Making Sense of Organizational Change and Innovation in Health Care

An Everyday Ethnography

Anne Reff Pedersen

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429638862
• Edition: 1
• Topic: Business
• Subtopic: Organisational Behaviour
• Index: Business

This book explores the hospital via organisational ethnography (OE), an approach that involves a mix of fieldwork methods designed to analyse the hospital which also includes participatory observation, qualitative interviews and shadowing.

One way to define a hospital is by its high level of formal organisation, resulting in written or digital communication as the main source of communication in patient journals, minutes and medical and quality guidelines. In contrast, in this book, the aspects of the informal organisation will be the focus. In spite of the many formal regulations of healthcare, hospitals are also chaotic organising places where many different groups of people interact in order to negotiate, to practice and to make sense of daily work tasks. The underlying argument is that, in the mundane everyday life of hospitals, frontline workers and their interactions with patients and local managers remain at the core of organising hospitals. The overall purpose of this book is to report stories back from the field of healthcare, demonstrating how people, spaces and work (as examples of events) become important elements of organising hospitals.

The book will be of interest to students and scholars in and across healthcare management, organisation studies, ethnography, sociology, qualitative methods, anthropology, service management and cultural studies.

1 Introduction

Making Sense of Organizational Change and Innovation in Health Care: An Everyday Ethnography

Source: Ahlefeldt-Laurvig

Encountering Everyday Life Through Meeting People

Many books and articles have been published on health care organizations in the last two decades or more. From a sociological and organizational perspective, studies have explored social and institutional systems (Goffman, 1968), the birth of the clinic (Foucault, 1973), the power of medicine (Turner, 1983), medical practice (Mol, 2002), institutional change (Scott, Ruef, Mendel, & Caronna, 2000), and organizing (Ferlie, 2016). One could then ask, “Do we really need more books about this topic?” After reading Finn Borum’s (1995) 1976 field study, I was incredulous that, even 40 years on, some of the same conflicts are still present in hospitals today. For instance, the large degree of autonomy surgical wards have when planning/cancelling operations, how doctor conferences are performed, and how clinical wards obtain status regarding their number of beds. Many of these issues are still relevant today because everyday routines such as bathing (Goffman, 1968), medical conferences, and operations (Borum, 1995) are still daily activities at hospital wards, confirming that everyday life in health care organizations are dominated by strongly routine, negotiated practices. After more than 15 years of conducting field studies at hospitals, I returned to a clinical ward that I had studied many years ago. The hospital had undergone change several times by adopting various management models and the ward had become a functional unit/department that was now part of a center. I asked the nurses and doctors on the ward about what had changed since my last visit. They responded, “Nothing, down here, we see patients just like we always have.” This empirical account supports the notion that change is perceived as a difficult process in hospitals, and even if management models and concepts continually change, everyday clinical life has its own time, pace, and way of doing things (Pedersen, 2009).

Still, recent societal trends have led to changes in hospital conditions: patient stays are shorter, IT facilities are making e-consulting more appealing, and politicians are demanding improved productivity, budget cuts, and faster patient trajectories (Nickelsen, 2019). So, worldwide changes in society are reflected by modifications in health care organizations, which are not isolated islands but part of a more global, digitalized, and individualized society (Ferlie, Montgomery, & Pedersen, 2016). As a result, contemporary studies of everyday life in health care organizations are always relevant, as they reflect our changing society while simultaneously mirroring the battle between dominant values and routines and new societal demands. These battles do not always end in bloody wars but are often dealt with in the everyday negotiations of employees and patients. The mundane, everyday practices of local employees and their collaboration with external stakeholders are at the core of any health care community; thus, their narratives are the focus of this book.

This book explores everyday life in health care organizations using organizational ethnography, an approach that involves a mixture of fieldwork methods (Hammersley & Atkinson, 2007; Neyland, 2007) designed to analyze organizations, e.g., the hospital, which includes participatory observation, qualitative interviews, shadowing, and document studies (Pope, 2005). Organizational ethnography applies not only to certain methods used to describe organizations but also to theorizing and understanding organizations using specific kinds of data. This means that, from an organizational ethnography perspective, health care organizations are defined by social interactions, relationships, and social dynamics, all of which represent activities that can be observed, talked about, and interpreted (Pedersen & Humle, 2016). When using an organizational ethnography perspective, it is not possible to present a complete picture of change processes in health care organizations, which is why this book employs a bricolage of snapshots of the narratives people tell in their everyday work life to show how sensemaking and value negotiations consistently play central roles in organizational change processes.

The purpose of this book is to explore how people in health care organizations use narratives to make sense of different organizational change processes in their everyday work life.

Health care organizations are meeting places for people, and their narratives and sensemaking of organizational change processes in everyday life become the focus of analysis. As the purpose of this book is to investigate everyday contexts, local employees are, thus, considered central to studying and understanding the surrounding narratives of change processes. New research on materiality, nonhuman actors, and digitalization has gained recent attention in science and technology studies of health care, addressing new and emerging conditions for organizing (Allen, 2002). Both in line and in contrast to many of these detailed science and technology studies, this book addresses the human aspects of a health care organization by acknowledging how people and their interactions and sensemaking continue to play central roles in changing health care organizations.

One way to describe everyday life in health care organization is by its high level of formal organization, resulting in digital communication by patient journals, medical guidelines, and quality standards as the main source of organizing. This book focuses on another way to describe everyday life through the informal organizing, as in spite of the many formal regulations, health care organizations are also chaotic meeting places, where health care professionals are negotiating to make sense of their everyday work tasks. The underlying argument in this book is that, despite new technologies and complex contemporary health care issues, the mundane, everyday lives of organizational members, and their interactions with external relations as patients (McDermott & Pedersen, 2016), remain a core element of organizational change in health care organizations. Even though we have read about these relationships before, contemporary narratives of the frontline workers remain a never-ending field of exploration for providing vital insights into organizational change processes in health care.

Organizational Change as Ongoing Sensemaking in Everyday Organizing

Health care organizations reflect the societies that surround them; a current pressure in Western society is to deliver faster patient trajectories and to innovate more efficient treatments plans to meet the individualized patient needs and the societal needs of a growing chronic and elderly patient population (Ferlie et al., 2016). Therefore, in one health care vision, health care organizations are fast-moving organizations, becoming the meeting place for new technological and digital development and expanding the possibilities of medicine and for contemporary social and economic population health issues, such as health equality, lifestyle consequences, and longer life expectancy. In another vision, health care organizations remain the same; they are populated by health professionals with strong health care values, having formalized routines and evidence-based work tasks, with strict validation, guidelines, and assessment practices. Thereby, health care organizations can both be viewed as places of resistance toward change and as places with accelerated change processes (Ferlie et al., 2005).

In the organization theory literature, organizational change is divided into studies of episodic change and continuous change, where the former understands organizations as stable entities and the latter understands organizations as an ongoing movement (Weick & Quinn, 1999). This book defines organizational change from a continuous change perspective, which means that change processes are part of the ongoing organizing process. A sensemaking organizing change perspective relates to how participants in organizational change understand and make sense of change processes; thus a sensemaking perspective on organizational change has the ability to provide essential meaning for maintaining or reproducing stability and/or promoting resistance to change in and around organizations (Vaara, Sonenshein, & Boje, 2016). A sensemaking perspective on organizational change provides valuable insight into how participants make sense of change projects and processes and how they support or resist change processes. These organizational change processes are also related to local values and multiple logics (Reay & Hinings, 2009).

The change projects presented in this book were all identified through organizational ethnography. This means that the empirically presented change projects in the chapters are not the results of an overall theoretical change framework or a certain way of understanding elements of organizational change. Thus, these change projects were identified through a bottom-up approach asking about current change projects in the health care organizations. Different field studies will have found other projects. Together, these local change projects are examples that illustrate the everyday human organizing perspective because they are unpredictable change projects and themes, maybe even mundane change examples, but nevertheless current and thereby relevant change processes for the participants involved. They include a large group of different people: patients, health care professionals, clinical managers, and external stakeholders, such as innovation consultants, administrators, regional politicians, and state policymakers because local change projects are often not intra-organizational processes. Instead, local change projects become part of everyday organizing as ongoing organizing processes of the past, present, and future (Hernes, 2014), which means that they require sensemaking, negotiations, and narratives because they often result in unintended organizing consequences. When talking with people about organizational change, a sensemaking and narrative perspective is the inevitable approach.

A Pragmatic Narrative Framework

A very simple argument about organizational change and its relation to sensemaking is that if people do not understand the meaning of a given problem or change idea, they will likely resist it. People need meaning to interact and function (Bruner, 1991; Gabriel, 2000), which is also the case for the people working and entering organizations as they make sense out of organizing in an effort to understand, legitimize, and act. In that way, organizing is intertwined with narratives (Czarniawska, 1997). Sometimes narratives are told as individual narratives, by one storyteller, e.g., a clinical manager or a patient. Other times, narratives are told as the shared narratives of many storytellers, sharing a sense of the same events, e.g., from a group of health care professionals. The following chapters present an analysis of individual and shared narratives.

The narrative approach presented in this book is a pragmatic narrative understanding that includes different types of narratives. This means that the narrative framework includes more than one definition of a narrative because organizational narratives reflect their complex and dynamic surroundings and therefore come in many forms. Some organizational narratives are fragmented, often defined as ante- (pre-) narratives, with a fragmented structure and no coherence of plots or events but often told as contradictory narratives with tensions, ambiguity, and discontinuity, and therefore drawing on diverse and fragmented storytelling (Boje, 2001; Cunliffe, Luhman, & Boje, 2004; Pedersen & Humle, 2016; Vaara et al., 2016). Other organizational narratives are structured where a chain of events directs a plot or causal relationships between the events. These narratives are often told to persuade others to follow an idea and can be defined as strategic spokesperson narratives (Gabriel, 2000; Akrich, Callon, Latour, & Monaghan, 2002; Pedersen & Johansen, 2012). Some studies have combined these narratives, arguing that both structured and more provisory narratives are useful in studies of organizing, change, and innovation processes because they both have the capacity to direct and make sense of coordination (Bartel & Garud, 2009). In the following chapters, both fragmented and structured narratives will be presented in more detail. An empirical insight from the chapters is that fragmented narratives are often found in individual narratives and structured narratives are mostly found in the shared narratives of many storytellers. Both individual and shared narratives can be presented as fragmented or structured narratives, as narrative theory has no explanation for their different forms, only that they are told in different situated surroundings that reflect their structure (Boje, 2001).

Common to both fragmented and more structured narratives is that they all entail storytellers telling their personal stories, i.e., they are the characters who act in the stories, with different intentions and events that are linked to the characters. Consequently, the telling of characters and events is the building block of narratives. Thus the main contribution of using a narrative perspective in studies of organizational change processes is to show how organizing does not happen because of only shared narratives, values, or dominant logics. Instead, the analyses demonstrate how a central condition of making sense of change processes is that this happens through multiple narratives. Some of these narratives never meet, others relate, but together they create opportunities for organizing change in and around hospitals.

The research questions are:

How can we understand organizational change by doing an everyday ethnography?

Which narratives can be found when making sense of organizational change processes?

In addition, what are the sensemaking consequences for organizational change processes?

These research questions are addressed by illustrating different narratives from four field studies and demonstrating how theses narratives make sense of situated everyday change processes. First, Chapter 2 is theoretical, unfolding a narrative framework in relation to understanding organizational change. Chapters 3 through 7 are analytical, illustrating a collage of different narratives and sensemaking conditions for organizational change processes in an everyday context. The analytical chapters are not presented in chronological order but in a funnel optic, starting with a presentation of individual narratives at a ward and concluding with national and policy narratives. This approach presents organizational change processes in an everyday context from the individual to macro-levels, illustrating that narratives of organizational change relate to other narratives and never take place in isolation.

Everyday Ethnographical Studies

A short description of each of the four everyday ethnographic studies ...

Table of contents

• Cover
• Half Title
• Series Title
• Title
• Copyright
• Contents
• Acknowledgments
• 1 Introduction
• 2 A Theoretical Narrative Approach to Organizational Change Studies
• 3 Making Sense of Everyday Innovation at a Clinical Ward Through Narratives of Visitation Routines
• 4 A Resistance and Everyday View on Health Care Professionals
• 5 Designing and Driving Collaborative, Everyday Innovation Using Narratives
• 6 Organizational Change Through Narratives of Administrative Coordination
• 7 Policy Narratives of Innovation Expectations
• 8 Concluding Remarks
• Index