negative responses from the recipients will not help the initiative either, since resistances is aimed to disrupt the change (Kanter et al., 1992). Therefore this study aims to look at the recipients responses toward the change, and how this response can be influenced by participation. In the field of lean in healthcare this subject has not yet been investigated.
Based on the earlier mentioned topics the following research question is drawn up: How does
As mentioned before this study will add to the field of lean in healthcare. This is nowadays a hot topic with lots of researches done in this field. In the field of change recipients responses toward change there is also some research done, for example papers from: Ford et al. (2008) and Oreg et al. (2011). But this paper aims to bridge the gap in the current literature by investigating the recipients responses towards the change and how this can be influenced by employee participation in the change project. This will be researched in order to help the employees deal with the ongoing changes that are required when working with lean.
Theory
In this section of the paper the relevant theories will be explained and discussed. And at the end of the chapter the framework used in this study will be drawn up.
Lean in healthcare
All over the world the healthcare organizations are faced with the problem of people getting older, and having to take care longer of ill patients, which leads to increased costs, on the other hand however are hospitals getting less funding from the government (Waring & Bishop, 2010) and next to that there is also the public demand for better quality(Ballé & Régnier, 2007). Health care systems are challenged to be as affordable, accessible, safe, thorough, efficient, and cost effective as possible (Poksinska, 2010). All those factors have led to healthcare organizations looking in to their way of operating (Ballé & Régnier, 2007). So the healthcare institutions need to improve their way of working if they want to survive. Due to this there is a growing pressure on the healthcare institutions to look at principles used in manufacturing companies to improve their way of working (Radnor et al. 2012). The method known as lean is the most used, and is well known for the superior performance and competitive advantages that are linked with using lean (Wood et al., 2004). It is even said that lean will be the standard production method for the 21st century (Rinehart et al., 1997). As
mentioned before, an important underlying element of lean is kaizen. Lean has many different definitions in the literature. Below here is one of those definitions which captures a great deal of what lean stands for. Lean is an integrated socio-technical system with the goal to eliminate waste by reducing all kinds of variability (Shah & Ward, 2007). This definition will be used in this research paper when we speak of lean.
al., 2018). However, lean does not focus on a complete reorganization which requires a large-scale investment, but it provides health care organizations with an alternative methodology for achieving improvements without high investments (Bahensky et al. 2005). However improvement require change.
Employee responses to change
There are many different ways in which employees can respond to a change project (George & Jones, 2001). For this research paper we will only look at two of the better known responses and everything that belongs to these responses. It cannot be said that one type of employee behaviour adds more to the success of the change project than the other (Carter et al, 2013).
The first response type is acceptance. Change acceptance means that the recipient is positive towards the change (Oreg et al., 2018). This type of behaviour is also called willingness to support the change (Miller et al, 1994). There are several emotions connected to this type of behaviour, the most noted ones are calm, relax and content (Barrett & Russell 1998). Most studies looked only at the attitude from the recipients towards the change, and found thus that change acceptance was positively linked to successful change outcomes (Oreg et al., 2018). However the neglected the fact that acceptance usually is combined with low activation (Oreg et al., 2018). This low activation, or participation results in no constructive feedback for the change leader to improve the initiated change project (March, 1991). Thus acceptance will ensure an easy implementation of the project but will deliver no meaningful feedback to improve the quality of the project (Oreg et al., 2018).
Participation from employees
Employee participation is considered to be one of the most successful ways to implement change (Crane et al., 2003). Participation from employees can be seen in two ways, as value-expressive or as instrumental (Cawley et al., 1998). Value-value-expressive is the opportunity for employees to voice their opinion (Mulvaney, 2019). The employees place value on the fact that they have the ability to share their thoughts and opinions (Tyler & Lind, 1992). Instrumental participation is the employees ability to influence the outcome of the change project (Cawley et al., 1998).
There are two moments in which an employee can participate. The first step is in the problem reporting phase. To get an high employee participation it’s important to adopt a culture of reporting and solving problems through the use of improvement tools (Jaca et al., 2012). Furthermore, the development of ideas through participation in improvement teams is essential (Cooney & Sohal, 2004). Thus the actual improvement teams are the second step in participation. These two steps of participation are used in this research. This is also in accordance with kaizen. Kaizen requires the involvement of everyone to work on improving the organization (Suárez-barraza et al. 2011).
High worker participation lowers resistance to change and increases the likelihood that the project will be successful (Middel et al., 2006). If an employee is involved in the change it promotes dialogue and input, which prepares the employee to accept the change (Helpap, 2016). Thus it is necessary to create formal teams and organize meetings for sharing information and solving problems (Bayo-Moriones & Merino-Dı´az de Cerio, 2004). It is shown that worker participation in the project increased the motivation of employees and this motivation directly influenced productivity and process efficiency (Jaca et al., 2012).
Framework
Based on the theory described above it is possible to draw up a framework for the remainder of the paper. This framework will be used to analyze the results from the interviews.
The framework goes as follows:
The first concept in the framework is the initial response. The employees can react to a change in multiple ways. It is important for this study to get a clear overview of their first reaction toward the change project. This response influences the willingness to participate. The employees can choose not to participate. They are free in their choice. However their choice is according to this framework influenced by their initial response. Their willingness to participate influences the actual participation. If the employees do not want to participate in the project then there is no participation. If they choose to participate their will be teams set up to realize this participation. Finally this participation influences the employees response towards the change project. Participation helps in accepting change, and therefore these concepts influence each other.
Based on this framework it is possible to draw up some proposition which will be tested in the remainder of the study.
The first proposition is: The initial response influences the willingness to participate. The second proposition is: The willingness to participate influences the participation. The final proposition is: The participation influences the acceptance of the change project.
Initial response
Acceptance Willingness to
Methods
In this section the methods used to conduct this research are discussed. Every step taken in this research is described in this section, which makes sure other researchers can replicate this research and come to similar results. For this study the “how” of the relation between participation and the acceptance of change projects will be researched. Because this phenomenon is not yet discussed in the literature it is important to do theory development (Van Aken et al., 2012). For theory development it is useful to make use of a case study (Eisenhardt, 1989). Therefor this study will be a cross case analysis done at a case site.
Case site
To do a case study it is necessary to have a case site to do the study. The case site selected for this research is an hospital in the north of the Netherlands. With approximately 1500 employees this is a rather large hospital. They have beds for over 300 patients. In 2018 the hospital made a profit of just under 4 million. Within the hospital there are various departments. For example departments for a short stay in the hospital, or a department for a longer stay. This study is done in one of these departments in the hospital. The so called day care department. Here the patient are prepared for smaller surgeries, and after the surgery they get the help needed till they are ready to go home, which is in most of the cases within the day.
Change projects
At the case site there are several change projects implemented. This is due to the fact that the hospital tries to continually improve their way of working. This is necessary if the hospital wants to survive and keep up with the demands of the public. In the future they want to keep improving the quality of working in the hospital though continuous improvement. According to Van Aij & Rapsaniotis (2017) this is one of the three ways in which lean in healthcare is used to improve the overall results of the healthcare institution. To research the how relation in the research question, it is necessary to take a look at two change projects. One change project in which participation plays a role, and the other in which participation does not play a role. This way it is possible to analyze both projects and make a cross case analysis to see the differences between the responses towards the change projects. The two projects are referred to in this research as project A and project B.
Project A
The first change is about putting on gloves when placing an IV. Working with blood brings about risks and to protect oneself from getting infected with a disease a simple but useful method is wearing gloves. This is necessary because whenever you have a small wound on your skin, and blood from another person comes in to that wound, there is a risk of getting infected. Thus to prevent this from happening there are several safety protocols. This protocol, putting on gloves when giving an IV to a patient, was already in place. However the hospital was not really checking if the nurses were working according the protocol. This changed, and there for the nurses now have to put on gloves. The change project is therefor aimed at safety, which is an important aspect in hospitals.
Project B
and for the future. Ensuring the quality of healthcare is of great importance and therefor changes like these are necessary for the hospital.
Data collection
For this research there will be different types of data used for triangulation. Using different types of data ensures that the evidence supporting the hypothesis will be stronger (Eisenhardt, 1998). For researching a “how” relation it is useful to make use of qualitative data (Eisenhardt, 1998). The first type of data that will be used for this research is the literature. The research started with an extensive literature review in different databases such as: Business Source Premier, Web of Science, Emerald and Google scholar. The studies found during this search were mostly in the field of lean in healthcare. However also other fields of study have been used. For example studies in the behavioral science have been used. The second type of data that will be used for this research his qualitative data in the form of interviews. The interviews are semi structured, they are based on a template. Those interviews will be conducted with the nurses in the hospital. The interviews will be recorded and transcribed afterwards. During the time spent at the hospital the researcher will also do some observations. In order to see if what the nurses say is the same as what they do in practice. This will give an insight in the way the nurses work and communicate with each other. During those observations fieldnotes will be taken. Fieldnotes are useful to quickly write down interesting things that might come up during the interview. Fieldnotes are a good way to remember what happened during the interview or what is seen in observations. The interviews that were held with the employees took around 20 to 30 minutes. Some were a bit shorter others a little longer. This was due to the fact that they did the interviews in between their tasks for that day.
Interviewees
few of the nurses were still in school, others recently started again in order to prepare themselves for the new role of directing nurse. Some work part time others are full time employees. There was however one common factor among the nurses, they were all female. Thus the nurses interviewed are a really diverse group, with different amounts of experience and different levels of education.
Data analysis
Results
In this section the data gathered will be analyzed by making a cross case analysis. This will be done by firstly analyzing the two different projects. Each project will be analyzed according to the framework described in chapter 2. The 4 variables from the framework and their relations to each other will be analyzed and described here for both projects. Afterwards, the results from the two projects will be compared in a cross case analysis. After the analysis is done the results from the analysis will be drawn up. By doing this the researcher hopes to answer the research question.
Project A
In this part of the chapter project A, the project with no participation involved, will be discussed. This is done in different steps. Starting with describing the initial response to the project. Then looking at the willingness to participate, followed by the actual participation. And finally if this participation helps in accepting the project.
Initial response
The initial response is the first reaction the employees have towards the change. The reactions toward this project are mixed, but mostly negative. A few nurses said they thought this was a good change. This negativity comes from the fact that the employees have the feeling that this change makes there task more difficult. And thus they have a negative response towards this change.
This makes our tasks more difficult (Respondent A13).
No I am not a fan of this change, it makes our work more complicated (Respondent
A18).
I think this change is a good change, eliminating the chances of infections and protecting us (Respondent A17).
fingers where the vein is. When a nurse misses the vein the cause unnecessary pain to the patient. This is something the nurses absolutely don’t want to do. Because some patient are already very ill and have veins which are hard to find. When missing the veins on these patient you not only hurt them, but you also lose the trust of these patients. And causing pain is not something a nurse wants to do.
Sometimes veins are hard to locate, and missing the veins causes pain, which is something you don’t want (Respondent A13).
Missing the veins is not only a painful experience, the patient also loses their trust in your abilities (Respondent A06).
The nurses know the gloves are needed for protection, and they know there is a risk of getting infections when working with blood. However they rather take the risk then risk hurting their patient. Furthermore, they say that the risk of spilling blood when placing an IV is really small. Some nurses said they have in all these years in the hospital never spilled a drop of blood when placing the IV.
I know it is for protection, but I don’t want to cause pain to my patient (Respondent
A02)
The risk of spilling blood is very small when placing an IV, it never happened to me in all my years here in the hospital (Respondent A10)
So to conclude, the nurses know the intention of wearing a glove are good and are there to protect them. However they find the risk of spilling blood to little and it does not outweigh the fact that placing the IV becomes more difficult. And when missing the vein they cause unnecessary pain, which is something they don’t want. Thus the initial response toward this change is negative.
Willingness to participate
The next step in this analysis is to check the willingness to participate. Do the nurses want to participate in this change project?
in more change projects. When the nurses participate they not only think of problems and a solution for this problem, they do this as well, but they do more. When they are involved in a change project they talk to their colleagues to try and convince them to work according the new change. Thus having the nurses participating in the change is beneficial for the outcome of the change project.
Of course do I want to participate, I have done so in some projects already (Respondent
A01).
I’m currently involved in a core team, which is working on implementing a change in to the department (Respondent A09)
When we are in a core team we also talk with colleagues about the benefits of the change (Respondent A18)
However, the nurses clearly stated that they only want to participate in a change project if they think it is a good change. Thus if their initial response towards the change is positive they are willing to participate in the change project. If they are negative towards the change, they are not willing to participate in that particular project.
If I can stand behind the change I’m willing to participate, if I can’t I’m not willing to participate (Respondent A04).
In order for me to sign up for a core team I need to like the change, otherwise I will not sign up for the team (Respondent A07).
Earlier it became clear that the initial response from the nurses was negative. As a result they are not willing to participate in this project. Due to the fact that they believe this is a bad change. This change makes their job harder and therefor they are not willing to participate and help to improve the change.
Because I can’t stand behind this change I will also not participate in this change project
(Respondent A06).
participate in this change. Therefor it can be said that this change is dropped on the team and they are not able to influence the change themselves.
Participation
In this step a closer look will be given to the actual participation. What is done in order to improve the project, and get more people on board of this project.
Since there is been no core team set up for this change nothing can be said about the participation. The employees were not willing to work on this project. Thus no improvements or changes have been made to the project. Which means that the project remains the same as when it was announced.
However, maybe there are other ways to help the change get positive feedback. Are the nurses talking to each other and convincing one another to work with this change?
They talk sometimes about this change, however not really to convince their colleagues to work with gloves on when placing an IV. Mostly the nurses talk about how this change makes their job more difficult. Thus this is also not helping the change.
Sometimes we talk about the change, but usually it is just to complain about it
(Respondent A13).
To conclude, next to the fact that there is no core group the employees don’t help the change get more accepted either. And thus it can be said that there is no participation from the nurses on this change project.
Overall acceptance or resistance
In this step the final response from the employees toward the change will be reviewed. Are they accepting the change and working accordingly, or are they resisting and sticking to their old working habits. And has the participation been of any influence on their response towards the project.
about the change with their colleagues. Furthermore when being involved in the change they find more information about why this change is good, and this helps them influence their own decision towards the change. Next to that, the employees have the ability to influence the change, and improve the change so it becomes more suitable for them and their department..
Participating helps me in accepting the change (Respondent A03).
When we are involved in the change we talk more with our colleagues about the change because you want to show what you stand for (Respondent A04).
Participating helps me in getting more background information about the change
(Respondent A06).
In the core team we can help make the change even more beneficial (Respondent A09).
This project however had no participation and thus these benefits are not applicable here. Due to a negative response towards the change the nurses were not willing to participate. Thus missing out on these benefits, they mentioned, of participating.
We didn’t participate so there is no way for us to influence the change (Respondent
A15).
Because the nurses did not participate their initial response toward the project did not change. The nurses are still negative towards the change of putting on gloves. And when placing an IV many of them refuse to put on gloves, whether it is in purpose or just because they are used to it differs. However it can be said that they are not accepting this change as a team, just a few individuals whom were positive are trying to work according to the new protocol. They however have the feeling they are a minority.
Usually when placing an IV I am not wearing gloves (Respondent A14).
I usually start with gloves on, but when I find it to hard to find the vein I take them off
(Respondent A12).
I always wear gloves, and I have the feeling I am one of the few (Respondent A09).
Wouldn’t it be better if we could wear one glove, so we can feel with our bare hands where the vein is and place the IV with the other hand which is protected by the glove
(Respondent A16).
Maybe if we had more training with gloves on, I mean some of us are used to it with no gloves, some of us are working here 30 years and always have done it without gloves
(Respondent A11).
Thus it can be said that this change is not accepted by the nurses. Not being able to participate in this change made sure they still had a negative response towards the change. Participation might have helped turn their opinion around, but there was no participation, and thus no way of changing their response towards the change.
Conclusion project A
To conclude, the initial response toward this change was negative. Due to this negativity the employees didn’t want to participate in the change project. Because there was no participation in the change the nurses are still negative about the change and therefor they do not support this change.
Project B
Now it is time to take a look at the second change project. This is the project in which participation does play a role. The analysis will be done in the same way as done for project A, and is also based on the framework discussed in chapter 2. So the same 4 concepts will be discussed and at the end their will be a short conclusion from the result of this change project.
Initial response
The first step in this analysis of project B is the initial response from the employees towards this change project.
The initial response was positive for most of the employees. This is because the nurses see several benefits in having a directing nurse, and thus thought this would be an addition to the team.
I think this is a good change (Respondent A17). I stand behind this change (Respondent A13).
The benefits from having this directing nurse come especially from the fact that the directing nurse has time to do background research in difficult healthcare cases. Getting a better understanding of these cases, and thus being able to take care of the problems faster and better. Furthermore, are the directing nurses able to carry this knowledge over to the other nurses and in doing so improving everyone in the department.
The directing nurse does research in to difficult healthcare cases, and is thus able to provide better care for the patient because they have a better understanding of the problem (Respondent A09).
They are also able to carry over the knowledge they found in the literature (Respondent
A06).
The quality of healthcare improves with this change (Respondent A06).
We are here to help patients the best we can, and if a change like that can improve us, then I am a fan of this change (Respondent A05).
Another benefit this change brings is a new ability to grow in function. It’s always nice to climb on the ladder in an organization. And by adding a new function to which the nurses can grow gives them the ability to climb on the ladder and get more responsibilities. This extra benefit is something the nurses were positive about as well.
Being able to grow is always a good thing (Respondent A18).
This new function is something we can get, and I want it, growing and getting extra responsibilities is great (Respondent A09).
To conclude, it is safe to say that the nurses are positive about this change project, and thus the initial response towards this project is positive.
Willingness to participate
The second step is the willingness to participate. The nurses are willing to participate on change projects, this became clear in the analysis from project A. However, are the nurses willing to participate on project B?
The nurses said they are willing to participate in projects which they think are good changes. If they think the change is a good change they will put time and effort in the change to either get it accepted by the other nurses in the department or improve the change.
If it is a good change I will spend time and effort on it to make sure it gets accepted
(Respondent A09).
According to the nurses this is a good change which they think is worth of spending time and effort on. The change is beneficial for the department, but also for the nurses themselves. And thus their response toward this change project was positive. As a result of this positive response the nurses are willing to participate on this change project.
Thus we can see that the nurses are willing to participate on this project, and are willing to spend time and effort on the project.
Participation
The nurses are willing to participate on the change project. However how are they willing to do so?
Firstly, there is a core group tasked with implementing this change in to the department. For this core group several employees signed up, because they were willing to help this change forward and want to make sure it gets implemented.
I signed up for this core group, together with some colleagues to get this change in to the department (Respondent A09).
Secondly the nurses are talking with each other about this change. They usually talk about changes which are happening in the department, however not always in a positive way. This change on the other hand is a change the nurses are positive about. And the nurses are trying to convince the ones who are not as positive by telling them about the benefits of this change. This way they also help the change in the department.
We talk a lot about changes, and this is a change we hear a lot of positivity about
(Respondent A17).
I try to convince my colleagues sometimes about the benefits of this change
(Respondent A09).
Thus the nurses are participating in this change, not only by being in the core group, but also by talking about the change and in this way trying to help the change.
Overall acceptance or resistance
The participation in this project helps the nurses in becoming more acceptant of the change. Talking with colleagues prepares them for the change and reminding each other of the benefits this change brings. Thus if one is doubting this change, the colleagues will try to convince him or her that the change is a good thing. This way the acceptance in the department is high.
When someone doubts the change we try to talk to him and show him/her the benefits of the change (Respondent A05).
Furthermore helps the participation team in implementing the change in a good way. This ensures that everyone, or at least the largest amount of people is happy with the change. If they feel that something bothers their colleague about this change they talk about it, and if more people feel the same way they try to find a solution for it. This way the participation team helps the others accept the change.
In the core team we try to find solutions for problems people have with the change
(Respondent A09).
In preparation of this change several nurses already started with extra education to be able to grow in to the new function. This shows their positivity about the change, and their support for it.
I started with a study again, to be able to get the new function of directing nurse
(Respondent A16).
Conclusion project B
To sum up everything from this project. The initial response of this project was mostly positive. The nurses were willing to participate in this project, because they thought the change was beneficial. This lead to participation of the nurses in this project. This participation strengthened the acceptance of the change project.
Looking at the framework in chapter 2 and comparing that framework with the results from project B, it is obvious that this framework gets confirmed. The initial response influence the willingness to participate, since the nurses were positive about the change they were willing to participate in this project. This willingness influences the actual participation. Several nurses signed up for the core team, and others helped in other ways. And finally participation influences the overall acceptance of the project. Since the participation strengthened the acceptance of this project.
Cross case analysis
The last step of the result section is the comparison of the results from both project A and project B. Looking at the differences and similarities between the participation within the two projects.
Similarities
The biggest similarity between the both projects is the fact that both of the projects supported the framework from chapter 2. Both of the projects showed the relationships between the different concepts in the framework. It showed how the one concept influenced the other concept and in that way showed the relation between the two.
Other smaller similarities are the fact that the nurses talk about both of the changes. They talk about the reasons behind the change, and whether or not they accept the change. They do this for both project A and project B. Furthermore, both of the projects are being enforced, so both of them are used in the hospital. Another big similarity is the outcome, both of the projects have the same response at the end as the initial response towards the change. So the whole process did not change to much about the response of the nurses.
Differences
The main difference is of course that in one project participation played a role, and in the other it did not. This shows the big difference between the two projects, and that is mainly where all the differences between the two projects are based on. The differences in the actual participation, the difference in the acceptance of the project. But the difference in participation came forth from the difference in the initial response towards the project. In the one the initial response was negative and in the other positive. Which lead to a difference in participation.
Overview
To put everything together, here are a few tables to give a easy and quick insight in the outcomes. And in this way give a better overview of all the results gathered from the interviews.
The table below gives an overview of the outcomes on the different concepts for each of the two projects.
Concept: Project A: Project B:
Initial response Negative Positive
Willingness to participate Negative Positive
Participation Negative Positive
Overall acceptance Negative Positive
The second table gives a more in depth overview of the results by looking at where the differences come from.
Factor: Project A: Project B:
The project comes from a lean perspective V V
Nurses feel it makes their job harder V X
Accepting the change can have consequences for patients V X
Nurses are able to back up the change X V
Participation team was started X V
Nurses spoke about the change V V
Nurses tried to convince colleagues about benefits of change X V
Nurses had ideas on how to improve the change V V
The change gave additional benefits X V
The change is for safety of patient and staff V X
Discussion & Conclusion
The aim of this paper is to answer the to the following research question: How does employee
participation influence the acceptance of change in lean healthcare projects? After the
analyzing the data several differences were revealed with regard to participation and no participation. Now a conclusion will be drawn up from the analysis. Then in the discussion the results will be compared with the literature again. After that section theoretical and practical implications will be provided. Furthermore, will be in this section the limitations and suggestions for further research.
This research has contributed to the existing literature on change. It has done so in comparing two different projects, one in which participation played a role and the other in which participation did not play a role. By drawing on the results from the interviews this research found several similarities and differences which were relevant for answering the research question. The research answered the research question because of the cross case analysis it is possible to see what participation has contributed. Participation ensures less resistance with the employees when faced with a change project.
This can also be found in the literature. Helpap (2016) said that employee involvement helps with the acceptance of a change. Fuchs and Prouska (2014) found similar results in their study. They found that participation has an positive effect on the change evaluation from the employee. Meaning that the employee is more positive towards the change when he or she has participated in the process. Furthermore has the study of Rafferty and Jimmieson (2010) found that a positive perception of communication and participation processes could foster a positive team change climate. This means that participation contributes to a more positive climate towards change in the organization. Thus so far the study was consistent with the current literature.
Employees who agree with everything do not come up with constructive feedback (March, 1991).
Furthermore did the study show that the communication between colleagues increased. Communication between colleagues is from the upmost importance (Bordia et al. 2004). Participation contributes to this communication and can therefore be seen as a positive contributor to the organization.
Theoretical implications
This research added to the field of lean in healthcare. Many lean initiatives in healthcare settings fail or are not as successful as intended. In getting a better understanding on how recipients respond to change, and the ability to influence this response positively might help the lean initiatives. Because, according to Oreg et al. (2011) recipient responses to a change project are the main determinant of success.
Furthermore, did this study add to the field of change acceptance studies. In getting a better understanding of how and why the employees might resist changes in which they were not involved, and favor changes in which they were involved. Helpap (2016) predicted this already when he said that participation promotes dialogue and input, which helps employees in accepting the change.
Practical implications
organization to look into the resistance literature. By not setting up a participation team at all, because the employees are not willing to participate is not helpful. Instead they might set up a team with some resisting employees and tr to come up with solutions to improve the change and in that way make more employees acceptant of the change.
Limitations
This study has some limitations. Firstly, this research is done in one organization, within one department. Thus should the results be handled carefully because there is a lack of external validity. Secondly, this study is not a longitudinal study. The research is done at one point in time. For more trustworthy results it would be better to have done the research over an extended amount of time. Thirdly, the results in this study were based on only two change projects. Because of these limitations the results should be handled carefully.
Directions for future research
Conclusion
This study provides insights on how participation influences acceptance of change. The study was done in the field of lean, because working with lean means you need to change. One of the goals of this study is to help the employees with the ongoing changes. Helping them in accepting and dealing with those changes.
From this research it can be concluded that participation helps in accepting the change. Talking about the change gives the employees the necessary information they need in order to decide for themselves if they think the change is good or not. Being busy with the change and possible improve the change makes it even better. Thus it can be said that participation helps employees in accepting changes.
However, there is one big issue here. If the employees are negative about the change in the first place, they are not willing to participate. Which means that participation does not completely change the view of the employees from resisting towards accepting. To achieve that goal it is beneficial to take a look in to the literature to find another solution to that problem.
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Appendix 1 interview protocol
Interview protocol:
Inleidend:
Welkom, bedankt dat u tijd heeft vrij gemaakt en mee wil werken met dit onderzoek. Mijn naam is Jacco Kramer en ik studeer verandermanagement aan de Rijksuniversiteit Groningen. Dit onderzoek is voor mijn afstuderen. Ik doe onderzoek naar veranderprogramma’s in zorginstellingen, vandaar dat ik hier in het ziekenhuis ben. Specifiek kijk ik naar het verbeterprogramma (Lean) en de rol van participatie hierin.
Het interview duurt ongeveer 30 minuten, wanneer er iets niet duidelijk is tijdens dit interview voelt u zich dan vrij om dat aan te geven. Graag wil ik uw toestemming vragen voor een audio-opname, dit maakt de verwerking van het interview makkelijker en komt de betrouwbaarheid van mijn studie ten goede. Ook wil ik u verzoeken het volgende formulier <INFORMED CONSENT> door te lezen en bij akkoord te tekenen. Hierin leg ik uit wat de belangrijkste voorwaarden van het onderzoek zijn. <ACTIVITEIT LATEN UITVOEREN>
Heeft u op dit moment vragen?
Dan kunnen we nu echt beginnen met het interview
Achtergrond:
1. Kunt u in een paar zinnen iets vertellen over uzelf. Bijv. hoelang doet u dit werk al? Bevalt het werk? Etc.
2. Heeft u het gevoel dat er veel kwaliteitsveranderingen plaatsvinden op de afdeling? Veranderingen die als doel hebben de prestaties van het ziekenhuis te verbeteren.
2a. Kunt u kort een voorbeeld geven van zo’n verandering om de kwaliteit te verbeteren?
Acceptatie/weerstand:
3. Wat zijn uw verwachtingen van die veranderingen? (positief, makkelijker maken werk of negatief, moeilijker maken werk)
3a. Wat is uw eerste reactie als u over die veranderingen hoort? (gevoelens/emoties) 3b. Waarom reageert u zo op die veranderingen?
4.En wat doet u met die verandering? (Support/hinderen) 4b. Waarom doet u dat?
5a. Waarom laat u dat wel of niet zien?
Participatie:
6 Denkt u op dit moment mee over veranderingen? Waarom wel/niet?
6a. Als u iets ziet waarvan u denkt dit kunnen we beter op een andere manier doen (dus iets veranderen in de manier van werken zodat het beter wordt) geeft u dat dan ook aan? 6b. Waarom doet u dat wel/niet?
7 Bent u bereid om daadwerkelijk zelf, alleen of in een team, bij te dragen aan het realiseren van de oplossingen? Bijdrage in de zin van tijd aan besteden
7a. Waarom zou u dat wel of niet willen doen?
Participatie → Acceptatie/weerstand:
8. Als u mee zou denken, en meepraten over een veranderingen, zou dat invloed hebben op uw verwachtingen en hoe u over die verandering denkt? (makkelijker maken werk/ moeilijker maken werk & gevoelens/emoties)
8b. Waarom denkt u dat het wel of geen invloed zou hebben?
9. Als u mee zou denken, en meepraten over een verandering, zou dat invloed hebben op hoe u met de verandering om gaat? (support/hinderen)
9b. Waarom denkt u dat dit wel of geen invloed zou hebben
10 Als u mee zou denken, en meepraten over een verandering, zou u dan ook aan anderen uw mening laten zien over de verandering? (sociale invloeden)
10a. Waarom zou u dat wel of niet doen?
Einde:
Appendix 2 Code book
Code: Citation:
First response to change I am always in for new things, I am not afraid of changes (A03).
Negative first response project A This change makes our task more difficult (A13). Positive first response project A I Think this is a good change, eliminating chances
of infections and protecting us (A17).
Willingness to participate Of course do I want to participate, I have done so in several changes already (A01).
Willingness in project A Because I can’t stand behind this change, I will not participate in this change (A06).
Willingness in project B I Think this is a good change, so I am willing to help with the change (A05).
Participation in changes I am currently in a change team concerned with the planning of patients (A15).
Participation in project A When we talk about this change it is usually to complain (A13).
Participation in project B I signed up for the core team together with some colleagues (A09).
Acceptance in changes Participation helps me in accepting changes (A03).
Acceptance project A Usually when placing an IV I don’t wear gloves (A14).
