Combining Institutional and Sensemaking Theory:

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Combining Institutional and Sensemaking Theory:

Multi-level Perspective when Implementing a New Medical Profession in Dutch Healthcare

University of Groningen

Faculty of Business and Economics

MSc Business Administration – Change Management Master Thesis

July 2015

Supervisor: Dr. M.A.G. van Offenbeek Co-assessor: Dr. B. Müller

Word count: 25.979

Vivian Mohr

Gedempte Zuiderdiep 23a 9711 HA Groningen Telephone: 06-34278666 Email: v.h.mohr@student.rug.nl Student number: S1856871

Acknowledgement: I would like to take this opportunity to express my gratitude to Marjolein van

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ABSTRACT

Institutional theory and sensemaking theory are different theoretical perspectives and both theories have their own explanatory power: institutional theory stresses macro-level structures and sensemaking theory emphasizes micro-level processes. In order to comprehensively understand the implementation of a new medical profession in the Dutch healthcare, the Ziekenhuisarts (ZHA), it is necessary to take a multi-level approach. A pilot of the innovation project of the ZHA was introduced and the Stichting Opleiding Ziekenhuis Geneeskunde (SOZG) coordinated the project. The aim of this study is to identify how institutional influences direct the ZHAs’ role and position and through which actions the ZHAs and the SOZG create, maintain or disrupt institutions. This research is performed by collecting interview transcripts from earlier interview rounds (round 1 and round 2) and by conducing interviews with different ZHAs (round 3). The institutional environment is rigid and the existing culture of a hospital is seen as one of the biggest barriers in the ZHA implementation. Next to that, multiple resources are needed in order to successfully implement the ZHA. On the contrary, because of the fact that the ZHAs’ education and function is still uncertain, the ZHAs and the SOZG can contribute to the future developments of the ZHA implementation. In the first round of the ZHA implementation most of the ZHAs were being passive. As the ZHA implementation progressed (second round), most of the ZHAs were sharing their ideas and experiences, actively giving feedback and showing the added value of the ZHA. In the third round, most of the ZHAs were contributing to future developments of the ZHA implementation, thinking about and working on their own future, promoting the ZHA or actively involved in establishing a science association for the ZHAs. This study has led to the occurrence of several opportunities for conducting further research.

Keywords: Institutional theory – Sensemaking theory – Institutional work – Human agency – Dutch

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1. INTRODUCTION

Institutions play a central role in most accounts of macro-organizational changes (Greenwood et al., 2008). Institutional theory supposes that organizations are subject to economic, social and cultural pressures that derive from interactions between organizations and the institutional environment that surround them (Meyer & Rowan, 1997). An institution can be defined as a ‘more-or-less taken-for-granted repetitive social behaviour that is underpinned by normative systems and cognitive understandings that give meaning to social exchange and thus enable self-reproducing social order’ (Greenwood et al., 2008: 4). In this context, institutional theory describes the effects of institutional pressures (Suddaby and Greenwood, 2009). According to Fligstein (2001), human actors can be seen as ‘cultural dopes’ or passive recipients who use readily available scripts provided by institutional carriers that structure their actions. Critique has been given on this rather structuralist approach by multiple researchers. DiMaggio (1988) criticises institutional theory for its relative inattention to the role of agency in shaping action. Moreover, Barley and Tolbert (1997) argue that institutional theory does not explain how social practices are internalised and reproduced through human actions. It can be concluded that institutional theory is well suited to explain the influences of institutional structures on organizational change. Therefore, institutional theory and its core concepts focus on the macro-level of analysis.

This dominant institutional perspective has been valuable for understanding how organizations are structured, how they operate and how they relate to each other (Lawrence et al., 2011). However, little attention has been given to development of human actors and the question how human agents inform and respond to institutional change. Research that has been conducted on the role of individuals in institutional change faces a paradox. If we assume that institutions shape individuals who therefore have a limited degree of agency, the question is ‘How can actors change institutions if their actions, intentions and rationality are all conditioned by the very institutions they wish to change?’ (Holm, 1995: 398). Lawrence et al. (2009) describe the concept of institutional work. Institutional work refers to ‘the purposive action of individuals and organizations aimed at creating, maintaining and disrupting institutions’ (Lawrence & Suddaby, 2006: 215). They focus on how human actors and their actions affect institutions.

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6 environmental cues trigger individuals to engage in a sensemaking process. Mailtlis (2005: 21) notes that, ‘organizational sensemaking is a fundamentally social process: organization members interpret their environment in and through interactions with others, constructing accounts that allow them to comprehend the world and act collectively’. Most research on sensemaking theory addresses local subjective processes and, therefore, focus has been on the micro-level of analysis. This is in contrast to institutional theory that addresses the macro-level influences on agents and human action.

Both institutional theory and sensemaking theory are highly influential in the field of organizational change. Nevertheless, research that links these perspectives is scares, as Weick et al. (2005: 17) note the ‘juxtaposition of sensemaking and institutionalization has been rare’. However, recent research has been studying the interaction between institutional environments and sensemaking processes (Weick et al., 2005; Weber & Glynn, 2006; Jensen et al., 2009). Barley and Tolbert (1997) use a framework to elaborate the connections between institutions and sensemaking. In their framework is shown how the analysis of sensemaking process focuses on micro-level of inter-subjective processes, while the analysis of the institutional context focuses on macro-level of extra-subjective structures (Weber & Glynn, 2006). To bridge macro and micro-levels or relate institutional context and sensemaking, three general mechanisms are presented: contextual, action-formation and transformation. Weber and Glynn (2006) argue that institutions are antecedent to and emergent from the sensemaking process. In their research, Jensen et al., (2009) combine institutional theory and sensemaking theory to conduct a multi-level analysis. To conclude, when linking institutional theory and sensemaking theory, it is important to make a distinction between the level of analysis that these two theories addresses. Institutional theory stresses macro-level structures and addresses the organizational field level and organizational level of analysis. On the contrary, sensemaking theory emphasizes micro-level processes and addresses the individual/socio-cognitive level of analysis. Thus, institutional theory and sensemaking theory are different theoretical perspectives and both theories have their own explanatory power.

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7 profession, the Ziekenhuisarts (hereafter ZHA) is implemented. This case study is particularly interesting for two reasons. First, the hospitals in the Dutch healthcare are seen as institutions and behaviours can be defined as stable and repetitive and activities are consistent over time without elaboration or justification. Second, the human agents in this case study (the ZHAs and the SOZG) play a significant role in implementing the ZHA. With their actions, they can create, maintain and disrupt institutions.

1.1 Sector Description

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Figure 1: Multiple cause diagram of the implementation of the ZHA in Dutch healthcare

In order to overcome these capacity and continuity problems as well as to create a more patient-oriented healthcare, a change is needed. Implementing a change in a healthcare setting is a complex process (McKee et al., 2002; Fleuren et al., 2004; Greenhalgh et al., 2004). Hospitals have been attempting to solve the issues that are mentioned above. In the US, a new medical profession called the Hospitalist was implemented in 1996 (Baudendistel & Wachter, 2002; Wachter et al., 2005). The implementation of this medical profession is the result of rising demands for generalists, the need for efficient care in order to overcome strong cost pressures and to improve hospital quality (Bellet & Wachter, 1999; Wachter, 2006; Wachter & Goldman, 1996, 2002).

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9 change thus occurs, due to the fact that organizational members value these institutionalized practices as habits and tradition. Therefore, institutional change and healthcare innovations can be seen as complex processes in which different types of forces and parties are involved (Battilana, 2006). Implementing a new medical role also involves shifting in structural institutionalized boundaries (Kathan-Selck & Van Offenbeek, 2011). Especially in hospitals, this redrawing refers to medical professions’ domains and will therefore be political in nature.

1.2 Research Question

In September 2012, a pilot of the innovation project of the ZHA was introduced in four hospitals and the Stichting Opleiding Ziekenhuis Geneeskunde (SOZG) coordinated the project. In addition, a fifth hospital individually initiated a simultaneous implementation trajectory. The project of the SOZG can be divided into two consecutive trajectories, each with a timeframe of three years. Trajectory I started in February 2012 and annually maximal five training places were created at each of the four hospitals. Trajectory II started in February 2015 and consists of a completion of and elaboration on trajectory I. Also, during this trajectory the training curriculum will be further developed and experiments will be performed with the new medical profession in healthcare settings.

In order to successfully develop the training curriculum and to experiment with the ZHA in healthcare settings, an institutional change is needed. The human agents in the case study, the ZHAs and the SOZG, play a significant role in this change. Interesting is to address how the ZHAs and the SOZG are coping with this change. Are these human agents passive recipients? Or are these human agents with their purposive action aimed at creating, maintaining and disrupting institutions? To comprehensively explain institutional change processes, it is necessary to take a multi-level approach that captures the interactions that exist between multiple levels of analysis (Battilana, 2006). This leads to the following central research question:

’How do institutional influences direct the ZHAs’ role and position and through which actions do the ZHAs and the SOZG create, maintain or disrupt institutions?’

In order to answer the central research question, two sub questions are developed:

1) How do institutional characteristics direct the ZHAs’ role and position?

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1.3 Theoretical and Practical Contributions

This multi-level research into the implementation of a new medical profession in the Dutch healthcare had both theoretical and practical contributions. In the literature, two gaps are identified. First, studies on healthcare innovations have primary focused on clinical and technical changes and limited research is conducted on the implementation of new workforce roles (Bridges et al, 2007). Second, research on institutional theory has concentrated on the institutional and organizational level of analysis and tends to neglect the individual level of analysis (Battilana, 2006). This study contributes to existing literature by showing the need to address macro-level structures, as well as individuals’ interpretations and actions in order to identify how human agents create, maintain and disrupt institutions.

The main practical contribution concerns in depth insights in implementing a new medical profession in a highly complex, multi-professional and institutionalized healthcare environment. Analysing this institutional change and focus on institutional work provides an understanding of how human agents cope with the implementation of the ZHA. In particular, results of this paper are interesting for the SOZG and contribute to their research on how to successfully implement the ZHA. Successfully implementing this new medical profession will decrease capacity and continuity problems, improve treatment quality, increase patient-centeredness, reduce throughput times and assure operating efficiency (Van Offenbeek et al., 2009). Furthermore, these benefits have been associated with both patient and medical practitioner satisfaction.

1.4 Outline of the Research

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2. LITERATURE REVIEW

This literature review will present a theoretical understanding of the concepts involved in this research. To start, the context of the ZHA will be discussed. Then, the concepts institutional theory – including institutionalization and deinstitutionalization – and sensemaking theory will be explained. Finally, this literature review will discuss how combining these two theories can give interesting insights in conducting a multi-level analysis.

2.1 Context of the ZHA

Since 1996, the US hospital settings changed when the profession of the Hospitalist was countrywide implemented (Baudendistel & Wachter, 2002; Wachter et al., 2005). The implementation of this medical profession is the result of rising demands for generalists, the need for efficient care in order to overcome strong cost pressures and improving hospital quality (Bellet & Wachter, 1999; Wachter, 2006; Wachter & Goldman, 1996, 2002). The reasons for implementing the hospitalist in the US match with the reasons for implementing the ZHA in the Netherlands. However, instead of implementing a new medical profession, the role of a Hospitalist is seen as an extended role for internists and primary care physicians (Wachter, 2006; Wachter & Goldman, 1996). Even though there are some differences, the implementation of the Hospitalist in the US is used as a benchmark for implementing the ZHA in the Netherlands. Parties that are involved with the pilot implementation of the ZHA can learn from experiences of the Hospitalist implementation, but it cannot be expected that the effects of both medical professions will be the same.

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12 institutionalized in organizations and note that ‘to maintain power and control, current power holders will seek to define organizational contingencies in those terms which will increase the value of their own competencies and enable them to retain their positions’.

Relating this literature to the implementation of the ZHA, it is important to address that the Nurse Practitioner (NP) and the Physician Assistant (PA) are two medical professions that had been earlier introduced in the Netherlands to perform routine medical procedures that were previously done by medical practitioners (Zwijnenberg & Bours, 2012), to engage a long-term relationship with the patient and, therefore, also to guarantee continuity. Because of the similarities between these medical professions, some work domains and roles will overlap. This may result in tension between these medical professions, which will influence the implementation of the ZHA. To conclude, when implementing the ZHA, it is important to take the organizational environment and the professional boundaries into account.

In order to identify how institutions constrain and enable human agents and how human agents create, maintain and disrupt institutions it is necessary to address multiple levels of analysis. Therefore, both institutional and sensemaking theory and their relation will be included in this paper.

2.2 Institutional Theory

’Institutions are social structures that have attained a high degree of resilience. They are composed of cultural-cognitive, normative and regulative elements, that together with associated activities and resources, provide stability and meaning to social life’ (Scott, 2001: 48; Scott, 1995: 33). In Scott’s (2003) definition of institutions, he characterises three basic elements that he sees as the pillars of institutions. First, the cultural-cognitive element that refers to the creation of a shared understanding and constitutes to the nature of social reality. Second, the normative element that includes the creation of expectations and introduces the prescriptive and obligatory aspects into social life. Third, the regulative element that involves the capacity to establish rules, laws and sanctions to influence behaviour.

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13 direct action. On the other hand, the theory focuses on the processes through which institutions are created, maintained and transformed (Lawrence et al., 2009). Therefore, institutions exhibit a duality: they constrain and arise from social interaction (Figure 2). This recursive relationship between institutions and action can be compared to Giddens’ (1984) notion of structuration (Barley & Tolbert, 1997). With the structuration theory, Giddens explains the duality of structure and focuses on the interaction between structures and human action.

Figure 2: The relationship between institutions and action (Lawrence et al., 2009)

2.2.1 Institutionalization

Institutionalization refers to the process, ‘by which a given set of units and a pattern of activities come to be normatively and cognitively held in place, and practically taken-for-granted as lawful’ (Meyer et al., 1994: 10).

Institution theory has given interesting insights into institutionalization in organization (Meyer and Rowan 1977; Zucker 1977; DiMaggio & Powell 1983; Tolbert & Zucker 1983). These insights include the causes of institutionalization and the process by which organizations adapt and conform to the norms and expectations of the institutional environment. Particular emphasis has been on the legitimation process and how institutionalized organizational structures or procedures become taken-for-granted (Meyer & Rowan 1977). In institutionalized organizations, behaviours can be defined as stable and repetitive and activities are consistent over time without elaboration or justification. Resistance to change thus occurs, due to the fact that organizational members see these institutionalized practices as habits and tradition.

2.2.2 Deinstitutionalization

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14 can change over time. A phenomenon that is less explained is deinstitutionalization (Scott, 2001). Deinstitutionalization refers to the process by which an institution weakens or even disappears.

Interesting is to address how deinstitutionalization occurs. Oliver (1992: 564) suggests that ’under certain specific conditions organizational behaviour and change will be explained not by social consensus around the meaning and value of an activity or by conformity to institutional pressures, but by the failure of organizations to accept what was once a shared understanding of legitimate organizational conduct or by a discontinuity in the willingness or ability of organizations to take for granted and continually recreate an institutionalized organizational activity’. Institutionalized norms and practices can be threatened by three major types of pressure and can be analysed on the organizational and environmental level (Oliver, 1992). First, the political pressures, which are those that arise from a change in interests and power distributions that have legitimated and supported institutionalized practices. Antecedents of deinstitutionalization of political conditions include mounting performance crisis, conflicting internal interests, increasing innovation pressures and changing external dependencies. Second, the functional pressures, which can result from perceived problems in performances or utilities that are related to institutionalized practices. Antecedents of deinstitutionalization of functional conditions include changing economic utility, increasing technical specificity, increasing competition for resources and emerging events and data. The third pressures are the social pressures, which are influenced by organizational members who have the need to reject institutionalized practices. Antecedents of deinstitutionalization of social conditions include increasing social fragmentation, decreasing historical continuity, changing institutional rules and values and increasing structural disaggregation.

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15 Other researchers have been giving attention to the notion of institutional entrepreneurship (DiMaggio, 1988; Beckert, 1999; Maguire et al., 2004). According to DiMaggio (1988: 14), ‘new institutions arise when organized actors with sufficient resources (institutional entrepreneurs) see in them an opportunity to realize interests that they value highly’. These institutional entrepreneurs can be organizations, individuals and groups of organizations or individuals. Important is to note that not all individuals can be seen as institutional entrepreneurs, but only the ones who can break the taken-for-granted and develop alternative rules and practices. The likelihood for individuals to act as institutional entrepreneurs is dependent on their willingness to act (interest) and their ability to act (resources that they hold or have access to) (Lawrence, 1991). Batillana (2006) proposes a model and therewith explains what the impact of individuals’ social position in a given organizational field is on the likelihood for them to acts as institutional entrepreneurs. With this model she links the individual level of analysis to the organizational and institutional ones and therefore develops a multi-level approach.

Multiple researchers have discussed the concept of institutional entrepreneurs. In order to organize institutional research that focuses on the role of institutional actors in organizational change under a common umbrella, the concept of institutional work was introduced (Lawrence & Suddaby, 2006).

2.2.3 Institutional Work

Institutional work refers to ‘the purposive action of individuals and organizations aimed at creating, maintaining and disrupting institutions’ (Lawrence & Suddaby, 2006: 215). They argue that individuals actively engage in these process and they focus on how human actors and their actions affect institutions. So far, there are two categories of enabling conditions for institutional work that have received great attention (Lawrence et al., 2009). First, field-level enabling conditions, which include a crisis or a jolt that precipitates action that is different from a field’s existing institution or include heterogeneity and incomplete institutionalization. Second, organizational-level enabling conditions, which involve organizational characteristics and their position in the institutional environment. As a result of the focus on the field-level and organizational-level of analysis, the individual level of analysis has been neglected.

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Figure 3: Dimensions of agency and forms of institutional work (Lawrence et al., 2009)

As can be derived from the figure, there are three types of agency (Emirbayer & Mische, 1998). First iterative agency, which refers to ‘the selective reactivation by actors of past patterns of thought and action, as routinely incorporated in practical activity (Emirbayer & Mische, 1998: 971). Second, the practical-evaluative agency that refers to ‘the capacity of actors to make practical and normative judgments’ (Emirbayer & Mische, 1998: 971). Third, the projective agency, which refers to ‘the imaginative generation by actors of possible future trajectories of action, in which received structures of thought and action may be creatively reconfigured’ (Emirbayer & Mische, 1998: 971).

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2.3 Sensemaking Theory

According to Maitlis and Sonenshein (2010: 2), sensemaking refers to ‘the process of social construction that occurs when discrepant cues interrupt individuals’ ongoing activity, and involves the retrospective development of plausible meanings that rationalize what people are doing’ (Weick, 1995; Weick et al., 2005). In other words, the sensemaking process is about connecting environmental cues and internal frames in order to clarify what is going on.

In the literature, various theories have been proposed to explain the sensemaking process. Because of the breadth and depth of this concept, it is challenging to provide a comprehensive definition. When deriving an integrated definition, there are four key themes (Maitlis & Christianson, 2014). First, sensemaking is seen as dynamic, where a meaning is made in an ongoing process. Second, cues are involved in sensemaking. Sensemaking can be triggered when people are confronted with confusing or discrepant events. In order to give a meaning to these events, individuals interpret and explain cues from their environments. Third, sensemaking is regarded as social where individuals’ feelings, thoughts and behaviours are influenced by the presence of others. Finally, sensemaking concerns the action that people take to make sense of an event, which, in turn, enacts the environment that they seek to understand.

Weick’s paper (1988) was one of the first studies on the sensemaking process and even though he explains sensemaking in a crisis situation, it is also relevant for organizational changes because of the many similarities. Ford et al., (2008: 363) discuss that ‘change is a situation that interrupts normal patterns of organization and calls for participants to enact new patterns, involving an interplay of deliberate and emergent processes that can be highly ambiguous’ (Mintzberg & Waters, 1985). During a change process, individuals can experience a violation of their expectations and can be confronted with an ambiguous or confusing event, issue or action. In these situations, individuals want to clarify and understand what is going on by interpreting cues from the environment. These environmental cues trigger individuals to engage in a sensemaking process (Maitlis & Christianson, 2014).

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18 recognized as a separate autonomous process, object, event’ (Magala 1997: 324). Weick et al. (2005) argue that sensemaking also includes the process of labelling and categorizing in order to stabilize the streaming of experience. Action is the final stage of the sensemaking process. The idealized plan of action represented in an individual’s mind turns into reality. As mentioned above, sensemaking is an ongoing process because from this final stage, new cues in the environment can influence further noticing, interpretation and action.

To conclude, institutional theory and sensemaking theory are different theoretical perspectives and both theories have their own explanatory power. Institutional theory stresses macro-level structures and addresses the organizational field level and organizational level of analysis. Sensemaking theory emphasizes micro-level processes and addresses the individual/socio-cognitive level of analysis. In order to comprehensively explain institutional change processes, it is necessary to take a multi-level approach that captures the interactions that exist between multiple levels of analysis (Battilana, 2006). Therefore, in the next section, their relation will be discussed.

2.4 Institutions and Sensemaking

In previous literature, several studies have linked institutional theory and sensemaking (Weick et al., 2005; Weber & Glynn, 2006). When relating institutional contexts and organizational sensemaking, this relation can be seen as a structuring process through which individuals consciously reorganize lenses to view the world (Jeong & Brower, 2008). The structuring process starts when individuals experience violations in their taken-for-granted interpretative schemes. First, individuals question the pre-organized scheme of reference in the mind (noticing). Second, they reorganize the scheme of reference in their mind (interpretation). Third, people actualize the reorganized scheme of reference, and in doing so channelizing the subsequent organizing process into either thematic or pre-thematic mode (action).

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19 Barley and Tolbert (1997) developed a framework to elaborate the connections between institutions and sensemaking, based on Giddens’ (1984) structuration theory. As derived from this framework, the analysis of sensemaking process focuses on micro-level of inter-subjective processes, while the analysis of the institutional context focuses on macro-level of extra-subjective structures. The framework addresses how a specific input will create a specific output. To bridge macro and micro-levels or relate institutional context and sensemaking, three general mechanisms are presented: contextual, action-formation and transformation. It is shown that institutions are antecedent to and emergent from the sensemaking process.

In the current literature, the traditional contextual mechanisms explain the internalized cognitive constraints and how institutions narrow sensemaking. In their research, Weber and Glynn (2006) go beyond this view and propose three additional contextual mechanisms by which institutions affect sensemaking: priming, editing and triggering. They note that institutions prime sensemaking, by providing social cues. An example of priming is that employees are only on time if cued by other employees showing punctuality. Furthermore, institutions edit sensemaking, through social feedback processes. An example of editing is that employees are expected to behave differently to their supervisor in a staff meeting than to their recruiter in a job interview. Finally, institutions trigger sensemaking, posing puzzles for sensemaking through endogenous institutional contradiction and ambivalence. This occurs in two different ways. First, by providing dynamic foci that demand continued attention. Second, by creating puzzles that require sensemaking due to the contradictions, ambiguities and gaps that are inherent in institutions. An example of triggering is that when a former employee is promoted and is expected to act as a representative instead of a fellow employee. Because of the fact that a former colleague is promoting and is getting a different position, identities are changing and sensemaking is needed.

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20 In this literature review, institutional theory and sensemaking theory have been discussed and in Figure 4, different constructs of previous research of both theories are included. In particular, it shows how the institutional context is a necessary part of sensemaking.

Figure 4: Mechanisms Relating Institutional Environment to Sensemaking (Based on Barley & Tolbert, 1997; Weber and Glynn, 2006; Jensen et al., 2009; Jeong & Brower, 2008; Lawrence & Suddaby, 2006)

In their research, Hedström and Swedberg (1998: 21) argue that when we want to explain change at the macro-level of analysis, we need to show ‘how macro states at one point in time influence the actions of individual actors, and how these actions generate new macro states at a later time. Sensemaking can provide micro-mechanisms that link macro states across time’.

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21 institutional environment constrains and enables human agents and how human agents create, maintain and disrupt institutions.

Institutional theory Sensemaking theory Institutions and sensemaking

Theoretical foundations

Institutional theory describes deeper aspects of how institutions are created, maintained and disrupted over time. It is also concerned with the influence of institutions on human behaviour (including the processes by which structures, rules and routines guide social behaviour).

Sensemaking theory describes the on-going relation between action and interpretation. Explicit efforts at sensemaking occurs when discrepant cues interrupt individuals’ on-going activity and involves the development of plausible meanings that rationalize what people are doing or experiencing.

In order to identify the influence of institutional change on human actors, sensemaking theory is needed. During the sensemaking process human actors make sense of the change and can respond to it. These actions can again create, maintain or disrupt institutions.

Level of analysis

Institutions and organizations Organizations and individuals Institutions, organizations and individuals

Table 1: Aspects of institutional theory and sensemaking theory

2.4.1 Institutions and Sensemaking in Practice

Before describing the methodology of this research, it is important to explain why this framework, which links institutional theory and sensemaking theory, is appropriate for this case study and is relevant as a lens in answering the research question. The research question is: ’How do institutional

influences direct the ZHAs’ role and position and through which actions do the ZHAs and the SOZG create, maintain or disrupt institutions?’ and can be divided in two parts.

In order to answer the first part of the research question: ’How do institutional influences direct the

ZHAs’ role and position?’, the focus is on institutional theory. Institutional theory stresses macro-level

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22 profession is implemented, these taken-for granted institutions are challenged and contested (Kathan-Selck & van Offenbeek, 2011). This raises the issue of the interruption of ‘normal’ structural and culture patterns and work practices and involves an interplay of change processes that can be highly new and ambiguous.

In order to answer the second part of the research question: ‘Through which actions do the ZHAs and

the SOZG create, maintain or disrupt institutions?’, the focus is on sensemaking theory. Sensemaking

theory emphasizes micro-level processes and addresses the individual/socio-cognitive level of analysis. During the ZHA implementation, institutions are challenged and normal patterns are interrupted. Therefore, human actors can experience a violation of their expectations and can be confronted with an ambiguous or confusing event, issue or action. In these situations, they want to clarify and understand what is going on by interpreting cues from the environment. The process of sensemaking can be divided in three stages: noticing, interpretation and action. First, human actors notice possible cues of trouble in the environment that need closer attention. Then, interpretation takes place when a noticed cue is connected to a frame of reference and a meaning for this cue is constructed. Finally, the idealized plan of action represented in their minds turn into reality. This is shown in Figure 4, where sensemaking pivots on mechanisms of action formation (input micro and output micro). The ZHAs and the SOZG see an opportunity to realize interests that they value highly, as both want the ZHA to be implemented and successfully. So, the ZHAs and the SOZG have the willingness to act and the ability to act. This is shown in Figure 4, as transformation mechanisms build bridges between micro-level (input micro) and macro-level (output macro).

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3. METHOD

The previous section summarizes previous literature and describes the concepts involved in this research. The following section will specify the methodology of this research. First, the research design will be elaborated on. Second, the case context will be described. Finally, an overview will be provided on how the data was collected and analysed.

3.1 Research Design

The aim of this paper is to answer the research question: ’How do institutional influences direct the

ZHAs’ role and position and through which actions do the ZHAs and the SOZG create, maintain or disrupt institutions?’. The unit of analysis is multi-level, as the first part of the research question

focuses on institutions (macro-level) and the second part of the research question focuses on human agents (micro-level). In order to describe the change process, to get detailed descriptions and to integrate multiple perspectives from different human agents, a qualitative research was used for this study (Weiss, 1994). In order to receive as many insights as possible about the underlying processes that are related to the implementation of a new medical profession in Dutch healthcare, data was collected in three ways. First, interview transcripts from earlier interview rounds were collected. Second, multiple interviews were conducted with different ZHAs. Third, additional documents were collected to strengthen the data. The theory development approach seemed appropriate, since the central issues in this study had not been comprehensively examined (Eisenhardt, 1989). This process is based on the first part of the empirical cycle, and according to Van Aken et al. (2012) it is closely linked to case study described by Eisenhardt (1989). The essence of a case study is to clarify and describe a decision or a set of decisions by answering ‘’how’’ or ‘’why’’ questions.

3.2 Case Description

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24 In the healthcare environments, there are shifts in both the demand-side and supply-side that resulted in capacity and continuity problems (McKee et al., 2002). The main reason for implementing this new general medical profession in the Netherlands was to contribute to overcoming these problems in the hospital environment as well as to create a more patient-oriented healthcare especially with regard to admitted patients in hospital wards.

3.3 Data Collection

The data was collected in three ways. First, data was collected through secondary analysis. According to Heaton (2008: 34), ‘secondary analysis involves the re-use of pre-existing qualitative data derived from previous research studies’. Interview transcripts were collected from interviews with 12 ZHAs that were conducted in earlier interview rounds. These interviews were conducted in March 2013 (round 1) and in September 2014 (round 2). Second, next to these interview transcripts, in-depth interviews with 8 different ZHAs were conducted in May 2015 (round 3). The information of all participants is shown in Table 2. As can be derived from the table, some ZHAs were interviewed multiple times. Finally, additional documents were collected to strengthen my data. Both the interview transcripts and additional documents were collected through formal as well as informal data sharing.

Code Hospital Cohort Gender Age Round

ZHA1 H1 2 Male 40-45 3

ZHA2 H1 2 Female 25-30 2 & 3

ZHA3 H2 1 Female 30-35 1, 2 & 3

ZHA4 H3 2 Male 30-35 2 & 3

ZHA5 H4 2 Female 30-35 2 &3

ZHA6 H5 1 Female 25-30 2 &3

ZHA7 H4 2 Male 50-55 2 & 3

ZHA8 H1 1 Male 25-30 1 & 3

ZHA9 H1 1 Female 40-45 1 & 2

ZHA10 H5 1 Female 30-35 1 & 2

ZHA11 H5 1 Female 40-45 1

Table 2: Characteristics of interviewees

3.3.1 Interviews

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25 around three different subjects: the education for the ZHAs and whether and how the ZHA could contribute to the project, the (future) job of the ZHAs, and how the ZHA sees his/her own professional future. This interview protocol can be found in Appendix I. The interviews were recorded and verbatim transcripts were made from the interview voice recordings.

3.3.2 Additional documents

Next to conducting interviews, other qualitative data were gathered in the form of documentation to strengthen my data. These additional documents can be divided into different groups. First, the documents that explained the value of the ZHA and were used to make the educational curriculum for this new medical profession. Second, the documents that were developed to request subsidy. In addition, multiple reports have been developed to describe the evaluation of the ZHA implementation process. Fourth, reports from meetings that were held between multiple stakeholders (Concilium), were collected. Finally, the SOZG communicated the implementation of the ZHA through several press releases. The different newspaper articles that were collected can be found in Appendix II. Table 3 provides a summary of these additional documents.

Code Data Source #

EC Educational Curriculum N=1

SR Subsidy Request N=2

ER Evaluation Reports N=2

CM Concilium Meetings N=3

LPM Lint Program Meetings N=1

NA Newspaper Articles N=18

Table 3: Additional documents

3.4 Data Analysis

Different types of secondary analysis are identified and they vary according to the degree to which the aims of the primary and secondary research converge or diverge (Heaton, 2008). Supplementary analysis is one of these types and this refers to ‘a more in-depth analysis of an emergent issue or aspect of the data, that was not addressed or was only partially addressed in the primary study, is undertaken’ (Heaton, 2008: 39). In primary studies, it was not investigated how institutional influences direct the ZHAs’ role and position and through which actions the ZHAs and the SOZG create, maintain or disrupt institutions.

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26 compiled during a study. Two types of coding techniques were used when the interview transcripts and additional documents were coded: deductive and inductive coding. Because of the fact that both institutional theory and sensemaking theory are abstract perspectives, it was difficult to develop deductive codes as a “start-list”. Therefore, the transcripts were first inductively analysed. The Atlas.ti software was used during the coding process. After this inductive coding process, it was clearer which deductive codes could be developed. Deductive codes were created by the conceptual framework, key theoretical concepts and problem areas. If new insights were formed throughout the coding process, inductive codes were again constructed. Main concepts, code names, descriptions and quotes were implemented in a codebook and this can be found in Appendix III.

3.5 Quality Assurance

The most important research quality criteria are controllability, reliability and validity (Swanborn, 1996; Yin, 1994). These are important because they provide a basis for inter-subjective agreement, which means that there is a consensus between the actors who deal with a research problem (van Aken, Berends & van der Bij, 2012). Controllability is a precondition for the evaluation of validity and reliability and so is reliability for validity. These research quality criteria are discussed in Table 4.

Quality Criteria Sub-Quality Criteria Definition Applied tactics

Controllability

Reveal how

researchers executed a study

 A detailed description of the study was included in the methodology section and results were presented precisely

Reliability Researcher Bias Independent of person

 The same interview protocol was used for every interviewee

 The interviews were conducted by two researchers in three rounds

 The interviews that had been conducted, are transcribed

Instruments Bias Independent of instruments

 Triangulation:

o Multiple research sources were used (e.g. both interview transcripts and additional documents)

o Multiple research instruments were used (e.g. interviews were conducted face-to-face and over the telephone

Validity

Justification by the way research results are generated

 Both interview transcripts and additional documents were systematically analysed

 A coding scheme was used

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4. FINDINGS

In this section, the results of the collected and analysed data will be presented. The findings will be presented with the help of multiple quotes from the interviewees. This results section will be structured in the following way. First, findings on how institutional characteristics direct the ZHAs’ role and position will be discussed. Then, actions of human agents that create, maintain or disrupt institutions will be presented.

4.1 How institutional characteristics direct the ZHAs’ role and position

As mentioned in the literature review, institutions can enable and constrain human agents. Implementing a new medical profession in the Dutch healthcare can be complex, because of the institutional environments of hospitals. The findings show that the institutional environment enables and constrains the ZHAs and the SOZG in different ways.

The institutional environment is rigid and implementing a change is difficult. On the question if the ZHA could be implemented successfully, a ZHA answered: “I do wonder, because of the fact that

medical practitioners are seen as an occupation that involves a certain status and specialists are the ones with the highest status. The ZHA is seen as a generalist, which includes a lower status. This culture is dominant at the universities. If you want to successfully implement the ZHA, you have to break through these thoughts” – ZHA10-1. Another ZHA emphasized that the biggest problem is the

fact that the current system is fixed: “Everything is stiff and the system is stuck” – ZHA1-3. This ZHA also noted that they had to get more room to breathe. One of the ZHAs mentioned that it would be difficult to implement a change in the medical world due to the fact that: “The medical world requires

diplomatic and political tactics in order to put these plans into practice” – ZHA5-3.

The present culture of a hospital is seen as one of the biggest barriers in the ZHA implementation in the Dutch healthcare: “It is important to change the existing culture which emphasize specialists’

work and their own expertise. Continuity of care should be improved. If this would be more accessible, it will be easier to successfully implement the ZHA and other stakeholders will accept us more. The hospitals’ culture has to change and everybody should be seen as equal” – ZHA8-3. One of the ZHAs

quoted: “If a stakeholder accepts this new medical profession, depends on the culture of a hospital” –

ZHA11-1. Currently, surgeons do not want to lose their assistants: “Because they fit within the culture of the department” – ZHA9-2.

Some of the ZHAs argued that the present structure of a hospital is a constraint. On the question “In order to successfully implement the ZHA, what do you think is needed?”, a ZHA answered: “I think it

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example would be an oncological center, where oncologists and surgeons work together. In this way, we can combine knowledge and care and increase patient-centeredness. The departments of a hospital have to be set up differently” – ZHA2-3. In this way, “The patient can be seen as the key player” – ZHA3-3. Nevertheless, findings also show that the structure of a hospital enables human

agents. In contrast with what has been mentioned above, the current structure of a hospital can be appropriate for the ZHA implementation. In this structure, specialists and generalists are working side-by-side. On the one hand, specialists have a specific area of expertise; they are working in a narrow domain and are generally only concerned with specific issues they are treating. On the other hand, generalists adopt a central position, are more patient-centered and provide continuity of care.

Some stakeholders were being sceptical about this new medical profession. These stakeholders were most of the times older specialists who have strongly held and rooted beliefs about education. One of the ZHAs quoted: “Surgeons are doubting about the ZHA. They do not want to lose their assistants,

because these are the ones that want to become surgeons. They are educated within the same culture. The ZHAs are new, they have a different background and another way of working” – ZHA9-2.

Another ZHA noted that with some internships, instructors are stuck in a certain pattern: “This is the

way that we have been educating, and we will work the same way to educate you” – ZHA1-3. They

are stuck in the same pattern and it is difficult to change that. This change is needed if you want to train a patient-centered generalist instead of a profession-focused specialist.

The institutions also constrain human agents because of a lack of resources in the institutional environment. The initial findings show seven resources that human agents need to create, maintain or disrupt institutions. Resources that are identified include showing the added value of the ZHA, increasing familiarity, sharing ideas and experiences, getting more support and getting more time, providing more clarity and better communication. Below these resources are described in greater detail, and additional evidence with regard to these resources is provided in Table 5.

The first resource is showing the added value of the ZHA, as one of the ZHAs mentioned: “For

stakeholders it is still unclear what the added value of the ZHAs’ role is” – ZHA3-2. At this moment,

some stakeholders are sceptical and show resistance. According to one ZHA, “This is a result from the

fact that they do not know enough about what a ZHA contributes” – ZHA3-1. Some of the ZHAs

realised that they were the ones who were responsible, as one of them said: “We have to show the

added value of the ZHAs’ role, we have to do things” – ZHA5-2. Another ZHA noted: “We have to prove how beneficial we are” – ZHA8-1. Other specialists have to see the added value of the ZHA.

The only way they can see these benefits is by: “Showing the improvements of quality of care and

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working together with their own medical assistants” – ZHA5-3. Specialists should realize that the

working domains of the ZHAs are different: “We have a different job to perform and that is why we

will not take their place but contribute to the quality of care and patient safety” – ZHA1-3.

Stakeholders also have to be familiar with the ZHA and therefore, familiarity is the next resource. Several ZHAs noted: “There should be more awareness for the ZHA” – ZHA3-2 or “People have to

know that this new medical profession exists” – ZHA3-2. The ZHAs’ role should be become more

known and not only within the healthcare settings, but also patients should be more familiar with the ZHA: “Publicity about the ZHAs’ education and role must increase” – ZHA6-3. People will be familiar with the ZHAs’ field of study, if “Newspaper articles will be written about the ZHAs’ role and because

of this publicity, we will get more attention” – ZHA1-3.

Another resource that the human agents felt they needed is getting the opportunity to share ideas and experiences. In the first stage of the implementation, the ZHAs had the feeling that they were left out and were not involved in the implementation process. One of them mentioned the following:

‘’One of the points of criticisms that I have is that we want to be involved in the implementation process, because now we do not know where we will end up’’ – ZHA9-2. Decisions regarding the

implementation process were made top-down: “The Concilium is making decision and we are not

involved in that process’’ – ZHA6-2 or “The instructors are making their own decisions and they find it difficult to let go’’ – ZHA9-2. In the interviews that were conducted during these times (round 1 and

round 2), the ZHAs showed that they were not involved in future developments of the education, while during the application process the pioneers role of the ZHAs was emphasized. They found it unfortunate as one of them said: ‘’I want to have a say and play a role in future developments’’ –

ZHA9-1. In the interviews that were conducted in round 3, the ZHAs mentioned that they were more

involved in the implementation process, as they argued: ‘’We are involved in the project as

stakeholders want to know how we feel about it and what our experiences are’’ – ZHA2-3 or ‘’The ZHAs are more involved and the instructors will fade away into the background’’ – ZHA6-3.

The next resource is getting support from other stakeholders, as one of the ZHAs stated: “In order to

successfully implement the ZHA, I think that we have to get support from other medical specialists” – ZHA8-1. The ZHAs are being tolerated, but some stakeholders do not accept them in practice and do

not support the implementation. Also, it is important to convince the hospital’s Board of Directors, as several ZHAs argued: “We need more people in order to accomplish the implementation” – ZHA8-3 or

“More trust from others would lead to better improvements” – ZHA11-1.

The fifth resource is time. In order to successfully implement the ZHA, more time is needed: “I think it

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passed before they got acknowledged” – ZHA11-1 or “If you look at the US where the Hospitalist has been implemented for 25 years, they are accepted now, but that took years” – ZHA5-3. For some

ZHAs, the beginning of the education was very stressful. One of the questions in the interview that was conducted in round 3 was: “If you look back at the education program so far, do you think you have made a contribution to the content of the education?” One of the ZHAs answered: “Personally,

if I look back at the past, I did not have the time to think about those developments” – ZHA1-3. When

thinking about the ZHAs’ role, time is also needed: “It will take years before the ZHAs’ role is shaped”

– ZHA8-1 or “A lot of people do not know what to expect from a ZHAs’ role, that is something that will be figured out in the next few years” – ZHA6-3.

The next resource that is mostly mentioned by the ZHAs is that more clarity has to be given about the ZHA implementation, education and role. One of the ZHAs said: “Other medical practitioners

sometimes ask, what is your role?” – ZHA4-2. Not only other medical practitioners are wondering

what they can expect from the ZHA, even several ZHAs mentioned that the role is still unclear and, therefore, “it is difficult to explain what our work domain is, because that is something that is still

ambiguous for me too” – ZHA6-2. Several ZHAs explained that, as you progress in the education and

get more experiences, the role of the ZHA is getting clearer. Even though, one ZHA said: “The

theoretical interpretation is becoming more concrete, but the practical execution remains still unclear” – ZHA3-2. Therefore, more clarity has to be given about the role of the ZHA, “The purpose and the profile of the ZHA should be put down more clearly. Everything is new” – ZHA10-2. Another

ZHA argued: “If there is a clear vision and more consensus, it is easier to explain our role to other

stakeholders” – ZHA2-2. At this moment, this is something that is still vague in the Netherlands, “In that area, there is still a lot to do” – ZHA6-3.

The last resource is giving more information about the ZHA and this should be better communicated:

“I do not have the feeling that they have been informed well. I have the advantage that a colleague started earlier which resulted in the fact that they were somewhat familiar with the ZHA. But, most of the time, we have to explain it to everybody all over again” – ZHA11-1. One of the ZHAs mentioned: “Sometimes, I have the feeling that the communication to the outside world, is coming too late” – ZHA3-2. In order to successfully implement the ZHA, more information about the ZHA should be

presented, as one ZHA argued: “More information should be communicated to other specialists, so

that they know what our role is and also understand the added value” – ZHA6-3. Interesting is to

address that besides these constraining forces, the ambiguity that exists can also be seen as an enabling force for human agents. This ambiguity is the result of the uncertainty and the information that has not been communicated. One of the ZHAs said: “Other medical practitioners sometimes ask,

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31 ones that could explain the ZHAs’ role and create support, “If you explain what the ZHAs’ role

contents, people respond positive” – ZHA2-2.

To conclude, the findings from this subsection show that the institutional environment of a hospital constrains and enables human agents in different ways. On the one hand, the institutional environment is rigid and the culture of a hospital is seen as one of the biggest barriers in the ZHA implementation. Next to that, multiple resources are needed in order to successfully implement the ZHA. On the other hand, because of the fact that the ZHAs’ education and role is still uncertain, the ZHAs and the SOZG can contribute to the future developments of the ZHA implementation.

No. Resource Description Example # Specific

respondents

1 Added value Stakeholders have to see the added value of the ZHA

“We have to show the added value of the ZHA by improving the quality of care and patient safety”

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ZHA1, ZHA2, ZHA3, ZHA4, ZHA5, ZHA6, ZHA7, ZHA8, ZHA9, ZHA10, ZHA11

2 Familiarity Stakeholders have to be familiar with the ZHA

“In order to successfully implement the ZHA, we need more publicity” 15

ZHA1, ZHA3, ZHA4, ZHA6, ZHA7, ZHA9, ZHA10

3 Share

ideas/experiences

ZHAs have to get the

opportunity to share ideas and experiences

“I would like to be involved and think about the development of the ZHAs’ role”

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ZHA1, ZHA2, ZHA3, ZHA4, ZHA5, ZHA6, ZHA7, ZHA8, ZHA9, ZHA10,

4 Support ZHAs have to get support from other stakeholders

“I think that we have to get support

from other medical specialists” 7 ZHA1, ZHA8, ZHA11

5 Time Time is needed “It will take years in order to shape

the ZHAs’ role” 12

ZHA1, ZHA5, ZHA6, ZHA8, ZHA10, ZHA11

6 Clarity

More clarity has to be provided about the ZHA implementation, education and role

“The purpose and the role of the ZHA

have to be clarified” 39

ZHA1, ZHA2, ZHA3, ZHA4, ZHA5, ZHA6, ZHA7, ZHA8, ZHA9, ZHA10, ZHA11

7 Communication

More information has to be provided about the ZHA implementation, education and role

“I think that more information has to be communicated to other medical specialists”

20 ZHA1, ZHA3, ZHA6, ZHA9, ZHA10, ZHA11

Table 5: Resources that human agents need to create maintain or disrupt institutions

4.2 Actions of human agents that create, maintain or disrupt

institutions

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4.2.1 Actions of the ZHAs

The initial findings show nine actions of the ZHAs that create, maintain or disrupt institutions. Actions of the ZHAs that were identified include contributing to the future, contributing to the past, realising that they are the front liners, thinking about and working on own future, actively giving feedback, passively giving feedback, being passive, promoting and sharing ideas and experiences. Below, all themes are described in greater detail, and additional evidence with regard to these actions is provided in Table 6.

The first action of the ZHAs is contributing. This is divided in contributions to past changes in and contributions to future developments of the ZHA implementation, education and role. One of the questions in the interview that was conducted in round 3, was: “If you look back to the education program so far, do you think you have made a contribution to the content of the education?”. All the interviewees answered this question with a yes, as one of them responded: “Yes, we have changed

the internship program’’ – ZHA7-3. They stated that they got more feeling with the role of ZHA during

the education and, therefore, with these experiences, it was possible to contribute to changes in the education’s content. During their education, some of the ZHAs were actively contributing to future developments of the ZHA: “I have a lot of ambition regarding the process of shaping the ZHAs’ role. I

think this is a gradual process’’ – ZHA5-2 or “I want to be actively involved in shaping the role of the ZHA and processes that contribute to improving care’’ – ZHA9-2. Another question in the interview

that was conducted in round 3, was: “If you will graduate and work as a ZHA, is it then still possible to shape the role of the ZHA?’’. All the interviewees answered this question with a yes, as one of the ZHAs responded: “Yes, it certainly is. In fact, during the application process, we were asked if we

wanted to contribute to the development of a new medical profession’’ – ZHA1-3. They realised that

during their education, as well as during their future work, they are expected to think about the development and the shaping of the role of the ZHA.

Another action of the ZHAs is the fact that they were aware of being front liners and therefore were being part of the first group in the ZHA implementation: ‘’We are the first ZHAs, there are no role

models” – ZHA3-2 or “ZHAs of Cohort 1 were the first who had to experience everything’’ – ZHA1-3.

Because of the fact that these ZHAs were being part of the first group, they also realised that they were partly responsible for successfully implementing the ZHA. “If we do not get the opportunity to

shape the ZHA’s role, I think it is important that we put effort on it. We are the first group of ZHAs and we are the ones that can change and adjust things’’ – ZHA2-3. Some of the ZHAs addressed that they

were the ones who had to play a crucial role in the implementation, as one of them said: “Who can

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33 The next action of the ZHAs is thinking about and working on their future. The ZHAs gave different answers on the question if they were already working on their future. Some of the ZHAs had very little time to think about their future and the development of the ZHAs’ role, as one of the ZHAs stated: ‘’To be honest, time does not allow me to think about shaping the role of the ZHA and my

focus in the first year is on the education’’ – ZHA10-1. On the contrary, other ZHAs were more

actively involved: ‘’The focus is on my education, but next to that I am also already preparing myself

for the future’’ – ZHA2-3.

Giving feedback is also an action of the ZHAs and is divided into actively and passively giving feedback. The ZHAs noted that other stakeholders were open for input and most of the time they responded positively when a ZHA gave feedback: “if I suggest something, it is possible to look for

improvements for the following groups. By providing feedback, we can play a role in the implementation process’’ – ZHA2-3 or “There were a few ZHAs who disagreed and they mentioned that’’ – ZHA7-3. One of the ZHAs mentioned that giving feedback depended on how proactive a ZHA

was and thereby stated that some of the ZHAs only gave feedback when they were asked for their opinions. Before, during and after an internship, evaluations are organized for the ZHAs. During these evaluations, ZHAs were asked for their opinions: “After every internship, we had to fill in an

evaluation form where everyone could share their experiences’’ – ZHA2-3. Besides these forms, ZHAs

were asked for their ideas and experiences, as one of the ZHAs answered: “They motivated it. They

asked us frequently if there are things that can be improved or things that should be done in a different way’’ – ZHA4-3. Even though ZHAs gave actively or passively feedback, the question for

them remained if other stakeholders would respond to it: “If they respond to it? I do not exactly

know, but we shall have to wait-and-see’’ – ZHA10-1.

Some of the ZHAs showed no action, were passive and took a wait-and-see approach: “That is

something that I did not consider” – ZHA8-1 or “The ZHAs do not contribute to the development of the education and the role, but stand on the side-lines” – ZHA6-2. The ZHAs gave multiple reasons

when they were asked why they took a wait-and-see approach. As mentioned above, some of the ZHAs had very little time to think about future developments of the ZHA implementation. One ZHA argued: “Everything had already been planned out, ” – ZHA2-3. Most of the passive ZHAs wanted to focus on the content of the education and not on the positioning, role or other future perspectives.

The next action of the ZHAs is promoting and includes actions that ZHAs showed to address the added value of the ZHA: “I have to show the added value of the ZHAs’ role and should undertake

Combining Institutional and Sensemaking Theory: