3 RESEARCH METHODS
3.1 Methodology
The aim of the research was to examine the perspective and experiences of employees in the context of committing to change. Through this study a deeper understanding of this phenomenon could be achieved. The change context in this study is a change in the information system in the health care sector. Through this study, the knowledge on how employees experience such change processes and what are the factors affecting employees’ commitment to the change can be increased. Thus, the aim of this study is in gaining a deeper understanding of the elements in the process and how they influ-ence the commitment of the employees.
The empirical research of the thesis is done by utilizing case study methodology. Ac-cording to Eriksson and Kovalainen (2015), case studies generate holistic and contex-tual in-depth knowledge about the phenomena it studies. Furthermore, this is done through the use of multiple sources of data. They also note that case studies are done by first defining the case and secondly solving it. Since the aim in case studies is to create diversity and complexity, overly simplistic research designs are avoided.
Case study could be defined as an exploration of a bounded system, which can be defined in terms of time and place (e.g. an event, an activity, individuals or groups of people) over time and through detailed, in-depth data collection involving multiple sources of information that are rich in context (Creswell, 2012 in Eriksson and Ko-valainen, 2015). In this case, we are looking at specific time point after introduction of a new EPR system and the study is placed amongst health care professionals in one municipality. The case itself is a phenomenon called sensemaking, and it is bounded to the context of change.
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Case studies have a qualitative nature, but also quantitative data could be used (Eriks-son and Kovalainen, 2015). In this case, qualitative methodology is utilized. Qualita-tive methodology specifies individual cases from the perspecQualita-tive of the participants or through the meanings the participants have given (Koskinen et al., 2005). The re-search is conducted by studying only one case, which is implementation of new EPR system in one Finnish municipality. According to Koskinen et al. (2005), utilization of a single case study method has its justifications. Single case study methodology allows concentration on one event. Furthermore, Yin (2003) notes that case study is the preferred research strategy, when the research question includes ‘how’ or ‘why’
questions, when investigator has little control over events and when research is con-ducted relating a real-life phenomenon. They also note that distinctive need for using case study research strategy arises from the desire to understand complex social phe-nomenon, which can be seen as the case in this thesis.
According to Eriksson and Kovalainen (2008), case studies can be categorized by their focus on the case itself – intensive and extensive approach. Intensive approach draws on qualitative and ethnographic traditions. This methodology emphasizes inter-pretation and understanding of the case and elaboration of sense making process in specified contexts. This approach aims to understand and explore the case from the internal perspective and to develop understanding from the perspectives of the people involved in the case. Extensive approach is based on factual, quantitative and positiv-ist research. In this methodology the case is not the main focus of the study, instead, the case gives a frame for e.g. mapping common patterns, mechanisms of properties in testing or extending a given theory or creating a new theory. In this case study, a mixed methodology is used. The case examines individual perspectives and under-stands the variety between individual experiences. However, also extensive approach can be identified as it attempts in identifying given theories and assumptions in this specific context.
42 3.2 Research context
As was noted in the introduction, there are various nationwide reforms taking place in the Finnish health care system. At the time of writing this thesis, the discussion on patients’ freedom choice in health care is escalating and the politicians have only re-cently done decisions on the social and health care system reform. Some changes are also brought by digitalization - nationwide information system services in health care are developed to include for example electronic prescriptions, nationwide archive ser-vices and medical databases. Simultaneously, these new systems are embedded in the work of the health care professionals. These renewals aim in improving the continuity of the care and patient safety. (HE 219/2013) For these reasons, health care organiza-tions are forced to make changes inside the organizaorganiza-tions, while companies providing electronic patient recording systems are required to develop new compatible solutions.
This study takes place in a Finnish municipality that has recently implemented a new EPR system in their health care system. The participants in this research include health care professionals that work in the same municipality. The municipality intro-duced a new EPR system only few months before the interviews were conducted. The new EPR system was replaced because of noncompliance with the new requirements that are introduced above. A deeper introduction of the case and case participants cannot be provided for ethical reasons, ensuring the anonymity of the participants, when considering the uniqueness of the case.
3.3 Data collection
The goal of the study was to examine the sensemaking process related to the com-mitment to change from the perspective of the employees in the middle of the change.
The data collection was done by utilizing interviews. Thus, the research was done by collecting primary data. The data collection was done in five face-to-face individual interviews. The data was collected during spring 2017. The time of the interviews is not specified to support the anonymity of the participants. The participants worked in
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the same municipality, which had changed the EPR system before conducting the in-terviews. Inside the municipality, the same patient recording systems are in use, and thus the interviewees have faced the same change. The fact, that the implementation had already taken place in the past, brought a retrospective perspective to the study.
The interviews were not conducted immediately after the introduction of the new EPR system to allow the participants to experience the change and implementation of the system. It has to be noted, that implementation is not a fast process. Thus, interviews immediately after introduction were not seen as purposeful. The interviewees were seen as representatives of their work community and professional group, and thus used as study objects in this change situation.
Interviews are seen as almost the only way to examine the meanings and interpreta-tions of people about different topics (Koskinen et al., 2005). According to Hirsjärvi and Hurme (2010), interviews are appropriate data collection methodology when the study topic causes a lot of variety in the responses, the answers require clarification and some deepening. Furthermore, interviews are used when participants are seen as subjects that are given the freedom to give information and elaboration about their experiences and ideas.
The interviews were conducted as semi-structured interviews. Semi-structured inter-views lie between survey interview and unstructured interview (Hirsjärvi and Hurme, 2010; Koskinen et al., 2005). Hirsjärvi and Hurme, 2010) explain that they focus on some predefined themes that guide the progress of the interviews. It is noted that the researcher defines the questions, but the interviewee may answer as they like, suggest new questions and depart from the question order. The interview questions were de-signed based on the literature review on commitment to change and factors that are seen to affect the commitment. Koskinen et al. (2005) note that theory driven qualita-tive studies are justified - especially when conducting semi-structured interviews – as semi-structured interviews require making theory explicit.
The same themes were followed with all of the participants. However, the order of the questions was not fixed, and the questions were modified and added according to the flow of the interview. Thus, the interview scheme acted as a map that guided the in-terview towards the themes that were chosen. This allowed the participants to explain
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and elaborate on their answers. The schemes for the interviews can be found in Ap-pendix 1 and ApAp-pendix 2 in both Finnish and English.
The participants were chosen based on the availability of the participants during the time of the interviews. This was because of the time restrictions and the working pace of the health care professionals in Finnish municipalities. The contact person in the health district asked the consents to participate from the interviewees, at which point they were introduced to the topic and context of the interviews. At the beginning of the interviews, the topic of the study was introduced for the participants again. The participants were also told about their anonymity and consents for recording the inter-views were confirmed. The anonymity of the participants was ensured to encourage free insights from the participants.
The interviews were conducted and recorded in Finnish, since all the participants were native Finnish speakers. This was done to avoid errors in the interpretation. For the same reason, the interview data was also transcribed and analyzed in Finnish. Only the sample quotations provided in section 4 were translated into English. There was total of 39 transcribed pages of interview data and the durations of the interviews ranged from 40 minutes to 1h 16minutes. Table below shows the details of the gath-ered data.
Table 1. Data collection
Interview Interview time Number of pages transcribed
Employee 1 (E1) 68 min 24 sec 9 pages
Employee 2 (E2) 39 min 58 sec 6 pages
Employee 3 (E3) 55 min 25 sec 6 pages
Employee 4 (E4) 43 min 55 sec 6 pages
Employee 5 (E5) 76 min 34 sec 12 pages
All of the interviewees in this study were women that worked in the health care pro-fession in a Finnish municipality. The participants included only women, as the sector of health care studied in this study is predominantly female. They all had worked
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eral years in this municipality and had experienced other EPR systems in their career as well. The participants were not all from the same profession and they used the new system to varying degrees. This is often the case in health care organizations and in different divisions of these organizations, since various professions work in delivering health care. However, all of the participants were familiar with the new EPR system and had participated in the change process.
3.4 Analysis of the data
After gathering the data, the data was analyzed by conducting a content analysis with a deductive approach. According to Eriksson and Kovalainen (2008), deductive ap-proach has theory as its starting point. Theoretical aspects of a phenomenon act as a basis on which researchers can deduce a single hypothesis or various hypotheses. This approach is seen linear, as it proceeds from theory to empirical research.
According to Eriksson and Kovalainen (2008), content analysis is one of the analysis methods for textual analysis. Content analysis is more concerned with the contents and frequencies of the text rather than form, structure and meanings of the text. It is further concentrated on finding themes and patterns. Weber (1990) notes that content analysis includes classifying pieces of text into fewer content categories, which is done through coding. These pieces of text may include words, phrases or other units of text. They are places in the same categories based on the similar meanings they share. The process of content analysis can be done by following the process intro-duced by Weber (1990): 1) Define the recording units, 2) Define the categories, 3) Test coding on sample test, 4) Assess accuracy or reliability, 5) Revise the coding rules, 6) Return to step 3, 7) Code all the text, and 8) Assess achieved reliability or accuracy.
After conducting the interviews, the data was transcribed in Finnish language. There-after, the transcribed data was read through several times to get an overview of the data. After that key issues were extracted from the data – for example the issues af-fecting the commitment, usage and perception of the system outside of the Weick
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1995 scheme. After extraction, a theme was given for each extraction according to the main point of it. Finally, these themes were divided in the categorizations by Weick.
Here is an example of themes and categories were derived in the analysis process.
Table 2. Results of the content analysis: examples, themes and categories
Example from the interviews Theme Category Some feel that they are
complete-ly handicapped”
Reflection to
col-leagues Identity construction If my leader had very negative
attitude towards the change, it would be very difficult to help the process of this change myself.”
Leader’s attitude Social
Things do not happen at once, but they change constantly, like the previous system changed along the way. It is constant learning.
Big things happen at once, but then there will be all small changes.
Constant learning Ongoing
When people get access to their own health records, the profes-sionals need to adopt a new role.
Professionals work together with the patients to treat the patient; it is not anymore a relationship where professionals decide. It might be very different starting point.
External stakeholders Enactive of sensible environments
Even though I said in the begin-ning that the previous EPR change was kind of bigger, but now I see that this change is as big, just in an alternative way.
This change has different ele-ments.
Reflection to past Retrospective
47 3.5 Ethical considerations
In conducting academic research there are various ethical considerations, of which some have already been considered. These issues include for example voluntary par-ticipation, informed consents and anonymity of the participants. (Eriksson and Ko-valainen, 2008).
The participants in the study were involved voluntarily. According to Eriksson and Kovalainen (2008), research should not make the participants believe that they are required to participate to the research as study objects, for example because of their position in the organization. The organization that was chosen for this study was very large, thus having various participants available for this type of research.
It is also important to get informed consents from the participants of the study (Hirsjärvi and Hurme, 2010; Eriksson and Kovalainen, 2008; Koskinen et al., 2005).
The basic idea is that participants of the research have given their consents based on appropriate information. This may raise the problem of reactivity of the participants.
The information the researcher has to give for ethical consent from the participant may affect the results or affect the behavior of the participants. (Hirsjärvi and Hurme, 2010; Koskinen et al., 2005) Information about the topic and context of the interview was given to the interviewees for acquiring their consents. However, the themes of the interviews were not given beforehand in order to avoid affecting the results of the study.
Anonymity, privacy and confidentiality of the participants are important to maintain.
Anonymity of the participants is considered to be the first priority in the research.
(Eriksson and Kovalainen, 2008) These issues can be considered by keeping personal information confidential and the data has to be stored where unauthorized access can be avoided. Personal identification from the data was deleted and the anonymity was extended to include the case organization. After transcription, the anonymity of the participants was ensured by removing any identification. The anonymity of the mu-nicipality/health care district was also be ensured by avoiding the disclosure of the exact time and place of the change occurring.
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4 RESULTS OF THE EMPIRICAL RESEARCH
This section provides an examination of the results of the research. In examining the results, some identification is provided after the sample quotations. The participants are identified in here as employee 1 (E1), employee 2 (E2) etc. The quotations pre-sented in this section are the ones that are seen to represent the view of the partici-pants’ best. The quotations are free translations of the interview data that were con-ducted in Finnish.
4.1 The change process
The interviews showed that this process started from planning the change. Most of the interviewees felt that the planning was done solely by a special task force that had been comprised to go through this change in the information system. The work of the task force was left unclear for most participants of this research. However, they all knew who were involved in this task force and that it has a multi-professional group consisting of various professionals from different units of the organization.
Two of the participants took part in the planning phase of the process, which included a special task force from various organizations. The task force discussed about the requirements of building a Kanta-compatible system and about the need for structural reporting. An employee who participated in this phase told that here employees were asked concrete suggestions on how to design the system and what type of features should be involved in the EPR system.
After the planning stage there was a distinctive testing phase. There was a special test group formed for this purpose. This group was multi-professional that was given cer-tain parts of the system for testing. They were also asked for input in forms of feed-back and suggestions for further development.
All of the employees were included in the process at least at the education phase. The organization arranged a special day for educating the personnel for the usage of this new program. There were also employees educating the other employees, which al-lowed participation in the process as well. One of the interviewees told that she was
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asked to participate more, as a part of the education group. However, she felt she re-jected the invitation due to her work responsibilities. She felt that there have been opportunities to participate for all who have been willing, and that the organizers wanted even more educators that they found. However, contradictory she also noted that in these types of big organizations, it may be difficult to give enough opportuni-ties to participate.
After implementing the EPR system in the organization, there constant discussion about the problems in the system had taken place, and the employees were asked about these issues. This can also be found as a way for participation.
All in all, the interviewees felt that there was only little participation to the process before implementation of the system. This was even though all of the interviewees took part in some phases of the process, perhaps not in the planning stage. Surprising-ly, even the employees who participated in planning stages felt that their participation in the process was only minor. Many felt that their participation consisted mainly of the usage of the system and some suggested that the participation in the development of the program was rather informal.
“Some single things have been asked by some people, but definitely not
“Some single things have been asked by some people, but definitely not