19
Page 19 of 33
The project plans also revealed presumed notions of efficiency and rationality of public healthcare project management. The relevant patient depictions were based on a product orientation worldview and appeared to reinforce the role of the project management team as controller while maintaining the product orientation worldview within the institutional context. Moreover, this ubiquitous worldview also corresponded well with the bureaucratic hierarchy and mindset of healthcare organizations that strive for efficiency.
Service orientation, which draws largely from the worldview and values of business, was generally missing from the project plans as the patient was only marginally represented as a service user. Furthermore, the few representations of the patient as a service user emphasized the service orientation as well as the product orientation. Thus, service thinking may be regarded as recognized, though not prioritized, by the project plans. This observation of the project plans for this case reveals how the processes related to product orientation maintained and renewed its position within the institutional context of public healthcare.
Depiction of the patient from a services worldview seemed difficult for project plan authors.
The difficulty could be due to the service orientation being so unfamiliar or unconventional in the Finnish public healthcare context that it may be considered insufficiently powerful for use as, for example, a legitimization strategy in healthcare project management. As a result, healthcare projects are at risk of being managed with no influence from a services worldview, leading to healthcare organizations, such as the hospital in this study, becoming inefficient as service producers (see Osborne et al., 2013).
Analysing the temporal differentiation (Michaud, 2017) between the two project plans showed that, of the available moralization strategies, emotional adjectives occurred frequently in project plan 1 but not in project plan 2. This might indicate that as the project advanced – i.e. became larger and more official – language use became more neutral.
Nevertheless, both plans included moralization strategies which often intertwined with legitimization by validation. The authors of both project plans did not deem moralization, on its own, sufficient for an argument promoting the needs of a child/patient undergoing an experience.
Likewise, in the wider public healthcare context, arguments based solely on humaneness were considered insufficient – even in the special environment characterized by CWCs – and validation by some authority was also required.
Interestingly, issues that were strongly legitimized using arguments comprising both moralization and validation strategies, like the experience of the child while being hospitalized, were typically found in the realm of nursing. This may indicate, that “soft”
nursing issues required additional confirmation from authoritative sources to gain acceptance, and that they were still regarded as subordinate to the highly professional medicine or to the rational administration
Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
20
Page 20 of 33
represented by management. Therefore, the project plans upheld the social order of existing hierarchies in hospitals. However, by using moralization and validation strategies together, the authors quite successfully contributed to transformation of the social order by affirming the importance of the nursing issues presented (Fairclough, 2003).
Even the few depictions of patients as objects for mobilization demonstrated the authors’
commitment to healthcare perspectives as well as to the product orientation worldview. Although these depictions allowed diverse meanings of patient to co-exist, they also connected patient mobilization to the values of healthcare professionals and to product orientation by emphasizing organizational efficiency. Hence, the patient was diminished to an element of the intra-organizational considerations or a source of easily obtained metrics (Osbourne et al., 2013). Thus, the plans, yet again, reinforced product orientation within the institutional context. Moreover, these depictions pose the risk of the patient being tied to the commission of the public hospital instead of the other way around, of which the latter is more appropriate.
In addition, the project plan excerpts under-represented the patient as citizens and potential users of healthcare services, thereby posing possible risk that citizens’ actions are steered in a pre-determined direction deemed best by the project management team for the citizens and service users.
This risk would lead to citizen participation in the development and production of services remaining negligible or, at best, superficial. Overall, this analysis of the project plans seemed to corroborate the argument by Denhardt & Denhardt (2000; see also Sześciło, 2016) that public organizations tend to be more interested in productivity than in the services for users and citizens.
To conclude, the analysis of the five distinct uses of the keyword patient we identified showed that bureaucratic efficiency and professionalism were maintained while supporting arguments for uniqueness of the hospital organization, without acknowledging a service orientation or public governance in the healthcare setting. The interrelationship of patient depictions in the investigated project plans and the relevant public healthcare context is illustrated in Figure 1.
< Figure 1 around here, please. >
Discussion
The paper contributes to the methodological issues in the emerging literature about critical healthcare project communication studies (e.g. Lunkka et al., 2019). Typically, studies of healthcare projects have focused on producing knowledge for use in improving project management. The present paper problematized such conventional project management knowledge and suggested that the critical stance in healthcare project communication provides a useful perspective that would enhance
Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
21
Page 21 of 33
emancipatory knowledge. Such knowledge questions the presumed assumptions about healthcare project reality (Geraldi and Söderlund, 2018). The paper illuminated how a critical perspective on healthcare project communication moves beyond the common mechanistic image of projects. The paper also provided insights into the interrelationships between discursive project management practices and the broader public healthcare context as well as the creation of the social reality of healthcare projects. The methodology presented in the paper could also be used in studies that take a critical stance towards communication in the healthcare setting in general (Kitchener and Thomas, 2016).
Previous studies have suggested that ambiguity in planning documents may offer healthcare project managers a discursive strategy for conveying different meanings according to audience interests (Jarzabkowski et al., 2010). Yet, these studies do not typically consider the wider context in which documents are produced and interpreted. Drawing from Fairclough’s CDA (1992, 2003), this paper considered use of ambiguous language by project management in project plans as a discursive practice that is influenced by, and also influences, the wider public healthcare context. Integration of keyword analysis into CDA allowed examination of discursive practices involving the keyword identified that were both enabled and constrained by the public healthcare context in which they occurred. Moreover, CDA provided a way to reveal various values and beliefs around the keyword and, hence, to unveil worldviews that were either emphasized or marginalized through keyword uses (see Figure 1). CDA is a relevant methodology for empirically analysing ambiguous language in healthcare project plans within their unique context.
The study recognized planning documents as a valuable, though less frequently used, entry point for investigating project management practices in healthcare. Although planning documents have been studied in various settings (e.g. Denis et al., 1991; Vaara et al., 2010;
Abdallah and Langley, 2014), analyses of discursive practices in healthcare project plans within an institutional context comprising public healthcare have remained rare. Instead of regarding project management as a universal technical tool (Thomas, 2012) that treats project plans as factual evidence of ‘reality’, CDA provided a method for capturing the wider context within which the documents were produced and interpreted, and for illuminating how project plans participate in maintaining, or changing, the social world (Fairclough, 2001).
Overall, previous literature has shown practitioners that the use of ambiguous language in planning documents need not be considered a problem involving the promotion of misunderstandings between stakeholders (Jarzabkowski et al., 2010; Abdallah and Langley, 2014). Along with those studies, this paper enhances practitioners’ conceptual understanding of how project reality is constituted through the ambiguous language use of those involved.
However, in contrast to previous
Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
22
Page 22 of 33
studies, the current paper considered the wider institutional context in project management’s ambiguous language use. In this way, the present paper may help healthcare project practitioners realize that their use of ambiguous language in healthcare projects and project plans may emphasize some worldviews and marginalize others. Furthermore, this paper may enhance project management participants’ reflexivity towards their language use in healthcare projects, particularly in project plans.
This study is not without limitations. It can be argued that ambiguous discursive interpretation of the keyword patient is difficult to capture objectively. As previously acknowledged, the background of the authors of this article inevitably influenced the process of analysis, therefore the background of the first author who was responsible for the analysis, and the context in which the analysis and the authorship were conducted, were all disclosed. Moreover, the authors were interested in moving beyond the essentialist conception of the term patient and focused instead on use and interpretation of discourse in the project plans investigated; thus, the authors did not actually strive for objectivity. In fact, the authors’ backgrounds may have assisted with their interpretation of the discursive activity portrayed through the project plans.
Conclusion
The study investigated project management’s ambiguous language use in healthcare project plans in a manner that considered the wider institutional context. By addressing the potential of a keyword-assisted CDA to investigate discursive practices involving the keyword in two sequential versions of a project plan within the broader context of public healthcare, the study contributes to the scant existing literature on critically-oriented healthcare project communication studies. Emphasis on the institutional context in which healthcare project management is enacted made it possible to critically scrutinize the relationship between ambiguous uses of the keyword in project plans and the wider institutional context. The study argues that keyword-assisted CDA provides an alternative, but relevant, methodological approach to conventional healthcare project communication studies for investigating project management discursive practices in a pluralistic context, such as public healthcare, through texts such as project planning documents.
REFERENCES
Abdallah, C. and Langley, A. (2014), “The Double Edge of Ambiguity in Strategic Planning”, Journal of Management Studies, Vol. 51 No. 2, pp. 235-264.
Acerete, B., Stafford, A. and Stapleton, P. (2011), “Spanish healthcare public private partnerships:
The ‘Alzira model’”, Critical Perspectives on Accounting, Vol. 22 No. 6, pp. 533-549.
Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
23 Alonso, J.A.M. (2015), “The Public Sector of the Future: A quantitative and qualitative analysis of
efficiency, equity and social cohesion in Europe”, Doctoral Dissertation, University of Cantabria – Department of Economics.
Aluthman, E.S. (2018), “A Corpus-assisted Critical Discourse Analysis of the Discursive
Representation of Immigration in the EU Referendum Debate”, Arab World English Journal, Vol. 9 No. 4, pp. 19-38.
Alvesson, M. and Sköldberg, K. (2000), Reflexive Methodology: New Vistas for Qualitative Research, Sage Publications, London, Thousand Oaks, New Delhi, Singapore.
Alvesson, M., Hardy, C. and Harley, B. (2008), “Reflecting on reflexivity: Reflexive textual practices in organization and management theory”, Journal of Management Studies, Vol. 45 No. 3, pp. 480-501.
Battilana, J. (2011), “The enabling role of social position in diverging from the institutional status quo: Evidence from the UK NHS”, Organization Science, Vol. 22 No. 4, pp. 817-832.
Baker, P. (2006). Using corpora in discourse analysis, London, UK: Continuum.
Buchanan, D. A., Denyer, D., Jaina, J., Kelliher, C., Moore, C., Parry, E. and Pilbeam, C. (2013),
“How do they manage? A qualitative study of the realities of middle and front-line
management work in health care”, Health Services and Delivery Research, No. 1 Vol. 4, pp.
39-48.
Cicmil, S. and Hodgson, D. (2006), “Making projects critical: an introduction”, in Hodgson, D. and Cicmil, S. (Eds.) Making Projects Critical, Palgrave Macmillan, London, pp. 1-25.
Currie, G., Lockett, A., Finn, R., Martin, G. and Waring, J. (2012), “Institutional work to maintain professional power: Recreating the model of medical professionalism”, Organization Science, Vol. 33 No, 7, pp. 937-962.
Denhardt, R.B. and Denhardt, J.V. (2000), “The New Public Service: Serving rather that steering”, Public Administration Review, Vol. 60, No. 6, pp. 549-559.
Denis, J.‐L., Langley, A. and Lozeau, D. (1991), “Formal strategy in public hospitals”, Long Range Planning, Vol. 24 No. 1, pp. 71-82.
Denzin, N. K. and Lincoln, Y. S. (2005), The SAGE handbook of qualitative research, Los Angeles, Sage Publications.
Fairclough, N. (1992), Discourse and Social Change, Polity, Cambridge.
Fairclough, N. (1993), “Critical discourse analysis and the marketization of public discourse: the universities”, Discourse & Society, Vol. 4 No. 2, pp. 133-168.
Fairclough, N. (2001), Language and Power, Routledge, London, New York.
Page 23 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
24 Fairclough, N. (2003), Analysing Discourses: Textual analysis for social research, Taylor &
Francis, e-Library.
Geraldi, J. and Söderlund, J. (2018), “Project studies: What it is, where it is going”, International Journal of Project Management, Vol. 36 No. 1, pp. 55-70.
Habermas, J. (1987), Knowledge and Human Interests, Polity Press, Boston.
Hartmann, R. K., Kärreman, D. and Alvesson, M. (2016), “CMS in Scandinavia - A Hitchhiker’s Guide to the Realm of the Scandocrits”, in (Eds.) Grey, C., Huault, I., Perret, V. and Taskin, L., Critical Management Studies: Global Voices, Local Accents, Routledge Taylor & Francis Group: New York and London, pp. 244-266.
Hakulinen, H., Rissanen, S. and Lammintakanen, J. (2011), “How is the New Public Management applied in the occupational health care system? - decision-makers’ and OH personnel’s views in Finland”, Health Research Policy and Systems, Vol. 9 No. 1.
Henderson, L.S. (2004), “Encoding and decoding communication competencies in project
management – an exploratory study”, International Journal of Project Management, Vol. 22 No. 6, pp. 469-476.
Hoegl, M. and Gemuenden, H.G. (2001), “Teamwork quality and the success of innovative
projects: a theoretical concept and empirical evidence”, Organization Science, Vol. 12 No. 4, pp. 435-449.
Ika, A. L. and Hodgson, D. (2014), “Learning from international development projects: Blending Critical Project Studies and Critical Development Studies”, International Journal of Project Management, Vol. 32 No. 7, pp. 1182-96.
Jarzabkowski, P., Sillince, J.A.A. and Shaw, D. (2010), “Strategic ambiguity as a rhetorical resource for enabeling multible interest”, Human Relations, Vol. 63 No. 2, pp. 219-248.
Jørgensen, M. and Phillips, L. (2004), Discourse Analysis as Theory and Method, SAGE Publications: London, Thousand Oaks, New Delhi.
Katz, R. (1982), “The effects of group longevity on project communication and performance”, Administrative Science Quarterly, Vol. 27 No. 1, pp. 81-104.
Kitchener, M. and Thomas, R. (2016), “The critical health care management domain”, in Ferlie, E.
Montgomery, K. and Pedersen, A. R. (Eds.) The Oxford handbook of health care management. Oxford: Oxford University Press.
Kitzmiller, R. R., Anderson, R. A. and McDaniel, R. R., Jr. (2010), “Making sense of health information technology implementation: A qualitative study protocol”, Implementation Science, Vol. 5 No 1, pp. 95-102.
Page 24 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
25 Leitch, S.R. and Davenport, S. (2007), “Strategic ambiguity as a discourse practice: the role of
keywords in the discourse on ‘sustainable’ biotechnology”, Discourse Studies, Vol. 9 No. 1, pp. 43-61.
Lunkka, N. and Suhonen, M. (2015), “Ambiguous meanings of projects as facilitators of sensegiving”, Journal of Nursing Management, Vol. 23 No 7, pp. 842-850.
Lunkka, N., Pietiläinen, V. and Suhonen, M. (2019), “A discursive sensemaking perspective on project-based work in public healthcare”, Project Management Journal, Vol. 50 No. 6, pp.
657-672.
Michaud, V. (2017), “Words fly away, writings remain – paradoxes in and around documents”, Qualitative Research in Organizations and Management, Vol. 12 No. 1, pp. 35-52.
McColl-Kennedy, J. R., Snyder, H., Elg, M., Witell, L., Helkkula, A., Hogan, S. J., and Anderson, L. (2017), “The changing role of the health care customer: review, synthesis and research agenda”, Journal of Service Management, Vol. 28 No. 1, pp. 2-33.
Mumby, D. K. (2004), “Discourse, power and ideology: Unpacking the critical approach”, in Grant, D., Hardy, C., Oswick, C. and Putnam, L. (Eds.), The SAGE handbook of organizational discourse, SAGE Publications, London, Thousand Oaks, New Delhi, pp. 237-258.
Nicolini, D. (2012), Practice Theory, Work, and Organization: An Introduction, Oxford University Press: Oxford.
Nilsen, J. F. and Riiskjær, E. (2013), “From patient surveys to organizational change: Rational change process and institutional forces”, Journal of change Management, Vol. 13 No. 2, pp.
179-205.
Nordgren, L. (2008), “The performativity of service management discourse: ´Value creating customers in health care´. Journal of Health Organization and Management, Vol. 22 No. 5, pp. 510-528.
Osborne, S.P., Radnor, Z. and Nasi, G. (2013), “A New Theory for Public Service Management?
Toward a (Public) Service-Dominant Approach”, The American Review of Public Administration, Vol. 43 No. 2, pp. 135-158.
Peräkylä, A. and Ruusuvuori J. (2011), “Analyzing talk and text”, in Denzin, N.K. and Lincoln, Y.S. (Eds.), The Sage Handbook of Qualitative Research, Sage Publications, pp. 529-543.
Pohjola, T., Suhonen, M., Mattila, K. and Meretoja, R. (2016), “The work done in healthcare projects”, Journal of Nursing, Vol. 3 No. 1, pp. 1-8.
Reay, T, Goodrick, E. and Hinings, C. R. (2016). “Institutionalization and professionalization”, in Ferlie, E. Montgomery, K. and Pedersen, A. R. (Eds.) The Oxford handbook of health care management. Oxford: Oxford University Press.
Page 25 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
26 Slevin, D.P. and Pinto, J.K. (1987), “Balancing strategy and tactics in project management”, Sloan
Management Review, Vol. 29 No. 1, pp. 33-41
Simonet, D. (2013), “The new public management theory in the British health care system: A critical review”, Administration & Society, Vol. 47 No. 7, pp. 802-826.
Sotiriou, D. and Wittmer, D. (2001), “Influence methods of project managers: perceptions of team members and project managers”, Project Management Journal, Vol. 32 No. 3, pp. 12-20.
Sześciło, D. (2016), “New public management in health care organizations”, in Örtenblad, A., Abrahamson Löfström, C. and Sheaff, R. (Eds.), Management Innovations for Healthcare Organizations: Adopt, Abandon or Adapt? Routledge, Taylor & Francis Group: New York, London.
Söderlund, J. (2011), “Pluralism in project management: navigating the crossroads of specialization and fragmentation”, International Journal of Management Reviews, Vol. 13 No. 2, pp. 153-176.
Thomas, J. (2012), “Making sense of project management”, in Lundin, R. and Hartman, F. (Eds.) Projects as Business Constituents and Guiding Motives, Springer Science & Business Media:
New York.
Thomas, J., George, S. and Buckle Henning, P. (2012), “Re-situating expert project managers’
praxis with multiple logics of practice”, International Journal of Managing Projects in Business, Vol. 5 No. 3, pp. 377-399.
Torpie, K. (2014), “Customer service vs. patient care”, Patient Experience Journal, Vol. 1 No. 2, pp. 6-8.
Vaara, E., Sorsa, V. and Pälli, P. (2010), “On the force potential of strategy texts: a critical discourse analysis of a strategic plan and its power effects in a city organization”, Organization, Vol. 17 No. 6, pp. 685-702.
van Leeuwen, T. and Wodak, R. (1999), “Legitimizing immigration control: A discourse-historical perspective”, Discourse Studies, Vol. 1 No. 1, pp. 83-118.
Vuontisjärvi. T. (2013). “Argumentation and socially questionable business practices: The case of employee downsizing in corporate annual reports”, Scandinavian Journal of Management, Vol. 29 No. 3, pp. 292-313.
White, K.R. and Griffith, J.R. (2010), The well-managed healthcare organization. Health Administration Press, Chicago.
Williams, R. (1983), Keywords. London: Fontana.
Wodak, R. (2004), “Critical discourse analysis”, in Seale, C., Gubrium, J.F. and Silverman, D.
(Eds.), Qualitative research practice, Sage, London, pp. 197-213.
Page 26 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
27 Ziek, P. and Anderson, J. D. (2015), “Communication, dialogue and project management”,
International Journal of Project Management, Vol. 8 No. 4, pp. 788-803.
Page 27 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
Table 1. Examples of the typical collocations of the term “patient” in project plan 1.
Project plan 1 (in Finnish)
increases patient safety (lisää potilasturvallisuutta) supports patient safety (tukee potilasturvallisuutta)
enhances patient satisfaction (parantaa potilasturvallisuutta) patient centred perspective (potilaslähtöinen näkökulma) operability of patient processes (potilasprosessien toimivuus) long patient transfers (pitkät potilassiirrot)
transferring patient (potilaan kuljettaminen) patient guiding (potilaan ohjaus)
patient arriving (potilaan saapuminen) dying patient (kuoleva potilas)
long distance patients (pitkän matkan potilaat) sick patients (sairastavat potilaat)
the most fragile patient material (haurain potilasmateriaali) examination of patient (potilaan tutkiminen)
patient care (potilaan hoito)
the care of the patient in insolation (eristyspotilaan hoito) patient room (potilashuone)
patient moves (potilas kulkee)
massive patient flows (suuret potilasvirrat)
Page 28 of 33 Qualitative Research in Organizations and Management
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Qualitative Research in Organizations and Management
Table 2. Manifested “patient” and project management with examples in project planning document 1.
Patient Project management
Examples An element of
the care processes
Engines of a machine
“When transferring one patient [from ward to operation theatre], nurses working time is wasted 30-45 minutes.”
Object of
treatment Competent healthcare professionals
“The most common patient groups are mature new-borns and larger premature babies (breathing difficulties, neurological disorders, suspicion on chromosome or metabolism disorders etc.), infections, large operations that need follow-up with hemodynamics/breathing and trauma patients.”
A child undergoing an experience
Ethical and caring healthcare professionals
“The early and continuous interaction between mother and child has been noted to enhance the child’s socio-emotional
“The early and continuous interaction between mother and child has been noted to enhance the child’s socio-emotional