1.1 Aim and Positioning of the Volume
In this volume, we aimed for in-depth explorations of healthcare innovation processes as they happen in practice, with a particular focus on how innovation notoriously tends to involve controversies in many different ways. We have espoused the shift in research attention from structural explanations to process- and practice-based explanations in the social sciences (e.g. Schatzki et al. 2001; Hernes 2014). With the goal of collecting a plurality of contributions on the phenomenon investigated, we intentionally use the concept of controversies in a broad perspective, in line with Venturiniâs (2010) definition: âcontroversies are situations where actors disagree (or better, agree on their disagreement). The notion of disagreement is to be taken in the widest sense: controversies begin when actors discover that they cannot ignore each other and controversies end when actors manage to work out a solid compromise to live together. Anything between these two extremes can be called a controversyâ (p. 261).
The focus on the healthcare setting in this volume reflects the editorsâ involvement over the past few years in several projects1 related to innovating the healthcare sector in Norway; from studies on change of practices due to the implementation of new technologies and the introduction of health reforms, to studies related to e-health projects. Interest in the healthcare sector among policy makers and social science researchers has been growing in recent decades for many reasons. On the one side, the healthcare sector is one of the largest sources of employment in many societies (for example, projections show that one third of all jobs in Norway in 2060 will be in the healthcare sector), and it is experiencing rapidly increasing expectations from the public. On the other side, healthcare services are now facing significant challenges in adapting practices relating to innovation and change in knowledge, technology, organization and economy. This makes the sector extremely revelatory in terms of studying innovation processes, a fact borne out by several insightful contributions made over the past 10 years (e.g. Casebeer et al. 2006; Christensen et al. 2009). Some contributions have been a great inspiration to us in developing this volume on controversies in healthcare innovation: Moreiraâs (2012) work, which studies how changes in knowledge in the medical, managerial and public domains transform healthcare, comes close to our view on controversies in the field. Molâs (2008) investigation of what characterizes the patient/healthcare practitioner relationship when it works at its best is informative both at the levels of practice and policy. The contributions of the IKON group (e.g. Swan et al. 2016), whose studies investigate how innovation and knowledge in healthcare relate to change of practice and organization, have been important to our emphasis on, and understanding of, practice.
Our volume comes out of a long-term commitment to the contradictory aspects of innovation. We see innovation processes as fundamentally related to contrasts, contradictions, tensions and controversies; for example, between mobilization and exploration processes (Hoholm and Olsen 2012), between industrially embedded networks and novel resource combinations (HĂ„kansson and Waluszewski 2007; La Rocca and Snehota 2014), between established infrastructures and novel technologies (Aanestad and Jensen 2011), or between professional and organizational interests (MĂžrk et al. 2006, 2010, 2012). From this perspective, innovation processes consist both of the building of power relations in order to mobilize resources and drive the process further, and of systematic learning processes of formulating, testing and adjusting propositions about reality (whether technologies, users or other). The perspective we take in this volume builds on three assumptions. Our first assumption is that the social world is fundamentally unstable and in a continuous process of becoming. Our second assumption is that the âsocialâ is fundamentally heterogeneous and involves continuous processes of (re)combination. Our third assumption is that the social is fundamentally interactive; in other words, any social âentityâ, whether meaning, organization, technology or its use, has relational effects.
This volume is clearly in line with recent research that has shifted attention from the features of innovative solutions (used for a long time to explain the successful development and adoption of innovations) to the process of innovation, the so called âinnovation journeyâ (Van De Ven et al. 1999). This emergent research perspective shows innovation as being much less linear than has been traditionally assumed and stresses the importance of bringing innovation into use and interfacing the new solution with existing structures, resources and activities in the context of innovations that often span organizational boundaries (La Rocca and Snehota 2014). A more comprehensive view of innovation that takes into account the inter-organizational dimension of the innovation process is also emerging in the healthcare context (see Chapter 10 of this volume for a discussion on the intra- and inter-organizational forces at play in innovating healthcare). Stressing the view that innovation is about developing new solutions and bringing them into use makes users crucial in the process of innovation. The role of users is crucial because of the need to ânormalizeâ innovations (May et al. 2010) and connect them to everyday practices and already established resources in the user setting (HĂ„kansson and Waluszewski 2007; Harrison and Waluszewski 2008). Embedding innovations into user settings has consequences that are difficult to assess beforehand and will always involve confronting different views and agendas of different users and stakeholders. As a consequence, â[i]nnovation processes will always be characterised by tensions, controversies and conflicts. While conflict, of course, is not very pleasant for any participating actor, it is a precondition for learning, change and innovation within and across organisationsâ (Hoholm 2011).
Innovations always produce disruptions. The response of proposed alternatives to established practice is likely to be rejection and resistance, from ignoring new practices or manifesting skepticism and anxiety to counter-mobilization. While it is common knowledge that innovation, and especially radical innovation, involves the creative destruction of established technologies, economies and practices (Schumpeter 2013/1942), the role of controversy in the triggering and emergence of innovation processes is less studied. The aim of this volume has been to investigate exactly this dynamic: Starting out from the observation that there are always controversies present when people engage in innovation, we ask: What is the role of controversies in innovation?
The chapters of this volume help answer this fundamental question. Being anchored in different theoretical frameworks, studies in this volume converge in taking a practice- and process-oriented approach to innovation, and focus on some controversial aspects related to how innovation (in the forms of a new medical artefact, an IT system, a new organizational solution or a public-driven change/reform) unfolds in practice. The theoretical frameworks that influenced different studies in this volume originate largely from three research fields â organization studies, theories of industrial networks and infrastructure theory. Several chapters rely on âprocessual theoriesâ of organizing inspired by science and technology studies and actor-network theory, among others. In particular, the notion of âtranslationâ (Latour 1987, 1996), strictly linked to the idea of controversy, has been used in several chapters that address various issues related to âacceptanceâ of innovation within organizations. The process of translation explains how initiating a programme of action through which different interests may be translated into one common project, resources are made available, development processes are supported, and resistance is controlled to some extent. Translation puts emphasis on the role of meaning and that of materiality in explaining how an innovation process unfolds. Translation studies have also demonstrated the relationality, the fragility and unpredictability of such processes. Producing new knowledge/meaning and new practices is seen as two sides of the same coin.
Other chapters in this volume, stemming from the industrial network approach (and more specifically, the Industrial Marketing and Purchasing approach â see HĂ„kansson et al. 2009 for an overview), base their analyses on assumptions of relationality, meaning that the identity and shape of anything â actors, activity or resources â are an outcome of their relations. Of particular relevance to our project is the conceptualization of how changes in inter-organizational relationships typically create âfrictionâ, as such relationships are often highly interdependent as a result of years of mutual adaptation of material and immaterial resources and considerable economic investments over time (HĂ„kansson and Waluszewski 2002, 2007). The embedded nature of resources in use within and particularly between organizations produces friction when resources are moved, modified and recombined.
The link between the âestablishedâ and the ânewâ, and the related tensions, is also at the centre of the infrastructure theory applied in analyzing cases on IT application in healthcare. Infrastructure theory claims that a working infrastructure is deeply interwoven with practices, conventions, as well as regulatory, organizational and technical structures. These pre-existing arrangements, called th...