Taking Initiative in Self-Organizing Healthcare Teams

Taking Initiative in Self-Organizing Healthcare Teams

A qualitative study on how working in self-organizing teams influences ea e be initiative taking in the healthcare context.

June 20, 2020

LISANNE ROELFIEN BRANDSEMA Student number: S3847640 lisannebrandsema@hotmail.com

+31 (0)630772013

Master Thesis

MSc. Change Management - Business Administration Faculty of Economics and Business

University of Groningen

Supervisor RUG dr. J.F.J. Vos Co-assessor RUG

dr. C. Reezigt

Word count (excl. appendixes):

13.785

ABSTRACT

______________________________________________________________________________

Many healthcare organizations consider implementing the structure of self-organizing teams (SO-teams), because working with these teams is believed to result in more satisfied clients and employees, and lower the costs for the organization. Working in SO-teams stimulates taking initiative and responsibility, however it remains unclear (1) how self-organization influences initiative taking, (2) if employees convert the increased sense of responsibility into new initiatives, and (3) how these initiatives are taken.

This research integrates scholarly literature and interviews with employees of a healthcare organization to develop a framework for understanding the conditions for generating initiatives in SO-teams in the healthcare context. Qualitative data is retrieved from interviews with healthcare workers who were indicated by their manager as initiative-rich and experienced the transition towards SO-teams.

This study shows the most contributing aspects of self-organization to initiative taking: less asking for permission, doing what you like, having the manager as a coach, and feeling an increased responsibility towards colleagues and clients. Other contributing aspects are the expanded room for initiatives, the implementation of private companies and core roles, and the own structure employees are able to implement. This differs from traditional teams where the manager was physically present, leadership was more directive, there was no stimulation to think out of the box, and no involvement of the employee which resulted in less initiatives. Lastly, the model developed in this study contains six phases in which every initiative goes through: (1) starting points, (2) opportunity arises, (3) tuning, (4) preparation, (5) implementation, and (6) evaluation.

To conclude, working in a SO-team influences initiative taking because team members, among others, have to ask less permission, think more critical about their job, and have their manager as a coach. Although there is more room for initiative, working in a SO-team does not suddenly cause people to take (more) initiative. Therefore, it is essential that the management and teams ensure that the indispensable conditions are present and that all employees, also the team members who are not used to taking initiative, take part in the initiative process to receive the returns from initiative taking as well.

Key terms: self-organizing teams, self-managing teams, taking initiative, initiative taking, initiative taking in healthcare, proactivity.

TABLE OF CONTENTS

1. INTRODUCTION 4

2. THEORETICAL BACKGROUND 6

2.1 Self-organizing teams 6

2.1.1 Roots of self-organizing teams 6

2.1.2 Leadership in self-organizing teams 8

2.1.3 Employee satisfaction in self-organizing teams 8

2.2 Taking initiative 9

2.3 Research framework 10

3. METHOD 12

3.1 Research approach 12

3.2 Empirical setting 12

3.3 Procedures for data collection 13

3.4 Data analysis 15

4. RESULTS 17

4.1 Indispensable conditions for initiatives in self-organizing teams 17 4.2 Why people do (not) take initiative in self-organizing teams 19

4.3 Returns on initiatives 21

4.4 Contributing aspects of self-organizing teams to taking initiative 22

4.5 Initiative process in self-organizing teams 25

4.5.1 Starting points 25

4.5.2 Opportunity arises 25

4.5.3 Tuning 27

4.5.4 Preparation 27

4.5.5 Implementation 27

4.5.6 Evaluation 28

4.6 Integrative model 29

5. DISCUSSION & CONCLUSION 30

5.1 Discussion 30

5.2 Theoretical implications 32

5.3 Practical implications 33

5.5 Conclusion 35

ACKNOWLEDGEMENTS 36

REFERENCES 37

Appendix A: Interview protocol (DUTCH) 43

Appendix B: Interview protocol (ENGLISH) 45

Appendix C: Consent form research 47

Appendix D: Codebook 48

D.1 Overview codes 48

D.2 Extended code book 49

Appendix E: Infographic Philadelphia 55

1. INTRODUCTION

Nowadays, healthcare organizations search for more cost-efficient ways of delivering care, while patients demand higher quality, shorter waiting times, and more flexibility in the healthcare sector (Aronsson, Abrahamsson, & Spens, 2011; Joosten, Bongers, & Janssen, 2009). To cope with these challenges, many healthcare organizations consider implementing self-organizing teams (SO-teams) (Aronsson et al, 2011;

Joosten et al, 2009), because working with these teams is believed to result in more satisfied clients and employees, and lower the costs for the organization (Weerheim, Rossum, & Have, 2018). In this context, achieving the highest possible quality for the patients is, of course, the overarching goal (Porter, 2010).

Other organizations outside the healthcare sector have recognized human capital and agility as cornerstones of organizational success as well. Therefore, these organizations have increasingly flattened their structures and power is now more bottom-up to team-based autonomous structures known as SO-teams (Bernstein, Bunch, Canner, & Lee, 2016).

SO-teams consist of interdependent, autonomous individuals who are responsible for planning, organizing, a d a a a de e e ea a d ac e e a c a (Cohen, Ledford, &

Spretizer, 1996; De Jong, De Ruyter, & Lemmink, 2004). Research has shown that the introduction of SO- teams raises the feeling of responsibility and encourages employees to show more initiative (Banner, Kulisch, & Peery, 1992). Therefore, e ee own responsibility and the room for initiative are important aspects of working in SO-teams (Rosen, Fiore, Salas, Letsky, & Warner, 2008). This differs from traditional teams, where less input from employees is required due to supposed clear visions and specified frameworks of the organization (Banner et al., 1992). An empirical study executed in Canada revealed, furthermore, that SO-teams allow members greater flexibility to adapt to occurring and anticipated events, which a e e ea effec e e . The SO-teams in that study achieved higher performance and better coordination than the functional, traditional teams (Jobidon, Turcotte, Aubé, Labrecque, Kelsey, &

Tremblay, 2017).

Despite the important role of self-organizing and self-managing teams in the healthcare literature over the past 50 years, only a few studies include the role of the initiatives taken in these teams (Banner et al., 1992;

Karakus, 2017; Rosen et al, 2008). Firstly, literature states that there is more space for employees to take initiative in SO-teams (Banner et al., 1992), but it is unclear how self-organization influences initiative taking. Secondly, we know from literature that team members in SO-teams have an increased sense of responsibilities, but it is unknown if these people convert the sense of responsibility into new initiatives that contribute to the goal of the organization (Batt & Appelbaum, 1995; Karakus, 2017). Lastly, it remains unclear in the literature how a typical initiative process looks like in SO-teams (Frohman, 1997). This means

there is a knowledge gap in literature about the contribution of SO-teams on taking initiative and how these initiatives are given form in these teams. Therefore, further investigation in this specific field of SO-teams is of great importance.

Further research to SO-teams and the way their members take initiative contributes to (1) the understanding of how SO-teams differ from traditional teams in taking initiative, (2) insights into the typical initiative process to find out how people take initiative in SO-teams and how this can be stimulated more and, (3) possibilities for change agents and companies who would like to implement SO-teams to see if this new structure contributes to the proactivity and initiative-taking of individuals (Batt & Appelbaum, 1995;

Karakus, 2017). This study will provide such insights into SO-teams and their way of working towards initiative taking by team members. The research question is as follows: H d e king in elf-

gani ing eam infl ence he eam membe ini ia i e aking?

In this study, qualitative research is conducted in the form of fifteen semi-structured interviews with employees of a large healthcare organization in The Netherlands. This healthcare organization started with the implementation of SO-teams in 2017 and all the interviewees experienced the transition towards this new structure. Since the transition took place very recently, the employees can remember it well. Therefore, the organization is suitable for this research. The main interview method of this research is the appreciative inquiry. Interviews were conducted with employees who were indicated as initiative-rich by their managers.

In the next section, a theoretical background will be provided, giving the reader more specific insights in the concepts of SO-teams, taking initiative, and its related theories to identify what previous research has contributed. In the method section, an overview of the used methods in this study will be given with a specific focus on the interview method: the appreciative inquiry. The e ec e e e d findings in an analytical overview. Lastly, in the discussion and conclusion the findings are linked to the existing literature and conclusions will be drawn. This section also discusses limitations suggestions for further research.

2. THEORETICAL BACKGROUND

This section first discusses working in SO-teams, and the corresponding aspects in these teams: leadership and employee satisfaction. Leadership is a key aspect here, because there is relatively little supervision in these teams, thus lacking top-down control. Furthermore, employee satisfaction is essential because working with SO-teams is believed to results in more satisfied clients and employees. The second part of this section is about taking initiative and how this is related to self-organization. This theoretical background forms the main basis for the interview protocol.

2.1 Self-organizing teams

SO-teams consist of interdependent, autonomous individuals who work together under the guidance of a team leader to complete a task (Cohen et al., 1996; De Jong et al., 2004; Leliveld & Vink, 2000). They are

e b e f a , a a d a a a de e e ea a d ac e e

a common goal (Cohen et al., 1996; De Jong et al., 2004). Thus, the team self-coordinates work to achieve measurable results and can decide independently about internal operations (Leliveld & Vink, 2000). This definition will be used in this study, because it includes the guidance of a team leader. Leadership in SO- teams is in this context motivating teams by acting as a coach (Hoda, Noble, & Marshall, 2010; Takeuchi

& Nonaka, 1986). Self-organizing or self-managing teams are organizational forms that have emerged over the years. This will be explained in further detail in the following sub-section, together with the existing theoretical perspective that have recently been combined with new developments, converting these perspectives into new theories. In the last two sub-sections the main themes of SO-teams are discussed:

leadership and employee satisfaction.

2.1.1 Roots of self-organizing teams

According to Smets (2014), some characteristics of SO-teams date back to Ta l Scien ific Managemen from 1911. Over the years, new theoretical perspectives on the definition of a team and its responsibilities arose. These perspectives differ in terms of autonomy and decision-making authority (Burnes, 2017; Hoda

& Murugesan 2016; Smets, 2014). Ta l Scientific Management was followed by the Human Resource Perspective (HRP), the socio-technical theory, and eventually resulted in SO-teams (Smets, 2014).

In Ta l Scien ific Managemen , efficienc and c n l e e im an a ec ; in this context employees should follow a strict routine and proceedings were standardized (De Winter, Kocurek, &

Nichols, 2014). The introduction of these control mechanisms was, among other things, introduced based on the idea that employees were undisciplined and unmotivated (Burnes, 2017). However, due to several

factors such as globalization and technological change that transformed the business landscape, there was a need for more degrees of freedom: one believed that individuals should receive more independence at work (Sanchez-Bueno & Suárez-González, 2010; Sandberg & Targama, 2007). It meant that organizations needed more flexible and adaptable structures in order to thrive in an increasingly turbulent business environment (Frohman, 1997; Smith & Pazos, 2018).

Several years later, a more flexible and adaptable organizational form was introduced. The Human Resource Perspective (HRP), resulted from the idea that organizational performance was more than a sum of technical improvements (Miles, 1965; Smets, 2014). Different than in Taylorism, as explained above, the authors of the HRP argue that employees are a valuable resource to the organization (Miles, 1965):

According to Marciano (1995), managers should look at their employees as individuals and show interest in their welfare and happiness. Furthermore, active participation of the workers in the organization can lead to improved decisions and self-control, which in turn improves worker productivity and satisfaction (Marciano, 1995).

In the second half of the twentieth century, organizations began to shift their view from inside the organization to the outside of the organization, such as the environment. Resulting in the socio-technical theory developed in the 2000s. In this theory organizations consist of a technical system, with certain equipment and technological processes and a social system, where the psychological and social needs of the workers are central (Pais, 2010). The aim of this socio-technical theory is to achieve a joint harmonization between both systems, in order to have a structure that is productive and satisfying (Pais, 2010). The earliest references to SO-teams can be found in this socio-technical literature: self-organization has its origins in the British mines where miners get the responsibility for the coal mining process (Trist &

Bamfort, 1951).

These SO-teams are a concrete outcome of implementing the socio-technical system, because SO-teams also seek to design effective relationships between the social and technical aspects of work systems and their task environments (Cummings, 1978). Over time, workers in SO-teams are granted more autonomy, self-direction, and control over their work environment. For example, getting the responsibility for scheduling own work hours and vacations. But also, ordering materials, hiring and firing employees, and determining pay raises (Arnold, Arad, Rhoades, & Drasgow, 2000). Nowadays, the principles of SO-teams are the following: (1) variety in the skills of the team, (2) cross-functional ability in the team to supplement and replace each other when required, (3) make sure that team members not only learn new skills, but also learn them better ways to accomplish tasks, and (4) less critical specifications, let the team make their own

choices (Hoda & Murugesan, 2016). To gain more insight into the last-mentioned principle, containing the less critical specifications SO-teams get, the next sub-section will provide a theoretical overview of leadership in SO- teams.

2.1.2 Leadership in self-organizing teams

Leadership is an important theme in SO-teams, it is essential to give team members less critical specifications and let them make their own choices, as argued by Hoda & Murugesan (2016). SO-teams get relatively little supervision, thus lacking top-down control (Bonabeau & Meyer, 2001). However, SO- teams are not supposed to be leaderless and uncontrolled. Leadership is meant to be providing feedback and subtle direction and control, aligning people, obtaining resources, and motivating the teams by acting as a coach (Hoda et al., 2010; Takeuchi & Nonaka, 1986). Team leaders of SO-teams thus need to take on a new set of roles and responsibilities in order to lead these teams, since new and different skills are required (Arnold et al, 2000; Cummings & Worley, 2015). Furthermore, team leaders are expected to show appropriate behavior, provide emotional encouragement, build trust and openness, provide information and resources to complete tasks, and communicate a vision (Arnold et al, 2000).

The shift in the expression of control from the leader to the team members is the fundamental difference between leaders of traditional teams and leaders of SO-teams, according to an empirical study from Arnold et al (2000). The actions from leaders of a SO-team are aimed at helping team members function and perform as a self-managed business unit (Arnold et al, 2000; Hoda et al., 2010; Takeuchi & Nonaka, 1986).

Additionally, the set of behaviors that are required for leadership in SO-teams seem to characterize eade a e a a a e e be a (A d e a , 2000). It is necessary to clarify exactly what is meant by these two behaviors, because they are not the same concepts, although they must go hand in hand (Muh, 2017). Management skills are mainly focusing on planning, building, and directing organizational systems to reach missions and goals, while leadership skills are used to focus on a potential change by establishing direction, aligning people, and motivating and inspiring. The leadership skills are used by the manager in SO-teams to align and motivate people to ensure that employees take initiative themselves (Muh, 2017).

2.1.3 Employee satisfaction in self-organizing teams

Another important theme in SO-teams is the growing satisfaction among employees about their way of working. Many healthcare organizations consider implementing the structure of SO-teams (Aronsson et al, 2011; Joosten et al, 2009), because working with these teams is believed to result in more satisfied clients and employees (Weerheim et al., 2018). An empirical study of Batt & Appelbaum (1995) has revealed that

professionals in SO-teams like their way of working because they get more autonomy, better cooperation, and greater recognition. 62% of the SO-teams help one-another with problem-solving versus only 35% in the traditional groups (Batt & Appelbaum, 1995).

The view of SO-teams is that it makes work more interesting and offers more opportunities for development. Many studies, comparing self-organizing and traditional teams, show increased job satisfaction of employees working with SO-teams (Batt & Appelbaum, 1995; Cohen & Ledford, 1994;

Jobidon et al., 2017; Weisman, Gordon, Cassard, Bergner, & Wong, 1993). However, an experimental study from Langfred (2004) shows that too much trust in a SO-team can be harmful. It can lead to performance loss because the more team members trust one another, the less they choose to monitor one another.

2.2 Taking initiative

Working in a SO-team requires taking initiative and responsibility (Bonabeau & Meyer, 2001; Tours, 2017).

However, a qualitative research from Tours (2017), has revealed that taking initiative must really be encouraged and people have to get used to the new way of working. Taking initiative is defined by Frese

& Fay (2001) as: the work behavior characterized by self-starting nature, its proactive approach, and by being persistent in overcoming difficulties that arise in pursuit of a goal (p. 98). According to Grant &

Ashford (2008), being initiative-rich means you (1) ask yourself what is likely to happen, and react to it before it happens, (2) find out for yourself what you need to know, (3) strive to overcome barriers, (4) persevere even when things get difficult, and 5) act as a role model for team members who, in turn, need to take initiative in their workplace (Grant & Ashford, 2008).

Now that a clear picture has been created about how taking initiative is defined and what it means to be initiative-rich, it still has to become clear how to research initiatives taken in SO-teams. Organizations can be divided in three different levels: individual, group, and organizational level (Cawsey, Deszca, & Ingols, 2016; Cummings & Worley, 2015; De Leede, Nijhof, & Fisscher, 1999). Therefore, the initiatives taken in SO-teams will be divided into these three levels, they can be self-oriented, group-oriented, but they can also be organization-oriented. The first level is the individual level; consisting of satisfaction, stress, the quality of working life, and identification. The initiatives at the individual level are about the quality of working life. The second level is the group level; with the aspects of functioning, development, competences, and the collective mind. The initiatives at group level (in other words: between the team members) are about developments, for example a new project or the design of team meetings. The last level is the organizational

level; in which the level of goal attainment, adaptability to the environment, and availability of resources is identified. The initiatives at organizational level are about reaching goals, stakeholders, and resources (Cawsey et al, 2016; Cummings & Worley, 2015; De Leede et al, 1999).

Research has already shown how people take initiative in traditional teams. Frohman (1997) describes in his qualitative study the power of initiative on local changes in corporations across America. In this study, each interviewee was identified as a mover and a shaker: someone who brought about change that was constructive in both its conduct and outcome (Frohman, 1997). As in this study, Frohman also uses the appreciative inquiry; he came up with the typical initiation process which will be used in this study as well to ask interviewees how they take initiative. This typical initiation process consists of seven steps. First, the individual should have a clear vision of organizational direction, strategy, and goals. Next, the individual can spot a problem or opportunity. Then he or she can take action personally. The fourth step consist of the employee pushing for broader action and results. After that, the action is accepted by the organization and implemented in one part or unit; the organization thus ada e c a e e b ad a e it. Lastly, feedback or learning is based on the results of the change (Frohman, 1997). The study of Frohman (1997) about initiative-taking is relevant to this study because it gives a clear description of how people take initiative.

The main value of employees who take initiative is their high engagement with the company and independent thinking (Campbell 2000). Once team members care about, feel involved in and identify themselves with their work environment, they are more likely to pursue goals. Achieving these goals can be done by taking initiative (Crant, 2000).Thompson (2005) shows that a proactive personality, which is related to taking initiative, is positively related to network-building. Network-building in turn can result in career success and overall job performance. With their independent judgement and active involvement, proactive individuals who take initiative add value to a company b e e c e e e eade efforts and other times relieving the leader of many tasks (Crant, 2000). In other words, the presence of employee initiative is important, which is encouraged in SO-teams

2.3 Research framework

Based on this theoretical analysis, it is clear that the concepts of SO-teams and initiative taking are interrelated. In particular, working in SO-teams stimulates taking initiative (Bonabeau & Meyer, 2001;

Tours, 2017). Further research into this area is useful for unraveling the way SO-teams influence taking initiative in the healthcare sector. F e 1 e c e d e ea c f a e a a e the

relationship between SO-teams and taking initiative: working in SO-teams f e ce e ea e be initiative taking. This relationship will be researched by conducting interviews with healthcare professionals in a large Dutch healthcare organization by making use of the three levels of initiative taking (Cawsey et al, 2016; Cummings & Worley, 2015; De Leede et al, 1999), which can be seen in Figure 1, and the typical initiation process of Frohman (1997). Next to this, respondents get the opportunity to come up with other experiences or aspects. The following section describes more about how these interviews will be conducted to unravel the influence of SO-teams on initiative taking.

Figure 1: Research framework: the influence of working in self-organizing teams on taking initiative in the healthcare sector.

3. METHOD

In order to answer the research question, a qualitative study was performed in a Dutch healthcare organization. First, the research approach is explained. This research concerns theory development, because relevant knowledge about the contribution of SO-teams on taking initiative is missing in the literature.

Subsequently, to explain the empirical setting, more information will be given about the researched organization. In the third sub-section, the procedures for data collection are described about the participants and the main interview method: the appreciative inquiry. The final sub-section presents the data analysis, regarding the transcribing and coding processes.

3.1 Research approach

To unravel the contribution of self-organization to taking initiative, a qualitative study has been conducted.

Acc d P a (2009), a a e e ea c a a e f e ea c e a d f understanding the world through the eyes of those studies, which is essential in a study about the experience of team members. Relevant knowledge about this contribution is missing in the literature, for this reason the qualitative research approach used in this study is theory development. According to Van Aken, Berends, & Van der Bij (2012), theory development is needed when the business phenomenon has not yet been addressed in academic literature, corresponding to this study. Theory development is a qualitative approach that is known for constructing a flexible guideline for textual data analysis in the context of human behaviors, social processes, and cultural norms (Hennink, Hutter, & Bailey 2011). This qualitative study consists of fifteen semi-structured interviews. The decision for interviews was made because conducting interviews is a method for learning with an open mind (Edmondson & McManus, 2007) and to ask follow- up questions. Openness to input from the field where the interviewees work in, helps to ensure that the researcher identifies and investigates key variables over the course of the study (Edmondson & McManus, 2007). The approaching of interviewees and the formulation of the interview questions were based on the appreciative inquiry; more information about this method can be found in the sub-section ced e f data collection .

3.2 Empirical setting

This study is executed in a large healthcare organization: Philadelphia. It is a Dutch national organization for people with intellectual disabilities. Philadelphia is currently supporting around 8,200 people with intellectual disabilities. Spread over around 530 locations in the Netherlands, 7,600 professionals provide tailor-made support for their clients (Philadelphia, n.d.). The structure of Philadelphia consists of three

clusters: (1) Care & Living, (2) Intensive Care and, (3) Work & Support. Philadelphia's mission is to support people with disabilities in the best life possible. As a result of their goal to strive for an organization that facilitates the execution of complex tasks, Philadelphia introduced self-organization in their company in 2017 (Faber, 2017). Philadelphia changed its direction towards self-organization by focusing on fewer systems, fewer rules, and taking the wishes of their clients as a starting point. Furthermore, they try to increase the knowledge, skills, and flexibility of their teams (Faber, 2017). The team members should try to act independently instead of waiting for orders, in other words: they need to show their own initiative.

In this context, the employees in SO-teams can take initiative on a daily basis, but can also search for improving their way of working (Faber, 2017).

Philadelphia is an interesting organization to do research in since the transition towards self-organization is still ongoing and employees can well remember how they experienced this transition. This research focuses on e d c e : W & S todemarcate the investigation. The purpose of this cluster is to teach its clients to work independently as much as possible. An employee in this cluster is working on da ca e a b a . This research took place from February until June 2020. Contact details of potential interviewees were provided by managers from Philadelphia.

3.3 Procedures for data collection

The Appreciative Inquiry was the basis for the interview method used in this study. This method first made its mark in the 1980s as a tool for organizational change (Michael, 2005). The Appreciative inquiry uses ways of asking questions, imagining the future to create positive relationships, and builds on the current potential of a given person, group or organization (Bushe & Marhsak, 2015; Cram, 2010). Appreciative

e e e a ce e a a e c e b fac e a a e e a d

potentials (Bushe & Marhsak, 2015; Cram, 2010). An appreciative inquiry is basically conducted in a cycle of five phases (1) Define, (2) Discovery, (3) Dream, (4) Design, and (5) Delivery (Fitzgerald, Murrell, &

Newman, 2001). The define part, which involves focusing and narrowing the topics of the inquiry, was executed in the first sections of this study. The interviews focused mainly on the discovery phase of the appreciative inquiry, which involved discovering the peak experiences for each topic and the drivers of those experiences (Fitzgerald et al., 2001). By making use of the discovery phase, the contribution of SO- teams on taking initiative by team members could be unraveled. Furthermore, the Appreciative Inquiry was also used in this study to attract interview candidates by asking managers of Philadelphia to come up with potential interviewees who are initiative-rich. Therefore, the approach of interviewees was very positive, involving a compliment from your own manager. Next to that, by interviewing employees who have a lot

of experience in initiative-taking, the surfacing stories of employees about self-organization towards initiative-taking could be extensively researched.

Fifteen interviews were conducted with team members of SO-teams. Due to the Covid-19 outbreak, visits to the workplace of the interviewees were not possible. Therefore, the interviews were conducted via videoconferencing instead, to maintain eye-contact and to make sure that body language was still noticeable. The interview-schemes that were used are semi-structured. This means that questions are formulated, but there was room to ask further during the interview to let the interviewee clarify his or her statements. The interviews were filled with open-ended questions, because this ensures learning with an open mind. (Edmondson & McManus, 2007). To increase the controllability and construct validity of this study, an interview protocol was used to structure the interviews (Van Aken et al., 2012). The interview protocol was reviewed by professionals to obtain more valid results. Next to that, a pilot interview was held to check if all questions were understandable and clear. The full interview scheme can be found in Appendix A (Dutch) and B (English). The interview questions were for example: Y a e bee a ed b manager as an initiative-rich employee, what makes you initiative-rich? Table 1 below illustrates the interviewees.

Table 1: Interviewees

Code Job Region Duration M/F Age

AMS1 Ambulant Amsterdam 77 minutes Male 25 - 35 years

APE1 Daycare Gelderland-West 80 minutes Male 46 55 years APE2 Daycare Gelderland-West 64 minutes Female 25 35 years ZWO1 Daycare Groot-Veluwe 87 minutes Female 25 - 35 years ZWO2 Daycare Groot-Veluwe 87 minutes Female 36 - 45 years LIM1 Ambulant Zuid-Limburg 48 minutes Female 56 65 years LIM2 Daycare Zuid-Limburg 75 minutes Male 36 45 years NUN1 Ambulant Groot-Veluwe 71 minutes Female 25 35 years NUN2 Ambulant Groot-Veluwe 61 minutes Female 36 45 years KAM1 Daycare Noord-Nederland 59 minutes Female 46 55 years KAM2 Daycare Noord-Nederland 69 minutes Female 36 45 years KAM3 Daycare Noord-Nederland 73 minutes Male 25 35 years DAL1 Daycare Groot-Veluwe 79 minutes Female 25 35 years DAL2 Daycare Groot-Veluwe 81 minutes Female 36 45 years DAL3 Ambulant Groot-Veluwe 73 minutes Female 56 65 years

The interviewees were informed about this research and had time to decide if they wanted to participate.

All participants signed a consent form to agree to the conditions, this form can be found in appendix C. The interviews were scheduled in April and May and each interview lasted between 1 and 1.5 hours. Before the interview started, the researcher asked permission to record the interview. All interviews were conducted in the mother tongue of the participants: Dutch. This increases a c a self-confidence, thinking skills, and it provides freedom during the interview (Ozfidan, 2017). The answers provided by the interviewees are treated confidentially, they are only visible for the researcher. Furthermore, the data was processed anonymously. During the research period, a logbook was kept with the aim that the research can be repeated and traced by others.

3.4 Data analysis

Analyzing data is seen as the core of theory building from case studies (Eisenhardt, 1989). First of all, the interviews were transcribed verbatim, which means that the taped interviews were written down in detail.

Transcribing is a powerful act of representation, because it can affect howdata is conceptualized (Oliver, Serovich, & Mason, 2005) and is seen as the preparatory phase of coding. Transcribing started after the first interview was conducted, so that relevant insights could be taken into account for the next interview.

This corresponds with Corbin & Strauss (2008) who argue that data collection and analysis are interrelated processes and should be done at the same time. By transcribing, a storyline was created for every healthcare worker. All transcripts combined consisted of 229 pages.

The next step contained the analysis of the transcripts, i.e. the coding process. Coding was done by using ATLAS.ti, a software program for qualitative data and research analysis. According to Esterberg (2002), the goal of coding is to focus on the potential meaning of your data. The coding process consisted of the following steps: deductive coding, open coding, axial coding, and selective coding (Wolfswinkel, Furtmueller, & Wilderom, 2013). Thus, the coding process started with a selective set of deductive codes which arose from literature. The codebook in appendix D shows which codes are deductive or open. The deductive codes in this study are related to the three levels of initiative taking: individual, group, and organizational level (Cawsey et al, 2016; Cummings & Worley, 2015; De Leede et al, 1999), and the typical initiation process of Frohman (1997) which were both used as the basis for the interview protocol. However, the interview protocol gave respondents the opportunity to also come up with phases other than the seven steps of Frohman (1997). This corresponds to the method of Wang & Park (2016) who emphasize the importance of keeping your eyes open as author for unexpected patterns and themes.

After the deductive coding, a more open approach was taken. Open coding techniques were used to label the various concepts, f e a e c de a : critical thinking a d job satisfaction . The open codes, emerged from the material, are related to the conditions for taking initiative, reasons why people do (not) take initiative, returns on initiatives, and the contributing aspects. All these codes reflected parts of the interviews where participants referred to their experiences in SO-teams.

Subsequently, the axial coding process took place. The codes that emerged from the deductive and open coding process, were connected in overarching themes (Mortelmans, 2013). In this phase, dimensions and relations between codes were drawn. To give an example, the codes of energy , job satisfaction , more task diversity , and possibilities for clients , together formed the axial code of returns on a e .

After this phase, a final codebook (Appendix D) was made consisting of the codes combined with a definition and a matching quotation. To increase the reliability of this study, the codes in the codebook are discussed with fellow researchers to check for inconsistency (Van Aken et al., 2012). Lastly, selective coding took place which was used to combine codes and categories to get a clear understanding of the results and to provide an answer to the research question. (Van Aken et al., 2012). Coding the interviews was an iterative process in which I returned to transcripts and prior literature over and over again to recode and refine codes and to combine them, requiring a revalidation of earlier coded material (Elliott, 2018). As a result, a new theory was proposed which can be tested by further research.

4. RESULTS

This section presents data derived from interviews conducted with healthcare professionals. Firstly, the conditions needed to take initiative are described, such as trust from management. However, even if these conditions are there, some people still do not take initiative. The reasons for taking or not taking initiative will both be discussed in the second sub-section, combining the separate code groups (2a and 2b) that can be found in Appendix D. Thereafter, the returns on initiatives are discussed in sub-section three. In sub- section four the aspects of SO-teams on taking initiative will be compared with the aspects of traditional teams, again combining the findings from two code groups (4a and 4b). Lastly, the typical initiative process will be shown, which has six phases that employees go through from the idea to the implementation of an initiative. It is essential to include how people take initiative in SO-teams to be able to clarify how this differs from traditional teams. Empirical evidence is provided to support the key arguments by presenting quotes from respondents. This section will be completed with an integrative model that presents an overview of the results.

4.1 Indispensable conditions for initiatives in self-organizing teams

During the conversations with team members it became clear that certain conditions have to be met before people are able to take initiative. One of the most mentioned conditions is the team composition: As long as you have many people in your team who are not self-employed or initiative-minded, you are never going to be a SO-team. Just implementing self-organization does not mean that everyone becomes initiative-rich (ZWO1). Another respondent mentioned: If a ea c a f e e a e not proactive and not enterprising, then you will never become a SO-team (KAM3). So, according to the team members, it is really important that you have a balance in your team, with people who are initiative-rich, but also with people who become enthusiastic due to the enthusiasm of their colleagues: S e e e eed e consultation than others, but in our team it is going really well, there is a good balance (NUN2). Besides that, a varied team is also useful to come up with diverse initiatives: I e a e a ba a ced ea , c means that we have very diverse ideas because everyone has their own interests and takes initiative in that area (DAL1). One of the respondents mentioned that there is a balance in initiators and followers: I that is what we need to be able to take initiative, it is not needed that everyone is a captain, but it is important to have a balance of initiators and followers (DAL1). To conclude, working in a SO-team does not suddenly cause people to take initiative, however, people who are initiative-rich can excel more in this and take others into it.

Team members take more initiative when there is a positive atmosphere in their SO-team: I like having someone next to me who also has positive energy (APE2). One of the respondents mentioned that a positive atmosphere also gives him more self-confidence: W e c eag e a : d d ce! , e I g in confidence. T a e e c ea (LIM2). The positive atmosphere is also important for the possibility to give each other feedback: Se f-organization and taking initiative often fail because people do not dare g e eac e feedbac (APE1). One of the respondents came up with an example she experienced last year: There were little initiatives in our team and everyone was looking at the supervisor to let him or her make the decisions. Nowadays, we are much more concerned with addressing people:

You are working in this team, you carry a certain responsibility, and you also have to ensure that initiatives are taken (DAL1). However, managing expectations is an important factor: If e e e thinks that one person is going to do it and they have the feeling they do not have to do anything, then it is not going to work. So, it is important to express your expectations to eac e a d a e ag ee e ab . (DAL2). The respondents thus advise SO-teams to create a climate, in which you can have this type of conversations, and to ensure that every team member takes initiative.

SO-teams get relatively little supervision or top-down control compared to traditional teams. Therefore, it is important that team members get signals of trust from the management: N e e f e ,

a age a : O ga e , be a g ! The trust from my manager is there and that works very well (APE1). Respondents argue that their level of initiative taking grows as they experience more trust from their management. Because if they do not feel that trust, they are hindered in their creativity for initiatives: T a a ea c e f a age , a e g e e c f de ce. Beca e e a a age a a a , b e d a a e a ? that does not motivate me to take more initiative (NUN2). One of the respondents notices that giving trust to your employees results in more honesty in the team: Some people show different behavior in a team meeting when the manager is present, compared to a situation when the manager is not there (APE1). The respondent had the idea that colleagues who experience less trust are not able to ventilate their own opinions and ideas during those team meetings. So, trust from management is an essential condition to take initiative.

Most initiatives taken in the team, must be supported by the whole team, meaning the team is rowing in the same direction: This is very important, since you have to work together to become a well-functioning SO- team (KAM3). The level of initiative taking depends on whether the team wants to go in the same direction: W e e e a e a e de e d e ea , a d e e e e a a d d e a

eac e a e g a , e a a (LIM1).

Other important conditions mentioned by respondents are courage: I I da e, I a e e g g aga g a d ece a a e e bea e ac (DAL2) and the availability of resources: Ye , exactly. It would be nice if we get also time to take initiative, we have to fit the initiatives in our daily activities, which is why initiatives are not always taken (DAL1).

4.2 Why people do (not) take initiative in self-organizing teams

There are various reasons why team members of SO-teams take initiative and why some do not. Almost all participants indicate they are taking initiative to have control over their work and, according to themselves, concepts such as a control freak and perfectionist suits them: I like it to have control, because then I get

e e b (APE1). Many respondents indicate that they always had these characteristics: I it is something that belongs to c a ac e . I e e g g e a I a (LIM2). In most cases, being a perfectionist and a control freak is the result of not having trust in others: If I a d e a idea and I ask about it one month later, usually the pe a O I a e a , b e a g too long in my opinion. (APE1).

Furthermore, work experience is an important factor why people take initiative. It is mainly something team members notice with new colleagues: Ye , e a e a g fe a , but they still have to master the ba c bef e e ca f e (ZWO1). Respondents say that initiative taking was not something they did from the start: I ad ea a e a e, because working with clients also requires a b f e e e e , I a e ea ea ed a e e a e ea (KAM3). Lastly, the diversity of your work experience plays a role. Some team members have worked in different clusters, so they have a broad view and create new ideas: Originally, I come from Care & Living, but I also worked in Work &

Support, and nowadays I do mainly job coaching, so I think I am initiative-rich because of my broad e e e ce (DAL2). However, work experience is not always a contributing factor as resistance can come from older generations: Se f-organization is not always working well due to the people in our team, especially the older generation. Because e de ge e a a a a : d d a a d e a e a ead ed a . That is something that is holding us back sometimes in taking initiative (APE1). Because of their broad experience in the work field they already found that taking certain initiatives has no added value in their opinion. In conclusion, work experience can promote initiative, because one has mastered the work and can think further, but it can also have an opposite effect when one shows resistance towards new initiatives based on earlier experiences.

People who take initiative are mainly driven by new challenges: I e a e e c a e ge a d g a .

new challenges also keep people from getting bored: I ea need to have something to do, because e e I ge b ed a d a g (LIM2). New challenges ensure team members to grow in their work.

On the other hand, not all team members are excited about new challenges, but are stuck in traditions:

S e e e a e ed a ce a c e f ab e, receiving instructions a d be e (KAM3).

Sometimes these employees need more direction than is normally given in SO-teams: S e e I ce a c eag e f d d ff c a e e ace e ge . A d e ace e a d f a c: W a d I d ? He ! (AMS1). Generally, respondents mentioned that they are driven by new challenges although they think that some of their fellow team members are stuck in traditions or in need for more direction.

Taking initiative is fueled by a proactive attitude of team members: I a e a a bee a g -getter, I am e e ea g b d g. T a e g I a a d , a a d be ac e (DAL2).

One of the respondents gave an example of proactively taking an initiative: Bef e a ca e e closed due to Covid-19, I thought on Sunday afternoon: Maybe it is useful to have an updated address list, because that is something we need tonight (DAL1). However, there are also employees who are not proactive, which can be seen during the Covid-19 crisis, as explained by one of the team members: T e organization asked for more help during the Covid-19 e d, a d e ca e e e d I ca d a a d a e e I ea e e eed e , e e ee e d ffe e ce proactivity (DAL3). Generally, all respondents agree that self-organization and taking initiative is not going to work if people do not actively participate in the team process. So, having a proactive attitude is essential.

Another reason why people do take initiative is their enthusiasm: I out of enthusiasm I have in the , I ea e g e g ! (LIM1). People also get inspired to take initiative out of the enthusiasm of others: I a e a c eag e a bee e ed f f ea , she was very negative, b e e c ed b e e a f e (APE2). Furthermore, earlier success plays a role in taking initiative. Team members notice that as soon as successes are achieved, more initiatives are taken, and vice versa as one of the participants explains: I a e a ad a c eag e took a lot of initiative, but the initiatives did not really succeed. Then you are done with it. She no longer da ed ac c age (DAL2). The caring character of team members also plays a role: I ee a initiatives within Philadelphia, but I think that is something typical in healthcare. A lot of people want to do something for another. So, e c a ac e (NUN1). Furthermore, having a helicopter view is a contributing factor in taking initiative: I a e a ive because I have more a helicopter view in general, c a ed c eag e (DAL1).

Sometimes the resistance is not conscious, but is it due to the extrinsic motivation of the employee: Ye I often come across people who work because they have to work. I also have to arrange my finances, but I a a a e f (ZWO1). According to the participants, if everyone is motivated to do their job well, then taking initiative does not have to be stimulated. People can also show resistance towards an initiative when they perceive the change as a threat: Pe e a e f e af a d f c a ge, e e ee , e ce a e a c a ge g (ZWO2).

People take initiative for the social contact they get in return for most initiatives: Ye , concerning clients, but also g g e e e e e, ee g e e e (NUN2). Various respondents indicate that they are good at making social contact, which makes it easier to take initiative. Lastly, people who take initiative are looking for continuous improvement: So, that means that every big change that comes every few years, I eagerly look forward to. I will be e f e a e a d (AMS1). Team members believe that changes in a location would do well, especially for teams that have been working in the same way for a long time although it can sometimes be difficult for a client.

4.3 Returns on initiatives

Interviewees mentioned job satisfaction most often as something they get in return for the initiatives they take. As one interviewee pointed out with an example of an initiative to determine the required presence during the Christmas holiday: The result is mainly increased job satisfaction. By making the decision that not everyone is required to be at the location during the Christmas break, no one feels guilty at home a d e c e (AMS1). The job satisfaction is linked to a successful outcome of an initiative: Uh, yes. When I have set something up and it works out well, it gives me satisfaction. (LIM2).

Another return that is mentioned frequently is the energy care workers get from the initiative: O , a really gives me energy, I really like it when an initiative succeeds. Yes, I really get energy from taking a e (NUN2). A new flow of energy is particularly strong when something seems to fail at first but succeeds at the end: A f u do not think it will work, but if you do succeed you really get a boos (ZWO2). Other respondents refer to how initiatives enrich the lives of clients which gives them energy:

Ye , a a a b g e. I a ee a b g e a d a g e e e e g (APE2). The participants all agree that creating possibilities for clients is what they get in return for taking initiative, one of the respondents gave an example about more social contact: Two clients I supervise got to know each other through the initiative of organizing meeting evenings. They now meet each other in the supermarket and have a chat. Those are the little things, but it really gives them new possibilities and self-

We , e a e I c d a e d e , ade b e f e! , a a a ab f e! (APE1).

Lastly, employees get more task diversity in their work by taking initiative: Instead of being in the office for four days with the same colleagues, I also spend two days in a different place with other colleagues because of the project we are doing together. So, I have more varied weeks, and I e a (AMS1).

4.4 Contributing aspects of self-organizing teams to taking initiative

In this sub-section the aspects of self-organizing and traditional teams are compared and used to see how SO-teams contribute to taking initiative. This sub-section differs from the previous sub-sections about the conditions and reasons for taking initiative, because those are necessary, but solely they are not sufficient to take initiative in SO-teams. This sub-section explains the contributing aspects of SO-teams towards initiative taking.

Clearly the most frequently cited factor is asking less permission from the manager. With the introduction of self-organization, each manager has taken on more teams to lead in their region and thus less time for each team than before, which makes it easier for the employee to take initiative: It is more difficult to take initiative if you have to ask permission for everything. I I d a e a e e a e (APE2).

Respondents mentioned that employees (including themselves) in traditional teams were not that initiative- rich because the managers came up with the ideas: We e e e e ea a e-minded, we always waited for the manager for advice. N e d e e a g a e a e ed bac (ZWO1).

Another respondent mentioned: Ta g a e a common, managers determined what we did at that time. Anything extra that we did had to be d c ed (LIM1). Furthermore, the manager is less physically present at the location, this also results in a lower threshold to take initiative: We automatically discussed a lot with our managers, because if someone is there, you will ask them (DAL1). Instead of discussing initiatives with the manager, teams are now discussing the initiatives mainly with each other: I think we operate much more independently, we discuss it more with each other a e a age (NUN2).

Doing what you like and are being good at it is key in SO-teams. Because teams get the chance to organize themselves, they can put people in functions they like in which they are being good at, which results in taking more initiative: You also take the responsibility for that function, so you automatically take more a e, I (NUN2). Another respondent mentioned: F e e a ea e a e a e