PREFACE P.

Dijkstra

CALL FOR A LITTLE EXTRA:

A STUDY OF HOW PEOPLE MAKE SENSE OF AN ORGANIZATIONAL
CHANGE INITIATIVE

PYTRIK DIJKSTRA

MASTER THESIS
P. Dijkstra Faculty of Social Sciences

CALL FOR A LITTE EXTRA:

A STUDY OF HOW PEOPLE MAKE SENSE OF AN ORGANIZATIONAL CHANGE INITIATIVE

by
P. Dijkstra

M.Sc., VU University, 2018

Amsterdam

Thesis Submitted in Partial Fulfilment of the

Requirements for the Degree of
Master of Science

in the
Department of Culture, Organization & Management
Faculty of Social Sciences

© Pytrik Dijkstra
VU University
th
7 of April 2018

Student number: 2582848

Supervisor: S. B. Ybema
Co-supervisor: E. van den Akker
Co-reader: H. Wels

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PREFACE P. Dijkstra

PREFACE
This thesis is probably the last one I wrote, and therefore my time has then ended as a student. People
often say: "The time of being a student is the most wonderful period of your life." Perhaps they are
nostalgic, looking back at their time while only thinking of the "nights they do not remember with the
people they never forgot” have a selective memory, or indirectly admit that the working-life is not as
bright as they perhaps thought it would be. This thesis trajectory was a somewhat difficult time. I was
granted access by organizations, again, and again. Then rejected by organizations, again, and again. This
had an impact on my confidence, and at one point, even made me think of quitting my Master's degree.
Finally, Sierk Ybema and Ernst van den Akker offered to take part in their research at Zonnehuisgroep
Amstelland. Even though I was just supposed to start with another investigation, which meant that this
time, I had to withdraw, I could consider myself very lucky to be approached by them. Their social
approach has helped me to gain confidence, which had to come from far away. They helped me to frame
the study, develop a foundation, and criticized the path I was following throughout the research.

My time as a student has been fantastic. Traveling the world, learning new languages, falling in love,
meeting people, exploring new cities, and the birth of many good stories. So many things have happened
in this timeframe, of which many I will carry with me for the rest of my life. This trajectory of writing a
thesis I do not consider as my most wonderful period in my brief time walking around on this planet.
Perhaps I become one of these nostalgic persons, looking back at this particular time in 20 years,
overthinking the study, longing to go back to the library on the 2nd floor of the VU. Perhaps I am now
just being postalgic, that things will only become better after this. Time, in this case, will provide the
answer.

Nonetheless, I am proud of the result. I would like to take this opportunity to thank several people who
made this possible, and without whom I could not have accomplished this. First of all, I would like to
thank my parents, because without their infinite support I would not have been able to graduate. Also,
the help of the rest of my family, brothers, and sister, who have opened my eyes and motivated me to
discover the world. Furthermore Matthijs Breeuwsma, not only because of the support throughout the
Pre-Master's and Master's trajectory but also for being a terrific friend and roommate. Finally, I would
like to thank Harry Wels - for having faith in me despite all the misery at the start of the thesis trajectory.
Sierk Ybema – for his critical and useful opinion and helping me to steer the study and assisting in the
last crucial phase of my research. Ernst van den Akker – for all the support, motivational speeches, and
helping me to direct the research throughout the fieldwork.

Pytrik Dijkstra

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P. Dijkstra Faculty of Social Sciences

ABSTRACT
This research aims to understand how organizational members make sense, through
narratives, of an organizational change initiative, and how they position themselves
towards each other. Employees and managers tend to make sense of organizational
change in different ways through narratives. These can be nostalgic – longing for the past,
stability narratives – accepting the status quo, or postalgic – longing for a bright future.
The perspective that organizational change is an on-going process was adapted
throughout this study (Tsoukas & Chia), which resulted in organizational members that
continually (re-)position themselves towards others (Thomas & Hardy, 2011). An
ethnographic study, combining semi-structured interviews, observations, informal chats,
meetings, and a document analysis was conducted at a healthcare organization, focused
on elderly care. It appeared that organizational members used different narratives to
make sense of the change project, and their role in this process was not clear-cut and
fixed. Employees confirmed the need for change but saw it as impossible to improve in
the current setting and held onto stability narratives to reduce uncertainty after recent
reorganizations. Managers were postalgic and looked at employees as resistors of change.
My findings challenge the existing categories of the employees being nostalgic, resistant
organizational members; and managers being the postalgic, change agents that
emphasize on the need for change to survive as an organization.

Keywords: organizational change, sensemaking, narratives, self-other, identity

construction, nostalgic, stability, postalgic

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ABSTRACT P. Dijkstra

Table of Contents

1. Introduction ........................................................................................................................... 9

2. Theoretical Framework ........................................................................................................ 13

2.1 Organizational Change ..................................................................................................................13

2.2 The Process of Sensemaking: Stories about Change ................................................................... 15

2.3 Identity: Self-other positioning.................................................................................................... 17

2.4 Bridge ........................................................................................................................................... 19

3. Methodology .........................................................................................................................20

3.1 Research Design: A Qualitative Method ......................................................................................20

3.2 Site and Access ............................................................................................................................. 22

3.3 Research Methods ........................................................................................................................24

3.3.1 Interviews ...............................................................................................................................24

3.3.2 Participant Observations .......................................................................................................26

3.3.3 Document Analysis ................................................................................................................ 27

3.4 Research Analysis ......................................................................................................................... 27

3.5 Trustworthiness............................................................................................................................28

3.6 Ethical Concerns ..........................................................................................................................28

3.7 Personal Reflection and Emotions ...............................................................................................29

4. Findings: Answer to the Call for a Little Extra ..................................................................... 31

4.1 Need for a Change Initiative..........................................................................................................31

4.2 Execution of the Project............................................................................................................... 33

4.3 Role of Relatives throughout Residency ......................................................................................36

4.4 Sensemaking of the Project .........................................................................................................39

4.5 Discursive positioning during the Initiative................................................................................42

4.5.1 Management: Presenting the Project ....................................................................................42

4.5.2 Recipients’ Response .............................................................................................................45

4.5.3 Management Memoires.........................................................................................................50

5. Conclusion ............................................................................................................................ 53

6. Discussion ............................................................................................................................ 57

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P. Dijkstra Faculty of Social Sciences

Limitations and Future Research ...................................................................................................... 57

References ............................................................................................................................... 60

Appendix I: Translations.......................................................................................................... 65

Appendix II: Book-of-Life Form ............................................................................................... 71

Appendix IV: Who-am-I Form .................................................................................................. 83

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 P. Dijkstra

LIST OF ABBREVIATIONS

ZHGA…………. Zonnehuisgroep Amstelland

M…………. Manager
H…………. Head of nursing home
P…………. Caregiver

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P. Dijkstra Faculty of Social Sciences

"Waking up on a Tuesday morning. Or is it Wednesday? I don't know actually. Oh wait,

there is Iris, I think, the lovely nurse. I can't really open my eyes yet, so I must have slept
like a stone. But where is Jan, and why am I here on my own? Where is he? He must have
left to work. I have to ask where he is to Vanessa. Is that Vanessa? Who is that woman in
my house? She doesn't know that I'm awake. What is she doing? I am afraid. I need Jan.
Then I hear a sound, a familiar sound, with a beautiful voice. Suddenly Jan and I are
dancing at the wedding of our oldest at a fortress near Amsterdam. The nurse closes the
door. ‘This music will do her well I suppose. She has been very restless lately, causing
trouble during breakfast. This will give me more time throughout the day, and perhaps
even space for a little extra'. She continues with her list, as she hears the sound of Ray
Charles fade away." *

* An imaginative anecdote of an everyday situation in a nursing home, constructed from observations experiences
throughout the fieldwork.

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1. Introduction P. Dijkstra

1. Introduction
The ‘call for a little extra’, what does that suggest? Throughout this study, the little extra was a major
theme. Managers who tell caregivers to give the little extra while providing health care because relatives
criticized the organization, and residents ringing the bell for nurses to help them, but nurses did not have
enough time nor colleagues to meet these demands. They all asked for a little extra. Every call was
interpreted in a different way by organizational members, which is the main topic of this study.

This research was conducted at Zonnehuisgroep Amstelland, abbreviated ZHGA, which took part in
the project "Dignity and Pride", literally translated from Waardigheid en Trots. This nationwide project
was presented in February 2015 by Dutch State Secretary Van Rijn in order to reform elderly care by
implementing changes concerning the quality and sustainability of this sector. Elderly care is a rather
broad term as there is a wide range of services within this definition, e.g., home care, intensive internal
care, and many other varieties in between. This research focused on nursing homes of the organization,
located in Amsterdam, Amstelveen, Ouder Amstel, and De Ronde Venen. Zonnehuisgroep Amstelland is
an organization with 1400 employees (705 fte.) and takes care of 1800 clients in eight nursing homes. As
stated on their website, the mission and vision of the organization are: "heart for the quality of life" and
"we excel in supporting what you value most", literally translated from “hart voor kwaliteit van leven” and
“'wij blinken uit in het ondersteunen van wat u van waarde vindt”. Both mission and vision have been an
essential outcome of the new policy plan of the organization, which was due to critique of the government,
media, clients, and relatives.

In the annual report of 2016, the Head of ZHGA, Nelleke Vogel, mentioned the reorganization that
started at the end of 2015, the time wherein the organization was on the brink of bankruptcy. Due to their
critical financial situation, the Board decided to cut expenditures through employee dismissals and the
closing of nursing homes. Another reason for the reorganization was the inspection on quality and safety
of the Ministry of Health in 2016, in which they criticized the performances of ZHGA. Two nursing homes
were placed on an "inspection list" because of the financial situation, and the Ministry of Health
mentioned several issues that occurred during every day as having a negative impact on the quality. In
order to intentionally improve quality, management renewed their long-term policy plan and created a
new mission. Management argued that chances of a successful implementation would increase by handing
more responsibility to the executive teams, consisting of nurses and caregivers. In interviews,
management saw this as ‘giving the profession back to the professionals,’ stimulating them to provide a
certain quality of life, while aligning personal care to the demands of clients. The role of management
would change due to this approach, from a prescriptive to a more supportive role.

The new direction of the organization led to the development of the change initiative called Cliënt
Centraal which was presented by management in October 2017. This was a project with the aim to adjust

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P. Dijkstra Faculty of Social Sciences

health care to the personal demands of the client, while they centered everyday practices around
residents, so-called person-focused health care. Implementing this initiative caused several reactions
throughout the organization, as organizational members made sense of the project in various ways. In
order to gain an understanding of the processes of sensemaking, the Board of ZHGA granted access to
conduct research and to provide information that could be useful and increase the chances of a successful
organizational change initiative. This was realized by doing research within the organization and
investigating the different interpretations of the change project.

Organizational change is considered among the most challenging events that an organization has to
respond to (Isabella, 1990), and managing these organizational changes have been a significant theme and
has been researched by several scholars (Thomas & Hardy, 2011; Sonenshein, 2010). Some scholars see
change as something natural, rather than exceptional (Tsoukas & Chia, 2002). Organizational members
tend to interpret change initiatives and construct meanings in different ways, which can cause conflict
within an organization (Boje, 1991). Existing literature on organizational change routinely makes a
discursive, or dualistic, distinction between these organizational members as change agents and change
recipients. Change agents are the initiators, leading and supporting change, whereas change recipients
undergo and oppose change (Sonenshein, 2010; Thomas & Hardy, 2011). It is frequently assumed that these
two types of change actors are in opposite positions. As this research was conducted at the start of the
implementation, the project was talked into existence and followed by a variety of actions, because of a
difference in translation of organizational members. They, therefore, constructed meaning of both the
change program and of other organizational members. But why is it relevant to research how people talk
about the change, and their self and others’ identity, during this process?

First, according to Sonenshein (2010), scholars have overlooked employees’ reinterpretations of the
narratives and the presentation of the initiative by managers, thus the active interplay between the
meaning constructions between managers and employees. Therefore, the results are placed in a discursive
context, a self-other perspective. “By accounting for the construction of meanings by both managers and
employees, scholars can understand a wider breadth of meanings during change, as well as how meanings
change over time and across organizational levels in ways that impact how strategic change gets
implemented” (Sonenshein, 2010, p.478). This research emphasized the relationship between employees
and management through analyzing the different meanings that employees gave to themselves, the
organizational change program, and the (re)interpretations of the narratives that management presented.

The second reason is that there is not enough knowledge on how change is accomplished (Thomas
& Hardy, 2011). "Even if we can explain, ex-post facto, how and why organization A moved from archetype
X to archetype Y, or from position A to position B [….], our explanation would look like a postmortem
dissection; it would not be fine-grained enough to show how change was actually accomplished on the

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1. Introduction P. Dijkstra

ground – how plans were translated into action and, by so doing, how they got modified, adapted, and
changed" (Tsoukas & Chia, 2002, p. 182).

At last, change programs should not only address the elements that are supposed to change, for
example, ideas, values, or practices, but should also include the management of meaning and
understanding of the different roles and identities throughout the organization according to Sveningsson
& Alvesson (2008, p. 163). These aspects should also be included and mobilized in the change initiatives.
Regardless of many contributions to this aspect on a conceptual level, few empirical in-depth studies
address the construction of identity on a personal level (Sveningsson & Alvesson, 2003).

Next to the relational aspects of a self and other perspective, which are seen as a discursive
positioning process of organizational members, the temporal imaging of Ybema (2004) was adopted. He
argues that narratives are interpreted in several ways by organizational members and that more narratives
of a change initiative may exist throughout the organization. Narratives vary, according to Ybema (2004)
between organizational members, and tend to use different temporal perspectives around change,
‘postalgia' and ‘nostalgia.' Whereas ‘postalgia,' a longing for a desired future, is often linked to
management (change agents), nostalgia, the longing for the romantic past, is often linked to employees
(change recipients. A third narrative was added in this study, called ‘stability' narrative (Sonenshein, 2010),
wherein employees and managers tell narratives about that their organization is not undergoing change,
and maintains the status quo. By adding the aspects of Ybema (2004) and Sonenshein (2010) to the identity
construction process of Tsoukas & Chia (2002), the existing categories and characteristics were
investigated.

The theoretical contributions of scholars used in this study created doubt on the categorization of
change agents and change recipients in opposite ways. Some scholars see identity and construction of
meaning through narratives, as a multiple, transversal, iterative process (Thomas & Hardy, 2011). Within
this research, both categories, agent, and recipient were involved. Some members facilitate the change
initiative and members that execute the initiative. Though, rather than dividing these two categories in
‘embracing' and ‘resisting' change, my interest was to understand how both organizational members made
sense of the change program, and also of each other, and whether this resulted in discursive positioning
while constructing identities.

In order to understand how organizational members made sense of change initiative Cliënt Centraal, and
of each other, the central research question was:

How does the management and healthcare employees at ZHGA make sense of the current change project
called Cliënt Centraal, and construct their identities in relation to each other during this process?

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P. Dijkstra Faculty of Social Sciences

Three sub-questions helped to answer the central question, which were:

1. What is the intentional reason and purpose of the change initiative Cliënt Centraal at ZHGA?
2. How do change recipients and change agents make sense of the change initiative?
3. How do change recipients and change agents construct their identity within the organization?

An ethnographic study was conducted at Zonnehuisgroep Amstelland in order to answer the research
questions. The fieldwork was within nursing homes, in which most residents suffered a form of dementia,
but also services for people with physical limitations, in need of medical rehabilitation, and unexpected
crisis situations were provided and took place between October-December 2017. Several research methods
were applied, e.g., document analysis, interviews, and observations, which are further described in
Chapter 3.

The findings of the study are relevant for change experts, as narratives can be used to possible predict
organizational behavior (Martin, 1992), while meanings shape both social realities and actors’ following
response to these realities (Sonenshein, 2010). The main view on change initiations does not account for
the reinterpretations of employees towards the narratives, and presentation of management, thus, this
research contributed to a more dynamic understanding of the construction of meaning. A more
compelling understanding is helpful in order to understand key responses of employees during change.
Therefore, this research provided an insight of the constructions of meaning, and identity, of
organizational members. The research helps ZHGA in understanding the (re)actions of organizational
members towards this change initiative, align the different views of providing health care services, and
consequently, result in potential benefits.

This thesis consists of three chapters. The first chapter of this thesis elaborates on the theoretical
debate on organizational change initiatives, sensemaking through narratives during change processes,
and at last discursive positioning during these periods. The second chapter emphasizes the methodology
which was adopted throughout the fieldwork, in which the reason for choosing specific research methods
is provided. The third chapter contains the empirical analysis, in which the data in its context is seen
through a theoretical perspective. Finally, to conclude and discuss the findings, a conclusion and
discussion were added in order to discuss the results and interpret the outcome of the research at
Zonnehuisgroep Amstelland.

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2. Theoretical Framework P. Dijkstra

2. Theoretical Framework
This chapter contains the theoretical framework and is used to limit the scope of the relevant data and
explain the theoretical argument of this study. Three concepts, 1) organizational change, 2) sensemaking
during change, and 3) constructing identity, are used to build new knowledge by validating or challenging
their theoretical assumptions. These concepts eventually helped to explain how organizational members
in this study made sense of the organizational change project through narratives, and of the self and others
through discursive positioning. In this chapter, the first part is an elaboration on different roles within an
organization during change, followed by the sensemaking process through narratives of organizational
members during this period, and at last theories on constructing identity through discursive positioning.

2.1 Organizational Change

The literature on organizational change tends to accentuate that shared meanings of the organization,
and its processes are essential for understanding the consequences of the change process. Traditional
approaches to organizational change, stated by Tsoukas & Chia (2002), treat the phenomenon as
something exceptional, rather than a process that occurs on a regular base. Tsoukas & Chia argue that
organizational change can be seen from two perspectives. It is either an on-going process or seen as an
accomplished event which typically involves a "stage model in which the entity that undergoes change is
shown to have distinct states at different points in time" (Tsoukas & Chia, 2002, p.570). In case change is
seen as something specific, an exception, Feldman (2000, p. 611) states that even routines change, that
change is an inevitable process in an organization and that people underestimate how pervasive change
is.

There are many different forms and shapes concerning organizational change, for example,
differences in the time frame, the industry, and types of change (Alvesson & Sveningsson, 2008).
Management, most often, sets future goals for the organization and elaborates on how this change should
be implemented throughout the organization to achieve the goals set (Armenakis et al., 2007). According
to Bartunek et al. (2006, p. 183), there are two types of actors during organizational change, change agents
and change recipients, agents as the people initiating change, recipients as the organizational members
that have to adjust to the changes that are being made. Higher management, according to Alvesson &
Sveningsson (2008), sees employees without managerial tasks as subordinates that receive and implement
the change. Lacking attention to the experiences of these change recipients can cause misunderstandings.

Most change studies (Balogun & Johnson, 2004) focus on the change agents, assuming that the
recipient interprets change in a similar way as a change agent does. Nevertheless, it is essential to gain
insights into how change recipients react towards organizational change (Oreg et al., 2011). The reaction
of recipients can reshape change fundamentally (Kanter, 1983) while Bartunek et al. (2006) argue that
change recipients have a key role in the potential for success. Kanter et al. (1993) suggest that there is no

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reason to assume that both parties share the same understanding of the change process. Orientations
towards change differs among the agents, implementers, and recipients, which contributes to the
establishment of distinct experiences (Kanter et al., 1993). Levi & Lawn (1993) discuss the establishment
of discursive experiences, as well as the agent-recipient perspective. They state that there are two forces
affecting change at the same time, in this case, the restraining forces and the driving forces. This
contributes to the belief that organizational change may result in causing conflict within an organization.

In this study, the used definition of organizational change is "organizational changes are situated
sequences of activities and complexes of processes unfolding in time," found in Tsoukas & Langley (2010,
p.9). By viewing the change project, Cliënt Centraal, as something non-exceptional, an on-going process,
the different stages (Weick & Quinn, 1999) are intentionally exposed and show how stable the foundation
of an organization is. Adapting this as a theoretical framework and lens to study the organizational change
at ZHGA may be beneficial to scholars that study organizational change and contributes to the current
literature on the topic. It allows researchers to gain more understanding of the micro-processes due to
organizational change.

Change is therefore seen as an ongoing process, a standard condition of organizational life. "Change
is the reweaving of actors' webs of beliefs and habits of action to accommodate new experiences obtained
through interactions" (Tsoukas & Chia, 2002, p.567). In other work of Tsoukas (Tsoukas & Langley, 2010),
they explain a process focus during change. They do not view change as a single process but as a network
of small processes and interactions that, together, form the organizational change process. But there are,
as mentioned before, defined points in time where the entity that undergoes change has a distinct state,
which can add fixed entities to an organizational change process (Weick & Quinn, 1999).

Using the perspective of Tsoukas & Chia (2002), seeing organizational change as an ongoing process
is due to three reasons. First, as mentioned above, it provides space for researchers to gain more
understanding of the micro-processes that occur during organizational change. Added to this, there is the
possibility of implications beyond the initially intended and planned organizational change, which must
be taken into account to understand the process of change. Second, stable parts, such as routines,
everyday practices, are potentially unstable. Routines are "flows of connected ideas, actions, and
outcomes" (Feldman, 2000, p.613). This argues that change is always potentially there, but it is essential
to look for these micro-processes. Third, when change is seen as an exceptional event or phase, the
perspective tends to be more pragmatic, and therefore does not produce change that often. This is mostly
due to the conceptualization of the organization, wherein management sees themselves as constructors
of the organization, rather than an entity that is built from the inside. Change is not a property of an
organization, but organizations should instead be understood as an emergent property of change
(Tsoukas & Chia, 2002).

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2. Theoretical Framework P. Dijkstra

2.2 The Process of Sensemaking: Stories about Change

In this study, change is analyzed from a sensemaking perspective regarding how members of the
organization visualized, interpreted, and constructed meaning during the project. According to Weick,
one of the most influential writers on the topic, sensemaking is "simply how we make sense of the world
we live in” (1995, p.4). To make sense, we select particular information to pay attention to, followed by
an interpretation of this, which varies between individuals. Organizational members can be seen as the
source within a sensemaking process, where organizational issues, e.g., goals, tasks, teams, exist through
peoples' way of thinking. "Sense is generated by words. It is language that arrests, abstracts, and inscribes
the otherwise evanescent behaviors and utterances that make up the stream of ongoing events that swirl
around us” (Goia & Mehra, 1996, p. 1228). Weick lists seven characteristics of sensemaking: (a) grounded
in identity construction, (b) retrospective, (c) enactive of sensible environments, (d) social- and, (e)
ongoing process, (f) focused on and by extracted cues, and (g) driven by plausibility (1995, p. 5), He
summarized these characteristics in “how can I know what I think until I see what I say?” (1995, p.61).

This summary of sensemaking argues that narratives, followed by an interpretation, are an essential
element of sensemaking. In later work of Weick et al. (2005) he explains that "sensemaking is the process
of social construction that occurs when discrepant cues interrupt individuals' ongoing activity and involve
the retrospective development of plausible meanings that rationalize what people are doing." While
sensemaking is seen as an on-going process of people "selecting and interpreting information," narratives
contribute to these sensemaking processes. Ybema (2010) and Gergen & Gergen (1997) agree on two
discursive types of narratives, “postalgia" and "nostalgia," and add possible perspectives that divide
employees and managers into two categories. This develops a discursive setting, where change agents and
change recipients are categorized through narratives into the imaginable nostalgic and "postalgic’ group.
Sonenshein (2010) adds a third type of narrative, called stability narratives. These narratives maintain the
status quo and suggest that there is no major change occurring throughout the organization at a certain
moment.

The sensemaking process that employees perceive depends on the information they receive (Balugon
& Johnson, 2005). As the process of sensemaking varies between individuals within an organization,
organizations can be understood as a complexity of conflicting interpretations and social constructions
(Martin, 1992). According to Demers (2007), only a few researchers look at the compelling and collective
stories of people studied within an organization. Most researchers focus on the management stories and
so-called single voice narratives. Taylor (1999, p. 524) argues that: “Regardless of whether we believe that
there is a single objective reality to organizational change, or whether we believe that change is socially
constructed, we should expect there are differences in how people interpret these changes." Researchers
that are focused on single voice narratives tend to look at how the change was designed, planned and
implemented, whereas researchers looking for the common stories focus more on how it was lived,
followed by interpreting stories and actions of the members.

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P. Dijkstra Faculty of Social Sciences

Researching sensemaking during change is, according to Maitlis & Sonenshein (2010), of importance
because integrating these new insights from studies may enable the natural extension to research on crisis
sensemaking. Organizational change is a more common and occurring event, or on-going process, than
crises, but both events have similar characteristics. Both are situations wherein a (rapid) change happens
in an environment that requires people to re-enact their role and situation. Crisis and change are
ambiguous events that possibly cause confusion, fear, and anxiety in the organization. Individuals
undergoing change are likely to be emotionally tied to the current organizational identity, which makes
them reluctant to abandon it.

While sensemaking is seen as a process of social construction, it is rather easy to overlook the
importance of social processes through which sense is made, including the shared meanings that can
emerge from these processes (Maitlis & Sonenshein, 2010). However, it is not necessary that change
management involves a shared meaning throughout an organization. Scholars debate the degree to which
meanings are and can be fully shared to enable collective action during a change, with some even stating
that the degree of shared meaning is of less importance than the extent to which meanings enable similar
behavioral consequences. Another characteristic of sensemaking is that it is not focused on obtaining an
accurate image of reality but on the plausibility of this reality (Weick et al., 2005). A sense-maker aims to
provide a meaningful image of reality for him- or herself. During this process, the sense-maker selects
specific elements called cues, out of the organizational context, and neglects other elements. Throughout
this process of continuously selecting, forming, and reforming of cues, the person tries to gain a more
meaningful image of reality (Maitlis & Sonenshein, 2010). This process can result in a wide variety of
meanings throughout an organization.

As said, narratives are a key element in the sensemaking process. According to Taylor (1999, p. 527)
narratives are our way of understanding the environment, and that we understand and make sense of the
world through and by stories. “Stories are vital elements of culture, creating and supporting virtually any
kind of reality that social actors embrace” (Brown et al., 2009, p. 328). When a person tells a story, this
can be seen as a reflection of how that person makes sense of a certain event, their work practices and
environment (Rhodes & Brown, 2005). Constructing a meaning of an event is put in a certain context, and
every actor creates their own truth, which means that there is no single ‘true’ story to be found (Rhodes
& Brown, 2005). This leads to pluralization of sense, as multiple narratives emerge as a response to
narratives regarding change (Taylor, 1999). Some of these narratives become dominant, whereas others
become marginalized (Boje, 1991) because the meaning of change is not fixed or resolute. Because of these
different views on sensemaking and narratives on change, it is important to emphasize on the
pluralization of meaning that is ascribed to the change project in this study. It is a process of interpreting
the stories and statements and making sense of the variety of meanings that are described by the
organizational members.

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2. Theoretical Framework P. Dijkstra

Narratives are seen as an essential element in the process of sensemaking during organizational
change. In this study, the perspective on narratives of Ybema (2004) is adopted, and the third type of
narratives by Sonenshein (2010) called ‘stability' narrative is added. Ybema (2004) argues that
organizational members tend to use “nostalgic” and “postalgic” narratives when talking and making sense
of change, by using present, past and the future of the organization as temporal aspects. Nostalgia is
described as the longing for an idealized and romanticized past, whereas “postalgia" is the longing for a
beautiful future. He says that postalgic is more ‘longing’ than realistic expectations of a glorious future,
which is often accompanied by concerns and doubts whether this future will come true. Both nostalgia
and postalgia, whether an organizational member emphasizes a positive past, or idealizes the future, are
seen as part of internal struggles in which organizational actors try to influence or resist change by either
celebrating or criticizing the collective past, present, or future.

The concepts of nostalgia and postalgia can be linked to the progressive and regressive concepts of
Gergen & Gergen (1997). Progressive narratives are similar to postalgic narratives, wherein they connect
experiences or events in a manner that direct towards the ‘good' evaluative aspects. Regressive narratives
are similar to nostalgic narratives, as they link experiences in a manner that directs towards the ‘bad'
evaluative dimension. Goffman (1961) and Ybema (2010) argue that the nostalgic voice appears most often
in the ‘organizational underlife,' whereas the managerial ‘upperlife’ tends to speak more of forward-
looking concepts. “Within an organizational context, ‘postalgia’ can, above all, be described in managerial
plans and policies for organizational change” (Ybema, 2004, p.826). Change agents might use ‘postalgic’
narratives, the desire for a wonderful future, to substitute a disappointing present for an improved future
(Ybema, 2004). According to Gergen & Gergen (1997), managers tell progressive narratives as they tell
stories that emphasize the potential improvements by adopting a new route. They as well argue that
regressive narratives are more often said by employees, as they construct initial change as leading to a
worse organization, therefore emotionally express their loss of something they find valuable, thus resisting
the change initiative. A third type of narratives, stability narratives (Sonenshein, 2010), are about how
employees and managers tell stories about how the organization is not undergoing a major change, and
about how the status quo is maintained. This could be of means to reduce uncertainty by constructing
meanings that are familiar to those who tell them. Sometimes management may use stability narratives
in order to accomplish organizational change by emphasizing continuity and remain a stable work
environment.

2.3 Identity: Self-other positioning

Next to sensemaking of the change initiative itself, organizational members make sense of their identity
in an on-going process of identity formation, and reformation (Ybema et al., 2009), and therefore create
several contradictories and changing, identities (Sveningsson & Alvesson, 2010). This can lead to
discursive positioning of the self, contrary to others. Through “discursive positioning” (Garcia & Hardy,
2007), placing ourselves opposite to each other, we differentiate or feel connected to others. This happens

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in everyday discourse, wherein identity is talked into being, and produces a feeling of “us or me” by
comparison to them (Ellis & Ybema, 2009). Creating identity is, therefore, a discursive process, wherein
claims of "sameness" and "otherness" are placed in relation to, for example, colleagues or clients, and
happens in a particular social context.

As constructing identity is an on-going process in everyday organizational life, it means that also
during organizational change processes this construction of identity is occurring. As mentioned in the
previous section, identity categories are formed through this process. These categories are not clear-cut
and fixed but instead constructed in complex ways over time (Thomas & Hardy, 2011). Both self-other, or
agent-recipient, are involved in settings wherein multiple organizational levels are included, and therefore
their identity can shift over time. The organizational members who face change at one point may interpret
change differently over time, and thus construct a different meaning of that change at another moment
(Thomas & Hardy, 2011). An example is middle-management, where they see themselves as both initiators
of change, and as recipient opposing change (Thomas & Linstead, 2002). In research by Ybema & Horvers
(2017), one of the findings is that organizational members, in particular managers, have to maneuver
between roles during change processes, which consequently leads to shifting roles that members attribute
to both themselves and others. Ybema et al. argued that this distinction between the initiators and
recipients is used by organizational actors themselves throughout everyday discourse: “It appears that the
‘observed’ have less difficulty with essentialist talk in their front-stage presentations. Hence, they often
depict self and other in an essentializing way, sometimes almost in terms of fixed character traits" (2009,
p. 305). People construct their identity as stable while representing the self and see others as rather
unstable, which means that when talking in a discursive manner, they engage in essentialist talk of "us vs.
them" (Horvers et al., 2014). With this in mind, it is feasible to interpret identities that people construct
for both themselves and others, as stable moments in an on-going process of the formation and re-
formation of identity.

As described in Section 2.1 on organizational change, some scholars separate two fixed identities
within an organizational change process: change recipients and change agents. This discursive positioning
produces categorical alternatives, mostly opposites as sane versus insane, hero versus zero, etcetera
(Ybema, 2016). The main characters are set in oppositional roles, the self-other perspective. This can be
seen as the self, a heroic agent, and the other as a resistant change recipient. "Even when organizational
actors switch their position from one situation to another, they nonetheless draw clear-cut self-other
distinctions and engage in “essentializing” talk (Ybema et al., 2016). The self-other can be used to
categorize individual behavior, quotations, and actions, and improve understanding of the individual in
its context. Self-other identity talk occurs when organizational actors tend to articulate their identities
through drawing boundaries between themselves and others (Ybema et al., 2009). Nonetheless, identity
cannot be seen as clear-cut and fixed because they are constructed in everyday life. Identity is built
differently over time, space, and setting, as it is linked to particular situational dynamics. Organizational

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actors make situational shifts in their identifications (Koot, 1997) and possibly switch their position from
agent to recipient, or perhaps back in their social identification (Thomas et al., 2011). Two other
possibilities are that the individual positions him/herself into two identities (Ellis & Ybema, 2010) or see
themselves as bridging and floating between the categories (Ybema et al., 2012). Therefore, the identities
of the change agents and change recipients should be seen as more fluid. In this study, the relational
identity talk is used to detach organizational members, and to redefine or define a collective identity
(Ybema, 2010). Focusing on the identity talks in a relational perspective may help in understanding and
locating a self-other perspective and therefore the positions of organizational members towards
themselves and other members.

2.4 Bridge
Categories of identity constructions, in this study change agents and change recipients, are constructed in
multiple, transverse, and repetitive ways over time (Thomas & Hardy, 2011). With this in mind, the
distinction between the nostalgic employees, who are change recipients in this setting, and the change
agents who are ‘postalgic managers', might appear to be limited as these identity constructions and
narratives cannot be put in fixed, stable categories. Managers might as well emphasize on an idealized
past or employees who elaborate on a bright future. Stability narratives are a third possible type of
narrative that emphasizes the status quo, a ‘change program that does not result in changes.' The study
of Sonenshein (2010) indicates that the managerial narrative that presents change is only one side of "what
really happened," as more narratives exist throughout the organization, which Alvesson & Sveningsson
(2010) see as possibly conflicting with the desired direction of management. A discrepancy was found
throughout that study, that managers and employees talk differently about a change process. Therefore,
there can be argued that employees do not directly import managerial narratives about change but
reinterpret and exaggerate them and construct their own reality by telling narratives in several ways.

As sensemaking processes, organizational change, and constructing identity are all continuing,
complex, processes, this study challenges these frameworks and suggests that organizational members
float through an organization by forming, and reforming, their identity through narratives. Through this
perspective, the research aimed to contribute to existing knowledge on the debated categories of both
employees'- and managerial narratives.

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3. Methodology
In this part of the paper an elaboration on the applied research methods, and the research process,
including a reflection, is provided to answer the central research question. Furthermore, the context of
the field, in this case, a shortened description of the organizational setting, is given.

3.1 Research Design: A Qualitative Method

This research aims to obtain in-depth knowledge of the sense-making processes of management and
caregivers within elder care experience after a reorganization and following projects. This sense-making
process of organizational change, as described in the theoretical framework, is placed within two
theoretical frames: relational (manager-employee) and temporal (past – present – future). Through
discursive positioning, both relational and temporal aspects are discussed. Below, in figure 1, you can see
the methodological framework which gives an overview of the applied research methods.

Research question
How does the management and healthcare employees at
ZHGA make sense of the current change project called
Cliënt Centraal, and construct their identities in relation to
each other during this process?

Qualitative approach
Qualitative data • Descriptive study
• Documents • Interpretive
epistemological
• Transcriptions
• Constructivist
• Fieldnotes
ontological
•

Qualitative methods
• Semi-structured
interviews
• Observations
• Informal talks

Figure 1: Methodological Framework

The sense-making process studied throughout this research adopts a constructivist approach as they
both see meaning-making as a construction of individuals that might differ between organizational
members. Weick (1995) considers sensemaking as a cognitive process as he suggests that organizations
are socially constructed as organizational members make sense of and order their surroundings through
cognitive maps or images – at an individual and social level. The sensemaking perspective is based on the
assumption that reality is constructed through the view of people and their meaning-making process, and
therefore a constructivist approach is applied in this study. Through the sensemaking process, people give
meaning to situations that occur, sequenced by a certain constructed reality that might differ from person

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Methodology P. Dijkstra

to person. By talking, organizational members create organizational realities. This constructed social
world is experienced as being objective in a way that it affects lives, and we have to learn about it, called
objectification. Berger & Luckmann (1966), in ‘The Social Construction of Reality,' argue that the social
world is produced by humans during, and in, continuing activities and routines, so-called externalization.
This means that we are socialized in a world as people interpret meanings, occurred events, and are
affected by others' subjectivities. By this process, an own identity and 'world' have been created, called
internalization. In short, through a constructivist lens, social realities and identities are developed, and
maintained by conversations with others, e.g. managers, co-workers, family – rather than in structures,
like hierarchy, positions etcetera.

In this research, a constructivist ontological, and interpretive epistemological perspective was

applied. Qualitative research is most often within an interpretive philosophy (Lincoln, 2011) as researchers
have to make sense of the subjective and socially constructed meanings of the phenomenon which is
studied. It is based on the assumption that there is no existing unified and objective world as people,
individually, create realities. According to Krauss (2005), therefore there is no chance for established
validity. However, to ensure the trustworthiness of this research, triangulation (Patton, 2005) was used.
Triangulation means using different kinds of sources or analytical tools to understand a particular
phenomenon and to enrich the findings. In qualitative research, it is not about looking for the clear
evidence, but to reveal patterns and systems that occur (Ybema et al., 2009). In this research, multiple
methods have been applied, e.g. participant observations, semi-structured interviews, document analysis,
and informal talks.

The reason for choosing an ethnographic approach is because this type of research emphasizes on
the organizations' inner social aspects, lives, and processes, and combines these details into a holistic
image that endeavors to clarify organizations' modes of social actions. Conducting an ethnographic,
qualitative research allows studying a phenomenon in its original context, which then provides room for
further questions to emerge and change during the data collection process (Krauss, 2005). The package of
theory and method requires, first that zooming in on the details of the accomplishment of a practice in a
specific place is necessary to make sense of the local achievement of the practice and the other, more or
less, distant activities. This is followed by and alternated with a zooming out movement through the scope
of the observation expands, following the trails of connections between practices and their products
(Ybema et al., 2009). This is an iterative process, which is finished when a convincing account of both
practice and the effects on the organizing part is produced. An advantage of ethnographic research
compared to other qualitative research methods is the detailed way in which visible and barely visible
aspects of an organization come to light.

What makes an ethnography different from other qualitative research methods is that most methods
focus on the findings themselves, whereas an ethnographic researcher tends to explain the ‘webs of

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meaning' within the findings (Geertz, 1973). As a researcher, I believe in the possibility of multiple
meanings rather than in a single, true meaning of a phenomenon. Therefore, this research was an
interpretive ethnography. These several meanings are shown in the constructed interpretations within
the social context of the participants. The study had an inductive approach as it aimed to explore a
particular phenomenon during the data collection and was data-driven. Reason for choosing ethnographic
research was because of the ability to both zoom-in and dig into an organization and its details, and to
zoom-out to see the organization in its environment. Nicolini (2009) states that it is essential to then
relate the two by switching theoretical lenses and reposition, as a researcher, in the field.

This research was a descriptive study, as the intention was to gain an accurate image of events,
actions, and persons at Zonnehuisgroep Amstelland. A descriptive research focuses on what is occurring
in the organization, employees, management, and aims to show what the crucial aspects are, and the
relations between these aspects (Saunders et al., 2016). By giving details on how the data was gathered,
e.g. descriptions of the settings, interactions, language, and events, the contexts of the ‘real life
experiences' were illustrated. The explicit writing of details of these aspects is called thick description
(Ybema et al., 2009, p.59). Important to notice here is that only for the research relevant features were
described in this thesis, as readers look for sufficient detail. Excessive details distract readers of the core
of the study, especially when that person is less familiar with the research setting.

3.2 Site and Access

Gobo (2008) states that gaining access is the most challenging feature for doing any research, which was
also the case in this study. In a period, from November 2016, till August 2017 access has been granted, then
rejected, promised to conduct research by a manager, denied by the Board, at several organizations.
Fortunately, in August, Ernst van den Akker and Sierk Ybema approached me to take part in their
research. They built the foundation for this research.

To gain the actual access to the research site, permission from the Board was necessary to conduct
this study. This started with an orienting chat with Marjan Vos (current IT manager at ZHGA) about the
research goals, possibilities, and expectations. She can be seen as the ‘gatekeeper’ (Saunders, 2017, p.223)
as she was my first contact and helped to approach potential respondents. Ernst van den Akker, a Ph.D.
candidate at the Social Sciences Faculty at VU University, joined the interview to participate in the
research eventually. During the conversation, she agreed on conducting several interviews with people
that were members of the project "Cliëntenportaal," and furthermore permitted to attend meetings till
the Board would provide access to the organization to conduct further research. The permission was
provided in September, and Marjan Vos immediately handed a list with six people to approach. Managers
of several nursing homes were part of the list. They were able to get me in contact with people working in
these homes. The intention was to interview three nurses per home and the managers of these nursing
homes. Unfortunately, one of these potential participants did not reply to the e-mails and following

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reminders. The other three houses cooperated in reaching this target. These people were able to provide
contact details of nurses, or sometimes would forward my information to potential respondents. At the
end of the interview, I always asked if they would possibly notify colleagues about the research and
whether they were available for further inquiries. This method can be seen as volunteer sampling, and
both techniques within this type of sampling (snowball and self-selection) were used.

Volunteer sampling means that the participants are volunteered to be part of the research rather
than being chosen (Saunders et.a., 2016, p. 303). First, all six potential respondents were approached by e-
mail or phone. Five people agreed to conduct an interview. This can be seen as self-selection sampling,
wherein individuals are asked to take part in the research to identify their desire and willingness to do so.
The second applied method is snowball sampling. This is the process of asking the respondents to
nominate another person with the same trait as the next respondent. This technique was necessary to
reach respondents because, apart from the five people that Marjan provided, there were not any other
potential respondents known. When researching a sensitive topic, snowball sampling is well suitable
(Biernacki & Waldorf, 1981) because respondents are more likely to cooperate when they are approached
by someone with whom they have a trusting relationship. As well, when respondents directly introduced
me to colleagues who might be interested in participating the research, they were more willing to
cooperate. The combination of an open, indirect approach, and a more confronting “would you like to
take part in the research” attitude, resulted in collecting respondents among the caregivers and nurses.

The list, given by Marjan contained people that were part of project Cliëntenportaal, a project which
at first was planned to be investigated during this study. To get in contact with these people they were
approached by an invitation letter, including a topic list. Reason for this was to explain them the purpose
of the research, questions they could expect, and my position as a researcher would be more distinct.
Marjan supported me from the start onwards and sent all respondents an e-mail confirming that the
research was approved by the Board and that the information would be treated confidentially. By using
both snowball-sampling and self-selection a number of eleven face-to-face interviews and two phone
interviews were realized. Furthermore, I attended a total of seven meetings of Cliëntenportaal and Cliënt
Centraal. ZHGA permitted to participate in all meetings, which were attended by middle managers,
nurses, caregivers, Board members, and doctors.

By mostly using volunteer sampling I barely came across people that were not willing to take part in
the research, though two people have not responded to e-mails and following reminders. Three people
answered that they were not able to take part due to a lack of time, of which one changed her mind after
being persuaded by a colleague. Two respondents asked for a clarification of the exact purpose of the
research and wanted to know in which way the results would be published, which did not lead to them
unwilling to participate. To get the number of respondents required, as said, snowball sampling and self-
selection sampling were used. This gave two opportunities to observe at nursing homes and observe

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nurses and caregivers performing everyday practices in their work environment. The result of these
observations was that I gained a better understanding of their actual work. This informal atmosphere and
natural setting gave useful information and narratives for this study and contributed to the constructive
approach which was adopted throughout the fieldwork. One of the caregivers invited me to have lunch
with the team and introduced me to two more people. This method appeared to be successful, which was
an essential methodological insight. Speaking to caregivers at the job, performing everyday tasks, I
realized that they were more willing to talk openly about themes that mattered to them, for example,
management, cooperation, colleagues, relatives of the elderly, and personal care. One reason for this was
that they were very excited to see a researcher looking at their work as they mentioned it multiple times.
“This is where it happens; the work is done aside of the bed. Everyone should see what we are doing” (P7),
said a nurse. She was enthusiastic of a researcher visiting her department who observed how she did her
work.

3.3 Research Methods

Several data collection methods were used throughout this study. Patton (2005) calls this triangulation,
as different qualitative research methods were used for one study. This is common in ethnographic
research and is used to discover and expose the deeper web of meaning (Geertz, 1973). In this section, the
various methods and purpose are explained, plus an explanation for choosing this particular source is
provided. The different research methods are shown in Table 1. Some include a number of visits or
interviews.

Table 1: Research Methods - Collected Data

Conversations Meetings Observations Documents

Semi-structured interviews – 13 Formal meetings – 6 Visits to nursing homes – 2 Internal documents – 5

Informal talks – app. 7 Public documents

Public information
(website etc.)

3.3.1 Interviews
The first method used to gather information was conducting semi-structured interviews. Semi-structured
interviews allow probing answers in case the interviewer is looking for an explanation, or build on the
response of the interviewee. This method is of importance in a research with an interpretive philosophy.
Understanding the meaning that participants link to various phenomena was one of the key objectives of
this study. By conducting these semi-structured interviews, there was a chance to focus on their practices,
experiences, routines, and communication that are somehow taken-for-granted or neglected, by
themselves. This gave the opportunity to display the web of meaning (Geertz, 1973). The interviews were

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Methodology P. Dijkstra

with managers (M), Heads of nursing homes (H), and executive personnel, consisting of both nurses and
caregivers (P), divider over a total of three nursing homes. At the start of the research two exploratory
interviews took place, wherein frictions between doctors (including medical specialists), management,
and caregivers was a theme. Therefore, two medical specialists were interviewed to gain insights and gain
better understanding of the conflict. The main topics of the interviews were everyday practices,
cooperation, experiences concerning reorganizations, (current) change projects, and changes within the
health sector. The primary objective was to discover the "webs of meaning" behind their practices and
understand how the organizational members made sense of the implemented change initiatives after the
most recent reorganization in 2015.

During the fieldwork, there was the opportunity to speak to three managers of nursing homes, two
medical specialists, one nurse, and seven caregivers, throughout semi-structured interviews. These
interviews lasted between 45-75 minutes, with one exception of 35 minutes. Two of the interviews were
by phone. A total of thirteen people were interviewed. This number is seen as sufficient because the data
gathered in the last few interviews no longer sparked new insights, which is a way of seeing it as saturated
(Charmaz, 2006, p.113). Researches on the ‘right' number of respondents for qualitative research, suggests
a number, anywhere between 5 and 50 participants are adequate (Dworkin, 2012). During the interviews,
I attempted to give the space for the interviewees to tell their own story. By leaving it silent after the
person seemed to be finished talking, they would sometimes continue revealing more details and
interesting information. Probing helped to gather information during interviews and find the webs of
meaning behind the everyday practices and discourse, even though after transcribing I discovered that
there had been some unused opportunities in which more information could have been revealed. Some
respondents seemed careful when touching upon sensitive topics, e.g., their communication with
management and their role during the reorganization. By comforting them, stating it is an independent
research and people were anonymized, they would sometimes continue on the topic.

Most important features of this research were displayed through these semi-structured interviews.
One of the features of conducting semi-structured interviews is developing a list of themes, including key
questions. These interviews might vary, depending on the setting, or "flow of the interview," according to
Saunders et al., (2016, p.391). By using a topic list, the same topics were discussed throughout the
fieldwork, but there was a difference in order of the questions, depending on the flow of the interview. As
Hermanowicz (2002) suggests, it is essential to have an open and informal conversation setting, which
was intended by starting the conversation about something recently on the news, a question about an
object that caught my attention, or by asking how their day has been so far. The interviews, after the
interviewee granted permission, were recorded by a mobile phone. None of the respondents disagreed,
which could be because of the informal setting and independence of the researcher. The recordings have
then been transcribed, which was followed by a data analysis.

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3.3.2 Participant Observations

To get a clear sense of the context of my research setting, I used participant observations in meetings, and
two observations at the worksite, in this case, a nursing home. In this research, participant observations
were a method to gather data. Ybema et al. (2009) state that a researcher can only be entirely part of the
research setting when taken the role of a participant observer. There were, due to privacy issues, not many
chances to observe during the daily practices of the nurses. Some managers did not allow observations at
the work site, mostly underpinned by privacy, lack of time, or lack of supervision. During the meetings,
the researchers observed and did not take part in the discussions. These meetings often started with a
short introduction of the research and its purpose, directly followed by the chairman’s announcement of
the general agenda.

As mentioned before, six meetings of the project Cliënt Centraal and Cliëntenportaal were attended.
These meetings consisted of several members, whom all had different roles and functions within the
organization. The group, as Marjan said, represented most professions within ZHGA. During these
meetings, it was essential to listen sharply to the discussions, observe the setting, and listen to the
responses of the members. This was helpful to gain an understanding and become familiar with the issues
that occurred within the organization. By noting and describing the details on-site,and during the
meetings, I discovered exciting information. At the start of a meeting, people tended to be curious about
the reason for our attendance, but after the introduction, there was little attention for us as researchers.
After the first two meetings, I compared the gathered data and found reoccurring topics and main issues,
which were used as the foundation for the interviews. The setting of the meetings was somewhat formal.
First, they discussed the agenda, followed by possible additions to the existing agenda. Second, the
researchers were introduced by the chairman, and people could ask questions to clarify and explain the
purpose of the research. After the discussion of the agenda, the researchers did not actively participate
the meetings, though sometimes a member asked an opinion from a researcher on a certain topic.

The two observations at the nursing homes were to understand their everyday practices, not just by
hearing, but by using all senses to get more in-depth knowledge. These observations were of importance
to understand the research setting and its context. According to Geertz (1973), it is crucial to use
observations at the front stage, while backstage behavior helps to understand the differences and perhaps
contradictions between them. Nurses appreciated the visits, which made them willing to talk openly about
their practices, daily routines, discourse, and their supervisors. Observing helped to gather data by looking
at spoken words, actions, responses, and attached feelings of those who were in the research setting, which
is mentioned in Ritchie & Lewis (2003, p.27). By observing, the researcher can identify relationships, what
is being prioritized by them observed, and show their work environment (Schensul et al., 1999). This was
important during the research in order to understand what the daily practices were, especially because I
was not yet familiar with the field of nursing homes.

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Methodology P. Dijkstra

3.3.3 Document Analysis

Documents were the fourth research input for this study. Managers of Zonnehuisgroep Amstelland
reached out a few documents, of which:
§ Action list of project ‘Clientenportaal.'
§ Project plan ‘Clientenportaal.'
§ Forms that new clients received when moving into a nursing home: (‘who am I,' and ‘book of life')
§ A quality framework of nursing homes
§ Plan of approach for an electronic patient file (ECD)

Next, to these handed forms and information, the official homepage of ZHGA and Waardigheid &
Trots Nederland, and available brochures at nursing homes were part of the research. Some of the sources
were confidential, on which I decided to limit the use of sensitive data which, and data that was not
available through open sources. Reason for this was not to publish information that might damage persons
or departments. The written interviews and texts, official statements, and news articles helped to enrich
the data that was gathered through other research methods. Triangulation (Patton, 2005) of three
approaches, observation, interviews, and documents, supported to obtain data on the sensemaking
processes of organizational members. Qualitative research methods helped to develop an in-depth
understanding of the social practices, procedures, organizational structures, and meanings that were part
of everyday life and therefore taken for granted.

3.4 Research Analysis

There are several ways to analyze the gathered data through research instruments. As said earlier, the
interviews were transcribed, notes were taken during meetings and then elaborated upon. The study was
conducted from an interpretative perspective. Through the research setting and its context, the data was
analyzed and understood (LeCompte & Schensul, 2013). The analysis was completed by following four
steps: 1) understand the terms that were used in the research setting, 2) analysed and encoded all data,
and subdivided them into themes, 3) subdivided these themes into codes that were attached to relevant
quotes, 4) discussed the analysis with the contact person of the organization. The findings of this analysis
then supported the answers to the research questions.

The first step was done by analyzing the given documents, asking general questions in the
exploratory interviews, and ask for clarifications if unknown terms were used. The second step, the
analysis of the data by encoding it, was possible by using the knowledge and information that was
gathered during the interviews. This provided a contextual setting in order to generate topics that were
relevant to the research questions. The following themes, visible in table 3, were used while analyzing the
interviews.

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Table 2: Thematic coding

THEME 1: PROJECT CLIËNT THEME 2: THEME 3: THEME 4: THEME 5: CHANGE AND

CENTRAAL WORKPLACE MANAGEMENT COOPERATION RESISTANCE

Characteristics Project Adaptability Evaluation Self-organizing Fear

Family Cooperation Money Consultation Incomprehension
Personal control Collegiality Organizing Support Insecurity
Educational options Workload Expectations Hierarchical Past-Present-Future
Dependency Feasibility Priorities Feedback Resistance
Goal Livability Convince Trend
Mindset
Routine

Instead of using Atlas.ti as software to analyze the qualitative data, Microsoft Excel was used. The
themes were subdivided into codes, which were then connected to relevant quotes. This resulted in an
overview of the quotes that supported the final findings.

3.5 Trustworthiness
Establishing trustworthiness is one of the concerns when doing qualitative research. By using thick-
description, some of these concerns might be covered as information and details from inside the
organization are shown. According to Ybema et al. (2009), this makes it easier for readers to form their
opinion on the credibility of this study.

Throughout this research, establishing trustworthiness was accomplished by transcribing, and

processing, interviews, and notes, as soon as feasible after the moment the information was gathered.
Sometimes notetaking was completed during interviews. These notes, observations, and feelings after an
interview were elaborated upon within one work-day to ensure further trustworthiness. Over time, the
interpretations shifted, which made it necessary to re-check the gathered data frequently. By doing so,
including the extra field notes, a better understanding was developed. During the fieldwork, it was of
importance to stay open for new information and insights, which is a characteristic of an inductive
approach (Ybema et al., 2009). It was a circular process of collecting data, analyzing, gaining new insights,
and based on these new insights new data was collected. This made it clear what information was missing
to answer the research questions. This repetitive process helped to increase the quality of the results and
the trustworthiness of the research.

3.6 Ethical Concerns

While researching sensitive topics, it is crucial to ensure the respondents' privacy. This was one of the
largest ethical concerns during this study. The invitation letter included a statement on the confidentiality

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Methodology P. Dijkstra

of the interviews in order to include more potential respondents and to possibly collect more information.
Their given information was coded in the transcription and after that anonymized. All information, field
notes, and other sensitive information were saved on my personal computer which was secured by a
password. During the meetings with the management about the current research process, there was no
personal information provided, and quotations were anonymized. This sometimes meant that only
general information was published, but the privacy of the respondents was of greater concern. It occurred
that one of the managers asked to provide more information, which felt as if I was torn between two
groups with on the one side the people that allowed you to do research and give them (in their opinion)
important information, and on the other side the respondents’ dignity. By stating that I promised not to
release sensitive and personal information it did not lead to any discussions.

3.7 Personal Reflection and Emotions

Conducting this research was an exciting and interesting time. My previous education program did not
involve research within an organization itself but instead in a business environment. The setting at
Zonnehuisgroep Amstelland demanded a different approach as the research took place within a fixed
setting and included meeting the same people frequently. Especially at the beginning where I felt nervous
talking to the managers. Luckily my self-confidence grew after the first two interviews. Because of the
challenging start of the research, the experiences I had of approaching other organizations at the start of
the thesis trajectory, it was sometimes hard to have faith in this study as getting rejected had occurred
several times. Ernst van den Akker helped me through this by having trust in me as a researcher and
stimulated me, through which I gained self-confidence. Doing this research alone was, as said before,
challenging. Especially the interviews were difficult at the start. I had too much focus on the questions
that I prepared instead of ‘going with the flow.' Therefore, the first two interviews were rather
uncomfortable. After a chat with Sierk Ybema, I gained some new insights into how to conduct these
interviews, and besides, act as a researcher. The following interviews were steady, wherein respondents
were open, and the atmosphere was more informal. This setting helped to gain information and overcome
insecurity. Reading my transcripts of the interview, I did notice that I could have ‘probed' more accurately
to some interesting quotes or narratives.

Researching within the healthcare sector, in this case, a nursing home, was a unique experience. Not
being familiar with daily practices and seeing the everyday practices in these homes has caught my interest
and appreciation. The two observations in the last period of my research developed a lot of respect for me
towards the work within health care, especially for people working with elderly that have dementia. It was
an emotional experience, which took some time for me to process. To me, it felt as if in some cases, their
soul had already left a person’s body. Seeing pictures of a man, in the prime of his life, fishing on the
ocean, happy and proud of his catch. Then, turning around, seeing him in a wheelchair, not being able to
talk nor move as a result of dementia, affected me emotionally.

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Looking back at the start at ZHGA, I recognized that I could have spent more time reading and
preparing the research. In this way, there would have been less time spent ‘swimming in an ocean of the
unknown.' It took time to understand the organization and its core, in which I could have been more
efficient by preparing the research and investigating the organization. This would have helped throughout
the research and writing process. At the same time, being unfamiliar in the field and looking at an
organization with a ‘strangers-eye' helped me to stimulate respondents to talk openly about their
profession and everyday practices at ZHGA. As Marjan Vos provided me space to conduct interviews with
organizational members by handing a list of potential respondents, just a few respondents were not
directly linked to either herself, or the project-meetings both Ernst van den Akker, and I attended. She
admitted that members of these projects were mostly people that were more determined to the
organization, which resulted in a perhaps more ‘one-sided' story compared to when I would have
approached organizational members randomly by myself.

Conducting ethnographic research was difficult at times. Analyzing the transcripts felt as if I was
searching for something while I did not know what I was searching for. Many citations, potentially useful
information, and links between data were read through, again and again. Because of the pile of
information, much information has not been used throughout this study. At one point I felt as my
gathered data was saturated, that new information would not add more to the existing data. This could
be due to my inexperience in this type of research. Spending extra time at ZHGA might have resulted in
a more in-depth study as the results would be more in line with the used theoretical framework.

This interpretive research intended to show these meanings in constructed interpretations, through
an inductive approach. By using an ethnographic approach, there is the ability to both zoom-in and zoom-
out in an organization, to see the organization in its environment including the social aspects, lives, and
processes. Therefore, several research methods were applied, with interviews, participant observations,
and a document analysis as a foundation. Using triangulation has improved the trustworthiness of this
research and respondents' privacy is ensured by anonymizing all data. The next chapter elaborates on the
research findings. Through an extensive analysis of the collected data, seen through the theoretical
framework, the current situation at ZHGA is discussed and explained.

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4. Findings: Answer to the Call for a Little Extra

In this section, an analysis of the results is presented. The analysis was completed through the thematic
coding method, which is described in Saunders et al. (2015). The first section focuses on the reason and
purpose of the change project Cliënt Centraal. Second, the methods that Zonnehuisgroep Amstelland
developed in order to implement the project are discussed. The third section elaborates on the role of
relatives within the organization, followed by the sensemaking process of organizational members of the
project. The last section is about the discursive positioning of employees (change recipients) and
management (change agents) throughout the change initiative and is divided into 1) the presentation of
management, 2) the response of employees, which is followed by 3) the answer of change agents to their
response.

4.1 Need for a Change Initiative

In 2015, due to their critical financial position, a reorganization at Zonnehuisgroep Amstelland took place.
The critical financial situation was partly due to high overhead and personnel costs and pressure from
care administration offices. The reorganization was in the same year as the publication of the national
project called Waardigheid en Trots, literally translated "Dignity and Pride." This was a nationwide project
to improve the quality of services at nursing homes according to the framework of Zorginstituut
Nederland (2017). To share knowledge, gain information, and implement changes, ZHGA joined the
project. The reorganization and participation in the national project led to a new vision within ZHGA
called "the client in a central position."

Throughout the fieldwork, three reasons, mentioned by respondents, for implementing this new
vision came to light. Instead of emphasizing the financial need for change, they mainly named societal
aspects and their interpersonal skills as reasons for the new vision. The three reasons were: 1) the image
of nursing homes, 2) an increased assertiveness of clients, and 3) the mindset throughout which service is
provided. None of the respondents argued that the implementation was due to the critical financial
situation.

First, the image of nursing homes was rather negative in recent years. One of the coordinating
caregivers, said: "I definitely think that it is due to the fact it has been in the news often, the terrible image
within the nursing homes. They have a bad name of course" (P7). One of the respondents mentioned the
image of nursing homes: "Most of the times it is the image of nurses who are very busy, running around,
and only cleaning poop. This image is not correct and not how it actually is. But you can only experience
that by a visit to one of these nursing homes and see it by yourself" (P3). She did not agree with the image
that was considered ‘truth’ but saw it through her caregiver’ lens. Asking respondents about whether their
job could be regarded as dirty led to them disagreeing on this image and stating that it was not dirty and
gross at all or rejected this question and emphasized on the aspects that they considered valuable.

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Second, there tended to be an increased assertiveness of new residents, other than previous
generations. According to H3, head of one of the departments, people turn old in a different way than the
nursing-homes and employees were used to. "You see this in society, people are more assertive, want to
make their own decisions and all that." That the changing society was a theme within the organization was
confirmed when searching for the word ‘mondig’ (outspoken) throughout the transcriptions resulted in
seven hits, from both managers and nurses. Assuming that people have become more assertive in general,
the employees stated that the clients were more willing to cooperate and accept their situation within a
nursing home in the past. In a report of the Ministry of Public Health, Welfare and Sports (2014, p.3) was
written: "We see that people more and more want to direct their own life and health, and actually take that
initiative too. Even when they're sick, or in need of help. Health care, in general, should anticipate on these
changing demands of people". The organization aimed to adjust their vision to the trend in society, by
providing optimal personal-care. Expectations of the organizational members were that the trend of
assertiveness would continue because of a changing society, the freedom of speech, ease of access to
information, and the assumptions that people had a more criticizing look to the knowledge of
professionals nowadays. Clients, as mentioned earlier, were more cooperating, and obedient, in past
generations, accepting their ‘faith’, according to the respondents at ZHGA. This was beneficial for their
work, as there was less time spent on discussions with clients and relatives, and therefore more time for
informal talks.

Third, most often mentioned aspect throughout the fieldwork, was the perspective in which
organizational members provided health care. The same report (2014) stated: "We have to stop thinking
systematically and start thinking from the perspective of the people that need health care." This mindset
was, according to managers at ZHGA, of major concern to improve services. They argued that employees
worked more systemically in the past and maintained this mindset, for example, the so-called toilet-
rounds, where clients would be picked up to go to the toilet at a specific moment of the day, and there
was a fixed list of their diet that would remain similar throughout their residency. Managers often argued
that the nurses and caregivers have an "us-to-them" mindset. Instead of trying to imagine what the client
would like or dislike, they were more focused on how they can provide the services to help them
throughout the day with as little discomfort possible. "What people have to learn again is that when you
enter someone's room, you can say ‘hello' to them, but also just start a conversation. I can tie your wound
and talk to you at the same time. People have lost that ability, I figured. If I talk with the employees, they
just do their work", said H1. This skill, according to her, has been lost throughout the years.

The third aspect can be seen as a desired switch from disease management to person-focused
management. In disease management, the health care is organized around the illness/disease of the client,
and the professional approach of nursing is the central element. Within a person-focused approach, it is
the person who is in a central position, not the illness. This was the essence of Cliënt Centraal. M1 argued
that: "The entire health sector is based on what we should do as health care providers to make things more

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comfortable. We have the care plan, and we provide this care. What should we do for the client? It's all about
our position towards the client, instead of: I'm the client, and I would like to be taken care of by your
organization". This mindset is more ‘about' someone instead of through the eyes of someone. To provide
the optimal health care for clients, there was the necessity to adjust to the personal demands of the
individual, as every person has different needs, background, and preferences. "There was always a heart
for the quality of life, but we filled it in for the residents, even though everyone has different wishes and
demands" (H3).

4.2 Execution of the Project

The reason for Zonnehuisgroep Amtelland to implement their new vision was mainly due to the image of
nursing homes, a changing society, and the methodical lens through which health care employees tended
to provide services. But how did ZHGA want to achieve their new goals? To reach their goals, they used a
quality framework developed by Zorginstituut Nederland. In January 2017, they published this framework
as a guideline for nursing homes in The Netherlands, which is included in the legal register of
Zorginstituut Nederland. The frame consists of three parts. First, it describes what clients and their
relatives may expect from healthcare institutes. Second, it contains objectives for healthcare providers
and healthcare organizations to cooperate in improving quality and the learning capacity. Last, it is
considered the framework for external supervision. Zonnehuisgroep Amstelland used this framework as
a guide for the implementation of their new mission "a passion for quality of life." According to M2, the
quality framework was the core of project Cliënt Centraal at ZHGA. “All information, more or less,
necessary for the best service for the client is included in the report. We give it our own touch" The
framework can be seen as the foundation for the implementation of Cliënt Centraal while developing own
methods to reach their intended targets.

Within the framework, there are ten aspects for nursing homes to improve the quality; these can be
found in Appendix II. This framework visualized what health care providers, clients, and insurance
companies have agreed upon regarding supervision and accountability, and was seen as a guideline for
the healthcare sector. In the paper is stated: "This describes for all involved parties what clients and
relatives may expect from nursing homes and their services." It contains both strict requirements and open
space for local implementation. The focus of the report was that the client is seen as the "spider in the
web," where he or she decides how both nurses and organizations should contribute to their quality of
life. During the residency, the way the resident sees life and his/her illness is the center of providing the
demanded health care, and they are also the person that judges the criteria to which organizations and
employees should align. Providing personal adjusted health care, or in other words, person-focused care,
was, according to the framework, the key to improve the resident's quality of life. Cliënt Centraal,
therefore, was about the personal demands of the client, which were central in the execution of nursing
services. It was a project where the essence of nursing related work was put under pressure, while the
implementation took place in a turbulent time of a reorganization, plus an increase of (administrative)

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workload, and the implementation of self-organizing teams. During this, by employees considered,
turbulent time, person-focused care was another aspect they had to take in mind during everyday
practices.

But what is considered person-focused care? According to Vlek et al. (2013), it is about an integral
approach of the client as a person. Next to this, the person-focused care is adjusted to the goals of the
client, e.g. their goals of improving life and sustaining a certain level of independence. Vlek et al. state
that person-focused care is only effective if the healthcare organization is well-informed about the
demands, expectations, goals, motivation, and skills of the client. A client has the freedom to choose
certain approaches, even when not seen as optimal for their health, but results in a so-called ‘higher
quality of life.'

Zonnehuisgroep Amstelland introduced several methods to implement their new vision, providing
optimal person-focused health care. These methods were wrapped in project Cliënt Centraal, of which the
following were mentioned explicitly during the field work: 1) Book-of-life, 2) Who-am-I form, 3)
Verenigingsleven, and 4) In-house support.

The first method was the ‘Book-of-life’ (Appendix III). This was a questionnaire of eleven pages for
the client, in case it was achievable, or otherwise for family, that contained questions on their life before
the illness, recent life, education, family, hobbies, social life, diets, etcetera. The goal was to gain in-depth
information of the resident, to then, have an overview and knowledge of how to provide person-focused
care. This method was not successful according to several respondents as it was considered a large effort
to actually fill it in and would often “end up in a drawer “ (P4). This was due to the size and applicability
of the form, and most information was considered irrelevant for caregivers.

"Because the book-of-life had to be filled in by family, including all sorts of photos, images,
and all that. They found it too much effort. We have the experience that those books end up
in a drawer, it was too colossal. People just want a short overview, a short story, like the new
project ‘who-am-I.' A few questions, whereas it was an art product before. People just did not
want that; it was too much. The new method is way more practical". (H1)

The ‘Who-am-I form,' the second method and in the previous citation the ‘new method,' was a form
that contained seven pages, including questions as: "What do I consider valuable?", "What do I like and
dislike doing?", "What can I do by myself and where do I need help?". The form can be found in Appendix
IV. The effort that family had to make to provide the right information was, according to the respondents,
an essential element. The dependency of employees on this personal information was often mentioned
throughout the fieldwork. Another respondent answered: "We especially use the who-am-I form. We tried
to bring the Book-of-life under attention multiple times, but because it was such a piece of artwork, it scared

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the family" (H2). Both times, the caregivers implied that the new method, ‘Who-am-I,' resulted in more
information of the client. The Levensboek contained a large number of questions, of which most focused
on particular aspects of a persons’ life, e.g. ‘which event has caused a lot of influence on your life’, followed
by ‘do you like talking about it’ and ‘what your response to these changes and/or unfortunate events was.’
The form contains more, similar, in-depth questions which were considered difficult to answer by
relatives. Next to these questions, there was the possibility to add photos. In case the entire form would
be filled in, the amount of information was considered too much for employees to remember or use while
interacting with a client. With the progressive illness in mind, many of these aspects mentioned in the
Levensboek were redundant, according to caregivers. The Who-am-I form was less in size and more
concise. There was a space to answer the questions on the form itself, and the questions were focused on
the client, and less on their personal environment, e.g. family, partner, and history.

The third method, Verenigingsleven, was some sort of umbrella association that stimulated residents
to join a group that shared the same hobby. Residents could join one or multiple groups, while
Zonnehuisgroep Amstelland would search for other residents who shared the same particular interest.
For example, a chess-club, where members were invited to play at a specific place and time every week,
and the organization would take this schedule in account and provided the transport if necessary. "We
are now in a ten-week pilot-phase and have already reached out to 50% of the clients, even though they have
to pay a small amount of money to join. This percentage is higher than before the implementation, also when
that was for free, said H3. The application of this method intentionally reached its targets and was seen as
an accomplished trajectory. Information about the hobbies of residents came from the ‘Who-am-I' and
‘Book-of-life' forms, mostly filled in by relatives.

The fourth method, in-house support, was the daily support of a few hours from someone who took
care of small everyday practices, for example, laundry, helping during mealtimes, dishes, etcetera. This
provided time for employees to spend on person-focused health care while they would feel less rushed
during all obligatory tasks. A nurse (P9) said: "Since a short while we have in-house support. They help
during meals and activities. This in-house support is a blessing; there is more time and peace within the
department. We needed this".

As said, four practical methods were implemented since the presentation of project Cliënt Centraal.
Verenigingsleven was a way to increase the temporary possibilities for clients to carry out hobbies, and
therefore potentially led to an increase of well-being. The other three methods aimed for an increase in
personal care throughout the residency, by being able to understand the residents' possible behavior
through the gathered information. Next to this, the forms would give space for caregivers to chat about,
e.g., interests, family matters, and therefore contribute to a more comfortable environment for the
residents. The in-house support should provide more time for employees to care for the residents, for
example by conversations, playing games, attending lunches, go for a walk, etcetera. Both the ‘Book-of-

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life,' and ‘Who-am-I form,' were methods that required information from either relative or the client, and
a successful implementation depended on the application of the employees.

Analyzing these four methods, there could be stated that only the in-house support had a direct
impact on the client, where the first method depended on the participation of the resident, while both
forms relied on the information of relatives. The dependency on this particular information was much
debated, which led to an unclear role of the client and their relatives. In the next section, an elaboration
of the role of relatives is provided to understand the process of sensemaking.

4.3 Role of Relatives throughout Residency

The name of the project Cliënt Centraal suggested that the resident is the core of the entire organization.
The organization, was in fact, dependent on clients as this was their main income. During the fieldwork,
residents of the nursing homes were seen as the primary client of the organization, whereas relatives had
a participative role. H1 mentioned that: "The client is always number one, always the center of our work.
The family is, of course, important, as a daughter is always closer to the client than any nurse". Respondents
talked about a client in this particular way, distinguishing this person from relatives, confirmed that the
client was actually the person that lived in a nursing home, or the one who received health care services
in any other form by organizational members. In none of the interviews were the family, relatives, or
others, interpreted as the client. The demands of the client were a central element for organizational
members, both change recipients, and change agents, to provide the optimal personal service.

But what if most clients could not make their own decisions, clarify preferences, wishes, and demands
anymore? Who is the one in charge from that point onwards? This was a situation that often occurred in
the nursing homes of Zonnehuisgroep Amstelland. "Some just cannot tell us anymore, they are not in the
position. This can be because of all sorts of reasons. We try to do it as much as possible with the people who
are still able. You will ask: ‘What would you like?" said P8. There tended to be a shift in the position of the
client during their, mostly progressive, illness. P3 mentioned difficulties regarding the decision-making
of residents: "I find it hard when you recognize that there's no decision made by the resident, that they turn
restless." This was seen as a turning point, where the provided space for making own decisions would
negatively affect the resident.

The projects’ name suggested that the client has the central position throughout the organization,
but their central position is questionable considering their illness, according to organizational members.
Most residents of nursing homes suffered a form of dementia. This group was the majority due to new
regulations, in which elderly were supported by the health sector to live at home for as long as possible,
which is extended by home-care services. Often, the client is placed in a nursing home because they
cannot provide themselves a stable situation anymore, neither is their surrounding able to. One of the
heads of a nursing home (H3) stated: “Well, if someone suffers a form of dementia, then this self-

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management sort of expires, but then the relatives come up with completely different requirements and
desires for their beloved ones." A caregiver (P3) confirmed this message, and said: "In some homes, you just
cannot do it anymore. That freedom of choice? We would love to do it, but they are already in a far state of
dementia, and therefore it is barely possible anymore. This makes it hard because then you have to make a
choice yourself". This was partly due to government measures, taken in 2013, which meant that people
with a slight demand for care were no longer eligible to live in a healthcare institution. Another measure
was that the ‘long-term care act’ (WLZ) made it possible to continue to live at home, even with a more
substantial demand for care. People who entered a healthcare institution, in this case, a nursing home,
were often in a heavier need for care than before the governmental measures. Employees sometimes saw
providing personal-care as senseless because of the state the resident is in due to their illness. Employees
saw this as an event that might occur more regularly in the future as the regulations caused residents to
enter the nursing home at a later stage of their, mostly, progressive illness.

"It is different than let’s say ten years ago, where people were in need of basic health care,
dressing, showering, and other daily tasks. It felt as if this was their home, they were
accompanied by people the same age, and they were able to play games. Most of the residents
now are suffering a form of dementia, mostly already in one of the last phases of this horrible
disease. Once they enter through the doors, it gets worse very quickly. They find it hard to
adapt, leaving their own home and not understanding what is happening to them. There is
sometimes little to do to entertain these people because they do not even know who and where
they are, so what is there for us left to do?" (P9)

Because of certain phases of their illnesses, organizational members gained most knowledge from
relatives. The needs of the client were visualized by the ‘Who-am-I’ and ‘Book-of-life’ forms, experiences
from employees, and the information that both client and relatives provided throughout the residency.
“Your mother, your father, he or she lives here. We have to hear from you which needs and wishes this person
has, so tell us!”, M1 said during an interview while she spoke about the sources of information. She followed
this by: "Based on the information and stories that I directly get from family, I know what these people have
done and what they love, and of course what they do not love." Throughout the fieldwork, the relatives had
a key role. Nevertheless, their role towards their, mostly, father or mother, remained unclear as is in who
was in charge of making decision and agreements between them. “Often, for us, it is not only attention for
the resident, but also for the family. Because it is just like that, the family decides” (H3). Taking this into
account, the family/relatives played a more central role in the decision-making processes than the clients.

Arguing that family had a key role, perhaps essential role, throughout the residency, it emphasized
the dependency of the organization on their information and knowledge. “If we do not have information
on that person, we cannot provide the best service. Otherwise, it is an endless trial-error story. We need this
information from the family in any way possible. But sometimes they are just too lazy to provide it, and they
expect us to know everything and that we are able to do everything for them. It is not written on their

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forehead, is it?”, was an answer of P2. The emotions of that person showed despair, looking for a
cooperation with relatives to provide the best care for residents. There was a positive side to it, that family
filled in their role as the major source of information; "Sometimes they become our extension. Their mother
has to go for a walk three times a day, and they are helpful and come over in the evening” (P1). Difficulties
were that the information itself was the interpretation of the relatives. The interests and other
characteristics of the resident perhaps changed over time, and the relationship between them and their
relatives was arguable. Family sometimes suggested that their relative was still preferring or disliking
similar activities as before their hospitalization, but these may have changed over time. The origin of the
information that relatives provided was most often from out of their ‘good days’: “This image sticks to the
relatives. But what if this all changes and someone wants to start a new hobby? We have to anticipate to
that”, H3 said. P7 mentioned: "It sticks to the interpretation of the children. They say; this is what my
mother really likes and dislikes. But yes, perhaps that has changed over time, you will never know". Even
when family provided this information, the preferences were likely to change because of the perspectives
of especially residents with forms of dementia. The implementation of projects that stimulated sharing
personal information did not reach its intentional goals. This could be due to several reasons. For instance,
a family who was not able to provide this information because of a lack of input, time, interest, or internal
problems like an interruption in communication flows within the organization or mistaken translation of
employees that had to work with the forms.

The illness of the client, changing needs of the resident, dependency on information, and demands
of relatives, were elements that influenced the practices of the organizational members. In case the clients
could not make decisions anymore, family tended to fill in the role of the client. Head of one of the nursing
homes (H3) argued that: "From then onwards it becomes hard for us because the family has a decisive role
and we, as professionals, only an advising role. We try to talk with family members to convince them that
the resident is of greatest importance". Nurses and caregivers tended to be searching for their individual
role within this setting, where the family was in charge of the decisions, while the client and their
professional knowledge might have asked for different approaches. “What happens is that family, for
example, thinks that their mother or father still wants to do a lot of things, and is able to participate. But
that mother or father does not want to do that anymore at all” (H3). The expectations, and perhaps hope,
of the relatives, was that their illness could improve, whereas the organizational members saw a
progressive disease through a professional lens. There seemed to be a gap between the rational notions of
employees, and heartfelt thoughts of relatives.

Throughout the fieldwork, many answers pointed to the role of relatives when it came to providing
person-focused health care. This could be either the dependency on the family in gaining information or
the contradictory demands during the residency. Because of the, mostly, progressive illnesses of the
clients, and the inability of them to make their own decisions, employees could be seen as a spider in a
web of insecurity of making the right choices. Either they followed 1) the needs of the client, 2) adjusted

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to the family, 3) or made rational choices that are seen through their professional lens. Their care-
providing profession and knowledge tended to be set aside, to ‘just do what they are told' by either family
or the client. This led to insecurity over their choices and decisions because they felt a lack of ownership
during everyday practices. They dwelled in liminal space between choosing what they have learned or
choosing what they were told. Difficulties regarding the gathering of information of the client were seen
as an external issue, in which their dependency was an aspect they could not fulfill without the support
of both management and relatives. Caregivers confirmed their importance during everyday practices but
visualized themselves as dependent on either information from relatives or of support from management.
The client had an unclear role, according to respondents, which had an impact on both managers and
employees. As organizational members constructed their own realities concerning the change initiative
through the process of sensemaking, the next section contains an elaboration on this process during the
implementation of Cliënt Centraal.

4.4 Sensemaking of the Project

This section draws temporal comparisons when analyzing the narratives of organizational members
through which they made sense of the change initiative. Initial reactions of respondents about the new
vision and implementation of the project Cliënt Centraal were mostly stating that they always had the
focus on the client, their personal needs, and wishes, and that nothing changed. Some of the responses of
nurses and caregivers were: "There are not many changes, the client has always been the core focus’’(H1),
"It is old wine, put into new jars"(H3), "We have always had the client as our main job" (P7). On the one
hand, they understood the possible improvements of their work and the changing society, but at the same
time stated that they always had the client as the focus of their work. The reasons for a decline in person-
focused health care were external according to employees, stating that a changing society, increase of
workload, assertiveness of clients, and lack of information given by relatives, resulted in the defect of
personal adjusted attention. Therefore, the argument of ‘it is old wine, put into new jars’ was seen as a
confirmation that they did not have much effect on this aspect of health care, and that it was mostly the
responsibility of managers and relatives to provide the possibilities for improvement. In this case, the
change recipients saw the organizational change initiative as unnecessary, and priority should be given to
other organizational aspects to improve the quality, especially the increased workload and shortage of
personnel, which were considered the major cause of a decrease of time to ‘do the little extra.'

As said, another aspect that was considered necessary by caregivers concerning the implementation
of the project was the workload of personnel and the call for more colleagues. P7 said: "That is quite typical,
that there is actually no, at least I have never heard of it, that someone said within the healthcare sector that
they want more salary. They all say that they want an extra person, more colleagues". According to some
employees (P7, P1, P3, P9, P5) at ZHGA, this would solve most issues within the organization, more time
for clients, better work environment, less burn-outs. Her saying that she heard no one mentioning salary
as more important than extra employees, contributed to the sensemaking process of employees as they

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shared this meaning. The shortage of personnel was a nationwide issue. In an article of Trouw (Oosterom
& Visser, 2017), a newspaper in The Netherlands, the critique situation concerning a shortage of personnel
within the healthcare sector was described. The number of open job vacancies had increased by 80%
percent since 2016, with especially a shortage of nurses and caregivers within nursing homes and home-
care. This shortage caused longer shifts, and a higher workload throughout the day, which caused issues
providing the essential services. In the report of Zorginstituut Nederland (2017) is stated: "Nursery is a
peoples' job, and without sufficient, qualified personnel, there's no possibility to provide quality and
responsible services." The need for skilled personnel was confirmed while wandering in one of the nursing
homes, where a poster on the wall caught my attention. It contained an ‘application award’ for finding
new colleagues. Both persons would be granted a financial reward (€1800.-) and a contract of indefinite
duration for the new colleague.

The lack of qualified and interested personnel made it difficult for organizations to find new
employees to improve the quality of provided services, and therefore organizations had to focus more on
the internal possibilities, but the employees who already worked for the organization still mentioned the
need for people, without mentioning the difficulties in the current labor market, or questioning their own
performances and productivity. This was partly due to the little communication they had with managers,
as their everyday practices were not in the same work environment. The employees saw extra personnel
within their own work environment, where most issues were due to a lack of time, as a solution for
problems that occurred during everyday practices. Therefore, this project prioritized the wrong aspects
that needed attention, and indirectly questioned their skills and performances.

According to the caregivers, the shortage of qualified personnel needed attention in order to
accomplish the intended goals of the project. The respondents agreed more colleagues were necessary.
The initial reaction of Heads of nursing homes and caregivers pointed to a stability narrative, in a sense
that the project did not cause significant changes, while the status quo was preserved. They emphasized
their role within the organization as being essential in performing their work, mentioning the stability of
their performances, and space for improvement that should be given by management. Because of the
recent reorganization, seen as turbulent, employees tended to emphasize on their current work
environment, and possible threats as a new change project are therefore defined as "that nothing changes."
They saw themselves as executives, whereas the role of management is to provide them possibilities.
Because the ‘nothing changes’ was implied by Heads of nursing homes, they attempted to reduce
uncertainty by narratives that emphasized on stable parts of the organization in order to reduce the risk
of anxiety at employees. Extra personnel were considered as the key to improvement, but their
performances in the current work setting were seen as optimal. Therefore, their construction of the status
quo could be considered negative, even when their narratives constructed the organization as only
minimally changing. This could be seen as a more subversive stability narrative, as it constructs the

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organization as remaining the same, but not in a state which is considered acceptable because of the
shortage of (qualified) personnel, and the lack of input from relatives concerning personal information.

The initial response of Heads of nursing homes and managers emphasized that the performances and
mindset of employees should improve in order to "make things better." They saw Cliënt Centraal as a
project that makes employees think about how they do their work: "We think this project is a very nice
way to let employees think about for example how they build reports and question their mindset. Because
then they think ‘Wow, I've never thought of that'" (M1). Emphasizing on the defaults, assuming this project
will improve the services in the future, suggests a more ‘postalgic' narrative. Also, the response to the extra
money that the Dutch Government promised the healthcare sector, especially elderly care, can be seen as
rather postalgic. Managers stated that the extra money would provide space for employees. The stress
would reduce, more colleagues, more time available to spend on residents, and higher wages.
Management strengthened their postalgic view by emphasizing the negative past within nursing homes.
H2 said: "We tied people to heaters in the living room when they were hard to keep an eye on, and they would
either walk away or be a risk to others when left untied," followed by a: “We came from far, far away. Things
are way better nowadays”. This example showed a negative view of the past by management. This, together
with that management mentioned several shortcomings during everyday practices, could be seen as that
management made sense of the current change initiative through more postalgic narratives. This image
was strengthened by M2. She emphasized on the current developments concerning technology and the
lack of these technological advances in the past. “I mean, they would prefer to go back to the old blue map
where they had to write in all details because it is easier according to them. Well, I think they would turn
crazy if they actually had to go back to these blue maps” (M2). This is an example of the manager that
mentioned the longing for the past of caregivers and stated that the current use of a digital environment
was better than the ‘blue maps' that they used before, strengthening the view that ‘things' are better than
they were in the past.

As described in the theoretical framework, organizational change initiatives tend to distinguish

agents from recipients. The sensemaking process through narratives showed that recipients tend to use
stability narratives, whereas managers use a more postalgic narrative, in order to make sense of the
project. The change recipients saw their work as optimal in the current setting, and agents should provide
extra possibilities (personnel) to improve their services. Change agents, therefore, emphasized on the
potential improvements, and a desired future state of health care, supported by a negative view on the
past within nursing homes. The distinction between the role of both agents and recipients was impossible
to make because their roles might have shifted over time as organizational change is an ongoing process,
and Heads of nursing homes tended to be moving between nostalgic-stability-postalgic narratives.
Although, these processes of sensemaking contributed to discursive positioning within the organization,
as different temporal images existed throughout the organization and therefore members constructed
sometimes opposite meanings. This is further discussed in the next section.

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4.5 Discursive positioning during the Initiative

This section contains an elaboration on the discursive positioning within Zonnehuisgroep Amstelland. As
described in the theoretical framework, some scholars argued that within change there are two identities:
change recipients and change agents. Recipients are the side that has to adapt to change, which are in this
study the employees who directly provide services to the residents. Agents are (Ford et al., 2008) the
people that help an organization to transform into the new structure, in this case high- and middle-
managers. Distinguishing these two groups helped to understand the organizational change through
discursive positioning and elaborated on the self-other perspective. First, the way management presented
the change initiative is discussed, including the underlying message. These messages were then
interpreted by the change recipients, the second step in the process, which lead to sensemaking through
narratives and positioning of organizational actors. The third aspect was the response of management to
the reaction of change recipients. As described in Section 4.4, the distinction between agents and
recipients was not fixed because their roles during the change project could not be placed in clear-cut
categories.

4.5.1 Management: Presenting the Project

The implementation of project Cliënt Centraal started in October 2017. Through responses of managers
during the fieldwork, there could be concluded that there was a general notification of management,
presenting the project throughout all locations of Zonnehuisgroep Amstelland. One of the managers said,
"that it would be very sloppy if I would not know about it, because it is in our mission" (H3), emphasizing
the importance of the project. The project was processed in both mission and vision, part of the multi-
year policy plan, and was a theme during policy-meetings, said another manager. Both managers
mentioned that it was an essential part of the organization, and every organizational member was
informed, or at least they assumed everyone was informed.

At the time of the implementation of project Cliënt Centraal, according to respondents, a turbulent
phase just ended for ZHGA. The earlier mentioned self-organizing teams were implemented, people
throughout the organization were dismissed, and the new vision was presented.

"The most important reason for the reorganization was the financial situation, which was
terrible. At the same time, the Board came up with self-organizing. By many colleagues that
was received as a disguised retrenchment, because in self-organizing your roster as a team,
which meant that all schedulers were fired. Self-organizing means that you guard the quality
of health care yourself, which meant that all quality guards were sacked. In self-organizing
teams, you learn to adopt new processes yourself, which meant that all trainers-on-the-job
were dismissed. The management, the layer I am in, half of them dismissed. That, the self-
organizing teams, was for employees hard to distinguish from a retrenchment. The board
has recognized this and has visited all nursing homes a year after the retrenchment, to

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explain that the timing was not good, but that there was no other choice. They admitted that
it would have been better to wait for one more year because then it would have been clear
that the self-organizing teams and the retrenchment are separate from each other. That is
now understood by employees, but at first, they felt as if the Board did not know how things
worked at Zonnehuisgroep". (H3)

Talking about the reorganization, managers argued that the change was necessary for the survival of
the organization, but communication and timing were often discussed throughout the process. There
were “many things happening at the same time”, said H3 “which was difficult for employees to handle."
Mentioning hope, and a necessary change of mindset to implement Cliënt Centraal, meant that there was
a lack of trust from people in managerial roles and the implementation of the self-organizing teams, that
employees were not able to adopt the new organizational structure and vision.

According to a manager at one of the nursing homes, management should have supported the
employees, whereas the actual work was done aside of the beds by caregivers and nurses. H3 argued: "I
think it is very important that the people around them, like me and the policymakers, should take care of the
fact that they create a chance to place the client in a central position." At this moment confirmed that she,
as a supervisor, should stimulate and create the environment to provide optimal personal care, in forms
of feedback sessions, evaluations, and other methods. She also tended to be worried about her role as a
manager due to the implementation of self-organizing teams, an initiative that was presented shortly after
the reorganization.

Self-organizing teams are teams without a supervisor, wherein team-members share responsibility.
In this way, the key-role was handed back, in theory, to the people that directly worked with the residents.
The project was presented in order to flatten the organizational structure, decrease bureaucracy, and give
responsibility back to the work floor. Asking how management see their role in this project, they talked
about their hope that the nursing teams would manage to adapt the new setting because their position as
a manager was more distant. "My role as a manager has shifted more and more to the background due to
the self-organizing teams. A bit of coaching and facilitating. They have to keep an eye on themselves now",
was the response of H3. Another person in a managerial role at ZHGA said that her position was already
far away from the work floor, and the connection with the personnel had decreased. Both managers were
anxious about their role and function within the nursing homes, as the new organizational setting created
a distance between them and the employees.

Next to the self-organizing teams, management of Zonnehuisgroep Amstelland argued that Cliënt
Centraal was an essential change project to compete with other nursing homes, and they considered it
necessary to adapt to a changing society. They stated that standardized health care was outdated and
focusing on personal care should avoid clients to choose for competitors. This suggested that managers
were aware of their competitive position as organization members compared their organization with

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nursing homes that were active in the same region. According to respondents in a managerial role, the
clients were the ‘directors’’ of their own health care, and employees should have tried to adjust to that at
their outmost. In Project Cliënt Centraal, management emphasized the necessity of adjusting personal
care to the demands of clients, and that employees were servants, which was carried out by management
and Heads of nursing homes by mentioning the decisive role of clients in everyday practices. "Is there a
lot of space for improvement?", I asked H4. "Yes, they are able to do it much better" was her answer without
hesitation.

Respondents with a managerial role at ZHGA argued that the project could be seen as a moment to
reflect on the everyday practices, on how change recipients performed, and "what if your mother lives here,
what would you want then" was used by M1 as a reflective question for the employees. A manager stated
that the project did not contain any desired changes, as the client was always in a central position, after
mentioning the response of change recipients on the personal attention they gave to clients, but that it
was mostly an issue of a certain mindset. As March (1981, p. 546) argued, “change takes place because most
of the time most people in an organization do more or less what they are supposed to do; that is because
they are intelligently attentive to their environments and their jobs."

While bureaucratic organizations could be exceptionally ineffective, change agents considered that
the current mindset was lacking in a sense that recipients did not overthink their practices in a manner
through which they provided personal care, in line with the new vision. The example of a nurse carrying
a wound (Section 4.1) and in the meantime having a conversation was seen as a typical example of
combining skills. But H1 argued that, apart from a lack of time to spend on personal attention, change
recipients found it unimportant to bring this personal aspect into their daily work. This statement was in
line with the argument of "not the right mindset", that the problem was on a deeper, internal level within
the change recipients, according to her. Management suggested that employees did not tend to prioritize
the essence of their work, and doubting their professional dedication, reappeared in the presentation of
the project. This had an impact in the discursive positioning, the gap, between change agents, and change
recipients, in which management implies that (some) employees resist change, and tend not to cooperate,
stating that they do not want the ‘best for the client.'

When taking this mindset in account, a situation during the fieldwork was a clear example of the
lacking mindset. During a meeting in October 2017, where members discussed an alternative organization
that would possibly provide ZHGA a digital healthcare environment accessible for clients and relatives,
the client had a central role. Zonnehuisgroep Amstelland was not content with the organization that was
currently in charge of their ‘electronic clients dossier' because of several reasons. Bottlenecks that ZHGA
mentioned in order to improve services earlier in the process were not solved, skilled personnel left the
company, and a so-called downward spiral was entered, according to the chairman of Zonnehuisgroep
Amstelland. Therefore, they approached an alternative organization in order to present their application,

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and abilities, to convince ZHGA of choosing them as a partner. This meeting was planned to discuss with
several organizational members of Zonnehuisgroep Amstelland, with varying professions, the
continuation of this process concerning a new ECD. At the start of the meeting, the chairman mentioned
the importance of adjusting health care, and related services, to the needs of the client. All members were
asked about their opinion on the presentation of the potential provider. After half an hour, co-researcher
Ernst van den Akker mentioned that the conversation was centered around the benefits and disadvantages
of the organizational members and their workability with the ECD instead of the client. The discussion
was from a perspective that focused on them, not the client. Van den Akker asked: "We are now looking
at the workability of the professionals. But what about the client?". This question exposed the mindset of
the organizational members that the client was not as central as their own professional role, their
workability, and convenience. Change agents presented a change of mindset of recipients as a key element
for a successful change initiative, but this particular mindset was found throughout the organization as
none of the group members had the benefits of the client in mind when discussing the ECD.

Management presented Cliënt Centraal as a change initiative, where the focus was on the ‘little extra,'
the small gestures, and an increase of personal attention. Organizational members gained the information
in order to execute the project through both clients themselves, and relatives. The change agents assumed
they had an important role in implementing this new mindset, throughout side-projects as f.e. the "Who-
am-I"-form, and by organizing feedback sessions to advise change recipients about their performances.
Management saw their role as a mentor for employees, the line between Board and floor, who were
responsible for the implementation of new initiatives, and who provided space for them to carry out the
new vision. But the perspective of management often differed from the view of executives, in this case,
nurses and caregivers. A new ‘mindset' from employees was necessary to accomplish the intended goals
of the project, but during a meeting, this ‘incorrect' mindset turned out to be absent throughout the
organization. The response of recipients to the presentation of Cliënt Centraal by management is
discussed in the next section.

4.5.2 Recipients’ Response

While management assumed that all organizational members were familiar with the project, interviews
during fieldwork showed opposite answers. These were sometimes contrary to what management implied,
varying from: "I have heard of it, but do not work with it as far as I know" (P2), "that project does not really
ring a bell, but yeah, you hear a lot about placing the client in a central position" (P1), and "I have not heard
of it, that is why I was very interested in talking to you" (P3). Assuming that the project was in the process
of implementation, and change recipients responded that they were unfamiliar with the project, the
organization apparently housed two opposite sides during the execution of project Cliënt Centraal. One
the one side the managers who emphasized the importance of the project, and on the other side the
change recipients who argued that they were unfamiliar with the implementation and stating that it was
not considered a priority.

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When mentioning the implementation of the change projects, skepticism was a reappearing response
on change initiatives at ZHGA. According to a caregiver, employees listened to the stories of management
and supported this view, but as soon as they turned around and are back at their own department, they
"just act like they have always done" (P1). There were many change projects recently, which had developed
ignorance to change recipients. Work was continued "like always” (P1), "we do not have to change" (P8),
and "another project will follow again anyways" (P8). Another aspect was the priority of the project. Asking
about whether the elements concerning personal-care were a theme during evaluation moments and
feedback sessions, there were, according to respondents, no specific questions and criticism on their
practices. Management was less connected with the everyday practices due to the self-organizing teams
that were currently implemented, which led to a decrease of personal feedback. Also, the yearly
evaluations and other official moments were not frequently held. This caused the respondents to question
the priority of the project, and perhaps influenced the impact of the initiative.

During the interviews, management stated that the employees were servants, and that providing
optimal care was their main task. As serving the client was the essence of their job, questioning these skills
by presenting a project named Cliënt Centraal exposed their insecurity concerning their performances.
This response of recipients led to them denying the problem. Therefore, quotes as "If I look at myself and
at my colleagues, I think the client is already very much in a central position" (P3), and, "everyone within the
healthcare sector puts the client in a central position, and now you hear from above that they should be
placed in the center" (P7), argued that they have always carried out this vision. They felt undervalued and
unheard. The reasons that employees mentioned, that apparently caused the lack of person-focused care,
differed from the essence of the project. Thus, change recipients, and change agents looked at the
initiative from a different perspective, which led to discursive positioning, ‘us' and ‘them', throughout the
process of sensemaking.

Nurses and caregivers felt criticized from two sides, emphasizing the influence of relatives on their
everyday practices, whereas management emphasized their wrong mindset. "Family can interpret things
in a wrong way, which can cause a vexing misunderstanding", said P2, and the anger that sometimes arose
when either client or relatives disagreed with a certain procedure, action, or care program, caused stress
and insecurity. Change recipients saw themselves as grasping every chance to give the ‘little extra’, but
still felt criticized on their work by relatives, and now added by management who argued that their
performances throughout everyday practices should be executed with a different mindset. This
contributed to the anxiety that employees felt while performing their work. Their response to the criticism
of management contributed to the discursive positioning within the organization.

Nurses and caregivers saw the choice between providing the personal-care the resident asked for,
requirements of management, and the demands of the family, as a dilemma. A caregiver gave an example
of a similar situation. She worked directly with clients, and was frequently in contact with relatives:

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“Daughter: My mother always wears the same clothes; I want from now on that she wears
other clothing'. But this is what happens, she grabs these clothes out of the dirty laundry
basket and puts her dress on. What do you do then? Or a woman who loved chocolate
sprinkles. What happens when you eat chocolate sprinkles is that, even while wearing a
napkin, you spill a bit and it might end up on your trousers, causing a dirty spot. At that
moment her daughter comes in and says: ‘WHAT? She is not wearing any clean clothes, all
covered in chocolate'. Yeah, that is because of her sandwich. What should you choose at this
moment?" (P7)

Her mother loved eating chocolate sprinkles, and not agreeing with her preferences in order to put
the family at ease, was a dilemma. This often led to stress at organizational members. The demands and
wishes of family and client were not aligned, which caused insecurity at employees within the decision-
making processes during everyday practices. Deciding in favor of the client was what the organization
implied, but the possibility to cause incomprehension or anger of the family was often a stronger variable
and therefore tended to be decisive, and led to employees choosing the preferences of the family. "We can
never do it as well as the family, cooking that nice, and giving the personal attention. We cannot provide
that, only within our possibilities. Then you should look for a different nursing home, but they will not give
that either" argued H2, stating that the expectations of the relatives were sometimes unreasonable. Even
when demands were considered unreasonable by employees they tended to listen and follow these
requests. “Also in the hard cases, in which demands are too high and things are never good enough, the
family is in a central position” (P7). This often felt as if their work was unthankful, and that

Another aspect was the workload. Respondents mentioned time, building a relationship, and the
little extra attention for the resident as important factors that contributed to person-focused care. “If there
is more time for the client, then we increase our attention. Otherwise it is just washing, showering, dressing
up, feed. Where is the actual attention for them?” (H1). Due to a lack of time, the caregivers argued that
they could not provide the care they aimed for. This, therefore, lead to less bonding between personnel
and the residents. Asking for moments where personal-care had been essential for the residents to feel
comfortable, carefree, and joyful, a few anecdotes were told.

“Then, one of the caregivers already entered the room before the alarm would go off. She
would switch on classical music, very quietly, which would wake her up in a very pleasant
way. They would leave her in bed for another fifteen minutes so that she could cuddle
comfortably" (H2)

“Now one of our colleagues has a new cat, a Siamese cat, who is called Kees. One of the
residents also had a Siamese cat in the past. That colleague will bring her cat, every week, for
an hour to sit with the cat next to her. If you see these pictures, they are so heartwarming.
She is so happy, yelling: “Kees is here again!” (H3)

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The respondents showed pride and emotion while telling these anecdotes. Their voice turned softer,
and emphasizing on that “this makes their day, seeing a resident happy” was often heard as a response
when people told these emotional narratives. This contributed to their feeling of being passionate and
determined while practicing their profession. The word passion, or a calling, was mentioned by several
respondents when asked about their choice for the healthcare. "It is not something you do for money, but
for fun", said P2.

The potential improvements that management mentioned were partially confirmed by the
employees. There was a general understanding of what; "placing the client in a central position" meant,
but there was no consensus about to which extent ZHGA achieved and was able to achieve, this goal. The
project was seen by employees as that the client should always be in charge, clients are in a key position,
and employees should adjust their services to the personal demands, making residencies as comfortable
as possible by giving personal-care, conform their provided information or current state. Apart from the
consensus on the definition was the current state of implementation of the new vision. According to
management, there was space for improvement, though change recipients struggled with this view. One
of the respondents (P4) sighed when talking about the ‘extra work' they had to do from now onwards
while saying "we will work it out again, one way or another." The high workload, stress, and demand for
qualified personnel has paid its cost, resulting in skepticism and a callous attitude.

As organizational members interpreted Cliënt Centraal as a ‘but we have always been doing that’-
project, seen as a stability narrative, while they felt that their practices were misunderstood by
management. If they looked at themselves and colleagues, they argued that the client was already in a
very central position. But after asking if there were any potential improvements, the nurses and caregivers
said that some colleagues did not carry out this new vision, acknowledging that improvements could be
made but that it was not their individual incapability. An understanding of the need for a changing
mindset, as in the notion of being more focused on the personal aspects of a client, existed, but employees
tended not to see it as a personal responsibility. This caused difficulties with implementing the project.

There was a perception of unfeasibility on the work floor concerning the person-focused health care.
On the one side, respondents claimed that they already did their utmost to provide services, and on the
other side, suggested that the ‘little extra’ could only be accomplished by hiring extra personnel. This
meant that there was a certain knowledge that improvements could be made, but not in the present
organizational setting. The requirements of clients and family were "impossible to fulfill" (P3, P4, P2)
according to several respondents, because of the arbitrary demands of these people, and the lack of time.
Therefore, the perception of change recipients was that management expected unachievable targets,
which caused stress and work pressure. This perception was confirmed when they spoke about the
implementation of Cliënt Centraal during the interviews, where respondents were enthusiastic about the
‘In-house support’ as that person added calmness to the department, provided extra time for personnel to

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do their tasks, and contributed to a more person-focused work atmosphere. "We really needed this" (P5)
and "I hope she stays" (P6). There was more time for providing personal attention due to the in-house
support and is therefore seen as an improvement, but employees seemed skeptical about following
measurements from management. “For how long they will stay? No idea. Perhaps again for a very short
time” (P5).

Recipients agreed to the possibility for improvement, but not in the current setting. They argued that
their performances were in line with the new vision, that there were no significant changes they had to
make regarding their work. More personnel was the solution for this project, according to employees,
expressed by the call for more hands at the bed “because that is where it happens." Responses throughout
the fieldwork mostly stated that employees did their utmost to provide personal-care, but often hindered
by interferences of relatives or a scarcity of time to do a ‘little extra.' Both reasons are identified as external
aspects for change recipients to not be able to carry out their everyday practices, whereas the inferences
of relatives derived from the client, which meant that they did not see themselves as the source of a
scarcity of time. Because of the lack of time and the high work-pressure during shifts, the employees
argued that it was impossible to fulfill the requirements of clients and relatives. "I love my work, it is my
passion," said P8, while she helped a resident into a wheelchair, continued by saying "I have a rather small
amount of administrative work to do, but there is too little time for personal-care, there is simply no space
for it." This implied that if there was more time, there would be more time able to spend on the residents
and their personal needs. Now they experienced their work as ‘doing the necessary,' like washing,
showering, dressing up, and help during meals. Therefore, project Cliënt Centraal interfered with their
belief of them being passionate and determined during their work at a nursing home.

The interference of project Cliënt Centraal resulted in a defensive position of change recipients
towards their everyday practices. They emphasized the personal moments they had with clients, such as:
"She was afraid of her death, that she would be buried while she was still alive. I spoke to her about it, and
while she was already quite sleepy, I held her hand, turned on music, while she kept looking at me with those
fearful eyes. I sat down next to her, holding her hand when she fell asleep. She was finally calm again and
slept for hours" (P7). These narratives contributed to their belief of having a determined attitude towards
their work, and underlined that, according to them, this was the ‘real’ task of health care. Their view while
telling these narratives was mostly focused on the positive aspects. The perspective of change recipients
while talking about the project was mostly in a positive ‘I’ setting, and when there was a critique on the
role of colleagues or management, it was in a more general ‘us’ or ‘them’ setting, or they projected it on
someone else like a co-worker. This added to the "heroic-self" and the other as a "villain" perspective, in
which an individual’s own performances are not mentioned as responsible for organizational failures.

As mentioned in Section 4.1, there were distinctive views on the roles and impact of the client,
management, and employees, throughout the organization. This lead to an opposing view towards

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management, wherein the change recipients doubted a general understanding of health care. About a
person with a management function was said: "She does not work in healthcare" (P8). This contributed to
a self-other perspective, wherein "we do the work" and "they do not know how healthcare works" are
images that consolidate the self and weaken the other. Throughout the fieldwork, examples of this
discursive positioning appeared. The project was seen as a theoretical story, with little attention to
practical elements. According to employees, management had the key role in managing the expectations
of relatives and clients. Legitimate expectations should lead to less friction with relatives and clients
because there would be a decrease of complaints and disappointments. But the problem was that,
mentioned by a respondent (P4), management did not know how healthcare functions. There was the
imagination that people with managerial roles have little knowledge on work floor related tasks and that
there is little attention for employees throughout their day. "I think that when you look at a higher level
within the organization, management level, clients turn into numbers, yes” (P1). Management thought ‘in
numbers’ instead of ‘in people’, was according to the employees also wrapped in the title of the project
because of the word ‘client,' whereas nurses and caregivers preferred to use the word resident. This
difference strengthened the distance they felt between them and management, and therefore resulted in
a wider gap between both organizational layers. The image of management "making shifts more
complicated by implementing new tasks, sitting behind their desk" (P4) was therefore existent. Change
agents tended to see their work as essential for the organization, and issues during everyday practices
were solved by themselves, and intentions were to not include management in these processes.

Cliënt Centraal confirmed for employees the image of management saw their work in a sense that
their, sometimes, passion for caring elderly, was suddenly an aspect they should improve. Management
presented the project as a necessary initiative to change the current mindset of employees, and improve
services, which was received as an assault on the everyday practices of nurses and caregivers. They felt as
if they had always been determined throughout their career, providing the best care possible, and were
hindered by external factors. Employees at ZHGA were in general skeptic about change initiatives at their
organization because of the number of projects that were implemented recently and saw management as
a group who was distant to their work environment. They argued that the work is done on the work floor,
hands at the beds of residents, whereas management did not know what it meant to work as a caregiver.
They felt misunderstood and underappreciated, sighed when another project was presented, initiated by
people that were not involved in everyday practices, strengthened the feeling of a distance between both
organizational groups, and resulted in self-other positioning in opposite categories. The next section
contains the response of management on the vision of employees to elaborate on the discursive
positioning.

4.5.3 Management Memoires

The reason that some recipients were not aware of the project throughout the organization was, according
to one of the managers, because the project was not implemented yet, after mentioning the unawareness

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Findings: Answer to the Call for a Little Extra P. Dijkstra

of some organizational member. This was surprising because another manager said that all nurses,
coordinating nurses, and caregivers were noticed of the project and that the implementation was difficult
so far. The manager who claimed the project was not implemented yet might have said it out of defense
to cover her own default, or priority she gave priority to other aspects. Some answers were contradictory,
from: “there is a lot of pressure by management to implement this project" (H1), versus, "this project has not
really started yet, and we have little to do with it"(P8). This suggested that the priority of the
implementation might have differed between departments, managers, and locations of ZHGA. Another
reason for the difference in sensemaking of the project probably was the interpretation of organizational
members in various layers.

In response to the change recipients, change agents emphasized the importance of the project, and
the client surveys accentuated this view of the necessity of the initiative. "The nurses think they do it, but
they do not” (H1), which could be seen as identity talk, stating that nurses are “resistant recipients”, while
they see themselves as “heroic”, being able to change stated that they are either unaware of their own
performances, or ignoring potential improvements. Management, therefore, pointed to the client surveys,
which visualized the complaints of clients and residents, and showed the need for improvements.

Change agents focused on the aspect of improving everyday practices, "having a conversation while
providing care" should be done throughout the care giving practicies. Nurses and caregivers have "lost this
skill" (H1) and even with a good intention they "want to go home at 3:30 PM” (H3), and said they are "too
busy" (P1, P2, P3) to give the ‘little extra.' Management, on the one hand, confirmed that the work pressure
is high, but attenuated this by saying that they stimulated each other in saying that there is a high
workload. This suggested that the current organizational structure was able to implement the new vision,
but that the skills of employees were insufficient. Another aspect was the need for extra personnel, which
was more desired than a rise in salary, according to nurses and caregivers. One of the respondents received
this as false: "Of course, they would prefer money over extra colleagues, this is nonsense” (H1). Therefore,
the perception of intrinsic and extrinsic motivation of employees was different. Another example was the
passion and determined attitude that caregivers and nurses possess according to themselves. H1 stated
that "most employees work in nursing homes because they are "simply not able to do any other work than
this", arguing the opposite, showed a cynical view on the skills and willingness of employees to carry out
the new vision.

Responses to the message that management "does not know how healthcare should be executed”,
they tended to emphasize on their history within the profession or sector. Most managers had a career in
healthcare, varying from ten to thirty years, and promoted to their current position in the organization
over time. They still saw experience as relevant, without mentioning changes that have occurred, both
internal and external, which affected nursing homes. One of the managers emphasized her age as a
strength, which, in combination with her experience, would leave a smaller gap between generations. "I

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can still sing songs with the clients, songs from a long time ago. The new employees don't know them, even
though music is one of the strongest memories that is sustained for a long time, even for people that suffer
a form of dementia" (H2).

The demand for extra colleagues was supported by management, but they stated that it was difficult
to hire skilled personnel because of the shortage of people who were interested in working at a nursing
home. "We are all fishing in the same puddle, and in the end, it is about offering the highest wage” (H1).
Because of the recent reorganization, there was extra attention to the finances of the organization.
Management pointed to external problems concerning the shortage of qualified personnel, which was, in
this case, the national scarcity of people who aspired a job in a nursing home. They criticized the attitude
and beliefs of change recipients by seeing them as resistant and incapable concerning the execution of
Cliënt Centraal. When mentioning the need for extra colleagues, seen as the most important reason for
not being able to perform as required by employees, managers tended to point to the national scarcity
and seeing it as something that ‘everyone has to deal with’. They considered the incapability of employees
had a higher impact than the shortage of qualified personnel. This was contrary to the belief of change
recipients, who saw themselves as passionate and determined throughout everyday practices.

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Conclusion P. Dijkstra

5. Conclusion
The findings that are presented in this thesis outline how organizational members construct their identity
in the context of organizational change. It illustrates how they see themselves and others. This study
provides further empirical evidence of how organizational members make sense of organizational change
processes, and of their own and others' identities. During this research, the focus was on the
implementation of project Cliënt Centraal, which is a change project which goal is to adopt the new vision,
an increase of person-focused care and adjusting services to personal demands. This ethnographic study,
conducted at Zonnehuisgroep Amstelland, has helped to gain in-depth knowledge of implementation
processes in a social context. To finalize the research, this chapter contains an analysis of the main
findings.

Change programs can be seen as triggers for ongoing, as argued in this study. These programs provide
discursive resources for making certain things possible, even though the results remain unclear until they
are experienced. The experiences of organizational members contribute to the appreciation and
implementation of the intended change. But the form of adaptation differed between nursing-homes as
these members tended to make sense of change in different ways, through narratives and the construction
of identity, and therefore local adaptation, and improvisation took place by human agents. The existing
categories were then imaginatively unfolded when implementation of the change program took place.

This organizational change was characterized as "atypical," as many changes have been recently
implemented, and the project was not seen as a major change program. This had an impact on the way
organizational members saw this project, as they tended to see change as something ongoing, which had
become a part of their everyday organizational life, and therefore almost became a routine because of the
many ‘follow-ups' that were implemented recently. The many changes throughout the organization
caused frustrations, and eventually skepticism for future change initiatives. Within this context,
organizational members constructed their identities through sensemaking and using narratives.

Through sensemaking, people discovered their own invented reality. As the findings reveal, all
organizational members made sense of the organizational change and their identities, both of their own
and of others, in several ways. The distinction between change agents and change recipients was not
inevitably fixed but discussed by actors in diverse ways. Respondents, in both managerial roles and
employees, were aware of the potential benefits of the project, and therefore not necessarily against the
initiative itself, but the presentation and communication of the project ‘raised eyebrows' throughout the
organization.

Management saw the change initiative and the new vision as a positive development, in which the
current services of the organization would improve by focusing on the personal needs of the client.

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Throughout the fieldwork, three reasons for the necessity of implementing the project came to light, in
line with the new vision. The first reason was the negative image of nursing homes, while the increased
assertiveness of society, and the wrong mindset of the health care sector as in more methodical instead of
personal, were the second and third reason.

Therefore, employees tended to interpret the change initiative as ‘another project' and resulted in
skepticism due to recent projects and the reorganization in 2015. They emphasize on the current work
setting in which a shortage of qualified personnel is seen as the major cause of problems that occur during
everyday practices. In this work setting, they did not have time to ‘do the little extra' and argue that they
do their utmost for the residents, while the demands of residents were impossible to satisfy without hiring
more people. They state that they always had the client in a central position throughout their practices
and that it was their passion to make the last chapter of the lives of residents as good as possible. They,
therefore, emphasized the dependency on both management and relatives.

The organizational members made sense of the project through narratives, wherein some referred to
a longing for a romantic past, nostalgia, or longing for a bright future, ‘postalgia.' A third narrative,
stability narrative, was found in the responses of employees. Within these narratives, there was no clear
distinction between organizational layers that emphasized either past or future with a romanticized view.

Managers tended to be more longing for a desired, and bright future, in line with the aim of the change
project. They emphasized the potential benefits, in this case, an environment wherein the personal
demands of the client are dominant throughout everyday practices. It was more an optimistic belief about
the potential benefits that a change in mindset would result in, combined with technological
developments, that would improve services of Zonnehuisgroep Amstelland and would help the
organization to survive. Management seemed unsatisfied with the current performances and therefore
pushed their imagination in order to think of an ideal world, where all demands of the client can be
fulfilled thanks to the mindset and practices of the employees. They saw the project as a process towards
perfection, where the gap between the goal and the current state could be closed and is a matter of time.
This perspective was because of the recent turbulent years, being on the brink of bankruptcy. Therefore,
the future was projected as a positive state, something to look forward to.

Employees did not tend to emphasize a longing for the past, even though they argued that there used
to be more time to spend with residents, a lower workload existed, and administrative tasks were limited.
The perspective on nursing homes in the past was rather negative, mentioning the restrictions of freedom,
working methodically, for example, ‘toilet-rounds,' and that these themes have improved over the years.
They argued that circumstances are better, and that the life of clients is has improved. Therefore, the
nostalgic perspective is not necessarily more typical for employees' narrative accounts. Employees told
subversive stability narratives in which they constructed the organization as remaining the same, but this

54
Conclusion P. Dijkstra

was in a state which was not seen as acceptable. This was mainly due to the high work pressure, lack of
qualified personnel, and the number of administrative tasks, which were considered irrelevant to their
profession.

Throughout these stories, employees and management spoke negatively about others. Organizational
members constructed their collective and individual identity in the context of organizational change,
which illustrated how they saw themselves and others. These images of self and other strengthened the
discursive positioning while constructing identity, wherein the self was seen as more important for the
sustainability of the organization. They did not question their own skills but therefore pointed to other
organizational members, while both tended to hold on to external reasons (e.g., scarcity of qualified
personnel, unreasonable demands of relatives) or internal reasons (e.g., incompetent employees, lack of
knowledge throughout management). When asked whether they can improve their performances with
direct colleagues, they continued talking about others' practices, that one or multiple team-members
could improve their execution of services. Project Cliënt Centraal triggered friction between management
and employees, whereas management saw the organization in a bright future perspective, and employees
emphasized the current setting as unworkable.

Management saw employees as servants, and that the project was a moment to reflect on the everyday
practices, and on how change recipients performed. They stated that the mindset of employees had
changed negatively over the years, which resulted in a lack of personal attention and interest in clients.
To change this mindset, employees should reflect on themselves and imagine ‘how it would be when your
mother would live here.' They emphasized the incapability of employees and the lack of certain skills
which were seen as a risk for a successful implementation of the change project. Management saw
themselves as heroic change agents, essential to maintain the organization as a whole, and saw employees
as disobedient in adopting the new vision. Management admitted the high workload but mentioned the
skills, and work methods as one of the roots of these shortcomings.

Employees argued that their main task is providing personal care to residents, while the project
suggests, according to them, that they did not have the client as the everyday focus of their work. This
contributed to them denying the implementation of the project, as not all organizational members
confirmed that they were informed of the implementation of the new vision, even though management
stated that the project was announced throughout the entire organization. Employees did not feel the
need to improve the person-focused care, as they always done it to their utmost while seeing themselves
as passionate and determined to their work and residents, while management argued that they have lost
the connection to the client. They argued that management should provide them with the relevant
information about the clients, and cooperate with relatives to give space for them to adjust their services
to the demands of the client. At the same time, the employees expressed their fear, anxiety, and
powerlessness in their everyday practices. They were afraid of external interfering, for example, relatives,

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and healthcare inspections, and feel powerlessness in a sense that the demands of clients are unachievable
in the current work setting, while both pressure from management, clients, and relatives, intensifies this
feeling.

Employees blamed management for the lack of sufficient qualified personnel and argued that they do
not know what the essence of healthcare is. They constructed an image of the organization wherein
management had little impact on their work because they were seen as an unnecessary layer in the
organization as the ‘real’ work was done on the work floor. Employees, therefore, saw this project as
something redundant, that they have always carried out their passion towards clients. Suggesting
potential improvements concerning the demands of the client, employees kept mentioning the lack of
time. They claimed that they already did their utmost to provide services, and on the other side, suggested
that the ‘little extra’ could only be accomplished by hiring extra personnel.

Employees identified themselves as a collective, as the core of the organization and indirectly see
management as surplus. Management should provide them with the right information concerning clients,
followed by the implementation by employees. This is contrary to the belief of management, arguing they
are essential to implement changes and improve services, and saying that personnel is incapable to
execute the tasks according to their demands. The desired future state of the organization was used by
management in order to stimulate personnel to implement the change project. Employees admitted,
through stability narratives, that the current state was not acceptable but still tended to hold on to the
present status quo due to the turbulent phase the organization recently experienced.

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Discussion P. Dijkstra

6. Discussion
The findings of this research on the implementation of a change program support the argument of
Alvesson & Sveningson (2008) that members of an organization give meaning to a change process and
their identities in different and complex ways. Findings of this study, show that the identity categories of
change agents and recipients are not fixed, but constructed in diverse and multiple ways. During
conversations, organizational members could shift between agent and recipient, both resisting and
embracing, or see themselves as initiator or subordinate. This especially varied from one employee to
another when comparing themselves with direct colleagues, which shifted their constructed identity to
somehow more supportive than when compared with management. According to Ybema et al. (2016), this
discursive positioning is accomplished through a process where individuals position themselves and
others in distinctive categories, most often discursive. This was confirmed in this research, as employees
saw themselves as a collective, but when talking about direct co-workers, saw themselves as more willing
than others.

Throughout the research, organizational members tended to be positive about the change, but
negative about the presentation and communication of the project. This led to different interpretations
of the change initiative. Findings on both postalgia and nostalgia have not challenged the existing
literature of Ybema (2004) and Gergen & Gergen (1997) but added the third narrative, stability narrative
of Sonenshein (2010). Though both forms of temporal imaging existed within separate organizational
layers, wherein managers were not only postalgic, but also skeptic about the future, while employees were
not always nostalgic, and in fact, argued that some things were better than before. This pointed more to
a subversive stability narrative, where the current state of the organization was not seen as acceptable but
do accept the status quo. The assumption by Ybema (2004) and Gergen & Gergen (1997) that nostalgia
usually exists within the ‘underlife’ of an organization and ‘postalgia’ in the ‘upperlife' can be partly
confirmed. Some narratives of employees emphasized on nostalgic situations, but most were admitting
that things are ‘better than before.' An exception was that some narratives, both of management and
employees, tended to be skeptic about the future within the healthcare sector. This was due to an aging
society, shortage of qualified personnel, and the physical and mental state that elderly enter the nursing
homes has shifted to a more critical phase of their illnesses. As the skepticism is due to sector-wide
problems, organizational members more often emphasized the current state of the nursing homes
compared to the past, accentuating the positive aspects, space, knowledge, and luxury the residents have.

Limitations and Future Research

Foundation of the research at Zonnehuisgroep Amstelland on the project Cliënt Centraal was the existing
literature on identity construction and sensemaking during organizational change. The goal of this study
was not to provide statistically generalizable answers, but to gain in-depth knowledge through a
qualitative analysis of the construction of meaning within the organizational context. As mentioned in

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Chapter 3, thirteen respondents were interviewed and results were supported by attending several
meetings and doing observations in nursing homes. Even though this number is seen as sufficient
(Dworkin, 2012), more respondents could have criticized the existing categories of both agent and
recipient, and nostalgic-stability-nostalgic narratives. Because of this small sample of the organization, I
cannot rule out that other organizational members have a different opinion on the current organizational
changes and their impact. The aim was to interview Heads of all nursing home, and a minimum of three
caregivers, which I did not accomplish. Adding the other nursing homes may contribute to a more
complete research for Zonnehuisgroep Amstelland, as every case might result in a different outcome.

Most observations and interviews were linked to departments concerning dementia. I can imagine
that conducting research at medical rehabilitation might lead to different answers. At these departments,
also mentioned by respondents, more in-depth conversations are held, which results in a different
ambiance. Residents are more able to tell their preferences, and employees depend less on their
interpretation of a situation. At these departments, the influence of family probably turns out different,
because the clients are self-evident.

Besides that, due to time constraints, there was no possibility to study a larger group of organizational
members. It was rather difficult to arrange a meeting because of work pressure from their side, and the
lack of having a mutual timeframe wherein a meeting could be organized was sometimes hard to find.
Because of this, there is no certainty whether the findings can be applied to all organizational members
or if this is restricted to the group that has been part of the research., for example, due to different
demographic area in which a home is based, or a different leadership approach of management within the
location. The second limitation is that this study only covers a specific, limited period of time, and
therefore did not investigate how the narratives and construction of identity during a change process
evolve over time.

Apart from these limitations, there is potential for further research based on this study. To gain a
broader understanding of the construction of identity during organizational change, and the temporal
imaging in the process of sensemaking of organizational members, it is interesting to conduct qualitative
research over a more extended period at Zonnehuisgroep Amstelland. Spending more time, and
intensifying the research, might contribute to existing literature as there is a potential variation in the
construction of identities over time (Sonenshein, 2010). Further research may include more participants,
or focus on a certain organizational layer, or nursing home, to look more intensively to the impact of the
project. This research has incorporated several organizational members from separate nursing homes.
Therefore, further research can focus more on one or multiple teams, or see the project from out a
management perspective. Tsoukas & Chia (2002) argue that to explore how meanings change over time,
it is of importance to understand the dynamics of change. Understanding how meanings change over time
provides a more dynamic view on the consequences of change implementation and different

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Discussion P. Dijkstra

constructions of meaning on change on the long-term. Further research might discover other types of
narratives or constructions of identity, or a discursive positioning.

Another direction for further research might be to systematically analyze the relationship between
the narratives of employees and the response of management. As this was a qualitative research, perhaps
quantitative research might contribute to existing knowledge on this theme and might expose causal
relationships between e.g. narratives, and years working for an organization or meaning construction and
age. Finally, the temporal imaging through narratives of Ybema (2004) called postalgia and nostalgia, and
stability narratives (Sonenshein, 2010) is interesting to conduct further research on. Even though this
research has partly proven that this concept exists throughout an organization, it is interesting to further
study this concept as the research sample was small. Perhaps there are differences between organizational
layers, types of managers, or between different roles on the work floor.

My recommendation is to conduct research through observations at Zonnehuisgroep Amstelland in

order to see the actions that organizational members take. By gaining access to the so-called 'work floor',
this study can be visualized and either confirmed, criticized, or neglected. During the fieldwork, caregivers
tended to be more open when executing their everyday practices. This may lead to new information, and
perhaps contribute to a more in-depth analysis of the discursive positioning, and the temporal imaging of
employees.

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References
Allard-Poesi, F. (2005). The paradox of sensemaking in organizational analysis. Organization, 12(2), 169-
196.

Alvesson, M., & Sveningsson, S. (2008). Changing organizational culture: cultural change work in progress.
New York: Routledge. Chicago (15th ed.)

Armenakis, A. A., Harris, S. G., & Mossholder, K. W. (1993). Creating readiness for organizational change.
Human relations, 46(6), 681-703.

Balogun, J., & Johnson, G. (2005). From intended strategies to unintended outcomes: The impact of change
recipient sensemaking. Organization Studies, 26(11), 1573-1601

Bartunek, J. M., Rynes, S. L., & Ireland, R. D. (2006). What makes management research interesting, and
why does it matter?. Academy of Management Journal, 49(1), 9-15.

Beech, N., Gilmore, C., Hibbert, P., & Ybema, S. (2016). Identity-in-the-work and musicians’ struggles: the
production of self-questioning identity work. Work, employment, and society, 30(3), 506-522.

Bell, D. (1973). The coming of the post-industrial age: A venture in social forecasting.

Bercovitz, J., & Feldman, M. (2008). Academic entrepreneurs: Organizational change at the individual
level. Organization Science, 19(1), 69-89.

Berger, P. L., & Luckmann, T. (1991). The social construction of reality: A treatise in the sociology of
knowledge (No. 10). Penguin UK.

Biernacki, P., & Waldorf, D. (1981). Snowball sampling: Problems and techniques of chain referral
sampling. Sociological methods & research, 10(2), 141-163.

Boje, D. M. (1991). The storytelling organization: A study of story performance in an office-supply firm.
Administrative science quarterly, 106-126.

Brown, A. D., Gabriel, Y., & Gherardi, S. (2009). Storytelling and change: An unfolding story. Organization,
16(3), 323-333.

Brown, A. D., & Humphreys, M. (2003). Epic and tragic tales: Making sense of change. The Journal of
Applied Behavioral Science, 39(2), 121-144.

60
References P. Dijkstra

Demers, C. (2007). Organizational change theories: A synthesis. Sage.

Dent, E. B., & Goldberg, S. G. (1999). Challenging "resistance to change." The Journal of Applied Behavioral
Science, 35(1), 25-41.

Denzin, N. K., & Lincoln, Y. S. (Eds.). (2011). The Sage handbook of qualitative research. Sage.

Ellis, N., & Ybema, S. (2010). Marketing identities: Shifting circles of identification in inter-organizational
relationships. Organization Studies, 31(3), 279-305.

Eubanks, D. L., Brown, A. D., & Ybema, S. (2012). Leadership, identity, and ethics. Journal of Business Ethics,
107(1), 1-3.

Feldman, M. S. (2000). Organizational routines as a source of continuous change. Organization Science,

11(6), 611-629.

Fiol, C. M. (2002). Capitalizing on paradox: The role of language in transforming organizational identities.
Organization Science, 13(6), 653-666.

Garcia, P., & Hardy, C. (2007). Positioning, similarity, and difference: Narratives of individual and
organizational identities in an Australian university. Scandinavian Journal of Management, 23(4), 363-383.

Geertz, C. (1973). The interpretation of cultures (Vol. 5019). Basic Books.

Gergen, K. J., & Gergen, M. M. (1997). Narratives of the self. Memory, identity, community: The idea of
narrative in the human sciences, 161-184.

Gilley, A., McMillan, H. S., & Gilley, J. W. (2009). Organizational change and characteristics of leadership
effectiveness. Journal of leadership & organizational studies, 16(1), 38-47.

Gioia, D.A., Schultz, M., & Corley, K.G. (2000). Organizational identity, image, and adaptive instability.
Acadamy of Management Review, 25 (1), 61-81.

Gobo, G. (2011). Glocalizing methodology? The encounter between local methodologies. International
Journal of Social Research Methodology, 14(6), 417-437.
Goffman, E. (1961). On the characteristics of total institutions. In Symposium on preventive and social
psychiatry (pp. 43-84). Washington, DC: Walter Reed Army Medical Centre.

Grey, C., & Willmott, H. (Eds.). (2005). Critical management studies: A reader. Oxford University Press.

61
P. Dijkstra Faculty of Social Sciences

Hatten, K. J., Schendel, D. E., & Cooper, A. C. (1978). A strategic model of the US brewing industry: 1952-
1971. Academy of Management Journal, 21(4), 592-610.

Hermanowicz, J. C. (2002). The great interview: 25 strategies for studying people in bed. Qualitative
Sociology, 25(4), 479-499.

Holt, D. T., Armenakis, A. A., Feild, H. S., & Harris, S. G. (2007). Readiness for organizational change: The
systematic development of a scale. The Journal of applied behavioral science, 43(2), 232-255.

Koot, W. (1997). Strategic utilization of ethnicity in contemporary organizations (pp. 315-39). London: Sage.

Krauss, S. E. (2005). Research paradigms and meaning-making: A primer. The qualitative report, 10(4), 758-
770.

Kuhn, T., & Corman, S. R. (2003). The emergence of homogeneity and heterogeneity in knowledge
structures during a planned organizational change. Communication Monographs, 70(3), 198-229.

Langley, A., & Tsoukas, H. (2010). Introducing perspectives on process organization studies. Process,
sensemaking, and organizing, 1(1), 1-27.

LeCompte, M. D., & Schensul, J. J. (1999). Designing and conducting ethnographic research (Vol. 1).
Rowman Altamira.

Levi, D., & Lawn, M. (1993). The driving and restraining forces which affect technological innovation in
organizations. The Journal of High Technology Management Research, 4(2), 225-240.

Maitlis, S., & Sonenshein, S. (2010). Sensemaking in crisis and change: Inspiration and insights from Weick
(1988). Journal of management studies, 47(3), 551-580.

March, J. G. (1981). Footnotes to organizational change. Administrative science quarterly, 563-577.

Martin, J. (1992). Cultures in organizations: Three perspectives. Oxford University Press.

Matos Marques Simoes, P., & Esposito, M. (2014). Improving change management: How communication
nature influences resistance to change. Journal of Management Development, 33(4), 324-341.

Ministry of Public Health, Welfare, and Sports. (2014, June). De maatschappij verandert. Verander jij mee?
Retrieved from: http://vwshuisstijl.nl/uploads/2014/07/vws-veranderingzorg-web.pdf

62
References P. Dijkstra

Nicolini, D. (2009). Zooming in and out: Studying practices by switching theoretical lenses and trailing
connections. Organization Studies, 30(12), 1391-1418

Oosterom, R. & Visser, M. (2017, November). Personeelstekort in de zorg is in een jaar tijd bijna
verdubbeld. Trouw. Retrieved from: https://www.trouw.nl/samenleving/personeelstekort-in-de-zorg-is-in-
een-jaar-tijd-bijna-verdubbeld~ab646e3c/

Patton, M. Q. (2005). Qualitative research. John Wiley & Sons, Ltd.

Piderit, S. K. (2000). Rethinking resistance and recognizing ambivalence: A multidimensional view of

attitudes toward an organizational change. Academy of management review, 25(4), 783-794.

Rhodes, C., & Brown, A. D. (2005). Narrative, organizations, and research. International Journal of
Management Reviews, 7(3), 167-188.

Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (Eds.). (2013). Qualitative research practice: A guide for
social science students and researchers. Sage.

Saunders, M., Lewis, P., & Thornhill, A. (2003) Research method for business students, 3rd edition. New
York: Prentice Hall.

Sonenshein, S. (2010). We're Changing—Or are we? untangling the role of progressive, regressive, and
stability narratives during strategic change implementation. Academy of Management Journal, 53(3), 477-512.

Staw, B. M., & Epstein, L. D. (2000). What bandwagons bring: Effects of popular management techniques
on corporate performance, reputation, and CEO pay. Administrative Science Quarterly, 45(3), 523-556.

Taylor, S. S. (1999). Making sense of revolutionary change: differences in members’ stories. Journal of
Organizational Change Management, 12(6), 524-539.

Thomas, R., & Hardy, C. (2011). Reframing resistance to organizational change. Scandinavian Journal of
Management, 27(3), 322-331.

Thomas, R., & Linstead, A. (2002). Losing the plot? Middle managers and identity. Organization, 9(1), 71-
93.

Thomas, R., Sargent, L. D., & Hardy, C. (2011). Managing organizational change: Negotiating meaning and
power-resistance relations. Organization Science, 22(1), 22-41.

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P. Dijkstra Faculty of Social Sciences

Tsoukas, H., & Chia, R. (2002). On organizational becoming: Rethinking organizational change.
Organization Science, 13(5), 567-582.

Van de Ven, A. H., & Huber, G. P. (1990). Longitudinal field research methods for studying processes of
organizational change. Organization Science, 1(3), 213-219.

Weick, K. E. (1995). Sensemaking in organizations (Vol. 3). Sage.

Weick, K. E., & Quinn, R. E. (1999). Organizational change and development. Annual review of psychology,
50(1), 361-386.

Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (2005). Organizing and the process of sensemaking.
Organization Science, 16(4), 409-421.

Ybema, S., & Horvers, M. (2017). Resistance through compliance: The strategic and subversive potential of
frontstage and backstage resistance. Organization Studies, 38(9), 1233-1251.

Ybema, S., Keenoy, T., Oswick, C., Beverungen, A., Ellis, N., & Sabelis, I. (2009). Articulating identities.
Human Relations, 62(3), 299-322.

Ybema, S., Yanow, D., Wels, H., & Kamsteeg, F. H. (Eds.). (2009). Organizational ethnography: Studying
the complexity of everyday life. Sage.

Zorginstituut Nederland,. (2017). Kwaliteitskader Verpleeghuiszorg. Diemen: Zorginstituut Nederland.

Retrieved from https://www.zorginstituutnederland.nl/werkagenda/publicaties/ publicatie/
2017/01/13/kwaliteitskader-verpleeghuiszorg

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Appendix I: Translations P. Dijkstra

Appendix I: Translations
ENGLISH DUTCH RESPONDENT
& MOMENT
I can still sing songs with the clients, songs from a long Ik ken die nummers van vroeger nog, dus kan ze makkelijk H2
time ago. The new employees don't know them, even meezingen. Nieuwe mensen kennen die niet, ook al is het Informal chat
though music is one of the strongest memories that is een van de sterkste herinneringen voor mensen die
sustained for a long time, even for people that suffer a dementie hebben.
form of dementia.

We are all fishing in the same puddle, and in the end, We vissen allemaal in dezelfde vijver. Het is nu ook een H1
it's about offering the highest wage. beetje van wie het meeste betaalt. Interview

Most employees work in nursing homes because they Meeste medewerkers hier doen dit werk omdat ze eigenlijk H2
are "simply not able to do any other work than this. vrij weinig kunnen qua werk. Interview

Of course they would prefer money over extra Natuurlijk zouden ze kiezen voor meer geld in plaats van H2
colleagues, this is nonsense. collega’s, dit is echt flauwekul. Interview

They just want to go home at 3:30 PM. Die willen best heel veel maar zeggen ‘ik werk hier tot half4 H3
en dan wil ik ook naar huis’. Interview

The nurses think they do it, but they don't. Ik zeg dus, van nee dat is dus niet zo. De zorg denkt dat we H1
het wel doen, maar het is niet zo. Interview

Making shifts more complicated by implementing new Ze maken het daar op kantoor alleen maar moeilijker voor P4
tasks, sitting behind their desk. ons, de diensten enzo, met allemaal nieuwe dingen. Informal talk

I think that when you look at a higher level within the Maar ik denk dat als je naar andere niveaus kijkt, P1
organization, management level, clients turn into management laag, dat het dan wel getallen zijn. Interview
numbers, yes.

She doesn't work in healthcare. Ja, ik weet dat niet of dat zo is. Ik bedoel zij werkt niet in P8
de zorg. Interview

We don't have to change. We hoeven niet te veranderen, het is opzich goed zo. P8
Interview

Another project will follow again anyways. En je ziet ook steeds meer dat projecten elkaar opvolgen, P8
dus dit zal dan geïmplementeerd worden maar dan weet je Interview
al van ja over een paar jaar wordt er weer iets nieuws
geïmplementeerd. Dus, dus de druk om allerlei nieuwe
dingen die op zich allemaal heel goed zijn in te voeren is
natuurlijk hoog, de interesse een stuk lager.

Just act like they have always done. Ja natuurlijk, ze praten overal in mee en ja leuk en P1
interessant. Maar zodra ze zich omdraaien en ze lopen de Interview
afdeling op en doen gewoon weer gewoon zoals ze het
altijd deden.

For how long they will stay? No idea. Perhaps again for Maar hoe lang dit zo blijft? Geen idee. Misschien wel weer P5
a very short time. heel kort. Informal talk

I hope she stays. Wel heel blij met de ondersteuning voor 20uur per week, P7
die doet dan een spelletje, smeert het brood en geeft eten. Interview
Erg fijn voor nu. Hopelijk blijft ze

We really needed this. De woonbegeleiders zijn een zegen, er is meer tijd en rust P6
op de afdeling. Dit hadden we nodig. Informal talk

She was afraid of her death, that she would be buried Ze was bang voor de dood, dat ze al begraven zou zijn P7
while she was still alive. I spoke to her about it, and while terwijl ze nog leeft. Daar heb ik het met haar over gehad en Interview
she was already quite sleepy, I held her hand, turned on terwijl ze eigenlijk al best wel moe was, heb ik uiteindelijk
music, while she kept looking at me with those fearful haar hand vastgehouden en muziek aan gezet en ze bleef
eyes. I sat down next to her, holding her hand when she me aankijken met die angstige ogen. Toen ben ik naast
fell asleep. She was finally calm again, and slept for haar gaan zitten op de grond, hand vasthouden en viel ze
hours. zo in slaap. Toen was ze eindelijk rustig en heeft ze uren
liggen slapen.

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It's not something you do for money, but for fun. Het is ook een beetje een roeping. Je moet het doen omdat P2
je het leuk vindt, niet om je geld mee te verdienen. Dat is Interview
een heel belangrijk aspect in de zorg.

I have a rather small amount of administrative work to Ik heb niet heel veel administratief werk te doen, maar er P8
do, but there's too little time for personal-care, there's is wel te weinig tijd voor de client, simpelweg geen ruimte. Informal talk
simply no space for it.

I love my work, it's my passion. Ik houd van m’n werk, het is een passie. Ja. P8
Informal talk

Family can interpret things in a wrong way, which can De familie kan dat dan weer verkeerd interpreteren, heel P2
cause a vexing misunderstanding. vervelend misverstand kun je daardoor krijgen. Interview

We will work it out again, one way or another. Links of rechtsom gaat het ons vast wel weer lukken P4
Interview

Everyone within the healthcare sector puts the client in Iedereen doet het al. Nu bedenken zij opeens dat de cliënt P7
a central position, and now you hear from above that centraal moet en nu moeten we ineens alles gaan Interview
they should be put in a central position and change veranderen
everything.

If I look at myself and at my colleagues, I think the client Mensen zijn heel erg geneigd te kijken naar wat de cliënt P3
is already very much in a central position. nog fijn vindt. Ik denk dat als ik naar mezelf en naar m'n Interview
collega's kijk dan denk ik dat de cliënt hier heel erg centraal
staat.

Many things happening at the same time”, said a En nu moet het er allemaal bij en naast. Heel veel H3
manager, “which was difficult for employees to handle. medewerkers kunnen dat gewoon niet tegelijk allemaal Interview
behappen.

The most important reason of the reorganization was Het management, dus de laag waar ik in zit, met de helft H3
the financial situation, which was terrible. At the same eruit. Dus dat was voor medewerkers heel moeilijk om dat Interview
time, the Board came up with self-organizing. By many te scheiden van elkaar. En dat heeft Nelleke zelf ook
colleagues that have been received as a disguised onderkend, die heeft na een jaar ook een rondje langs alle
retrenchment, because in self-organizing you roster as a locaties gemaakt om nog een keer uit te leggen dat de
team, which meant that all schedulers were fired. Self- timing niet goed was, ze kon niet anders, want de
organizing means that you guard the quality of health reorganisatie had gemoeten. Achteraf had ik beter een jaar
care yourself, which meant that all quality guards were kunnen wachten met die zelforganisatie door te voeren,
sacked. In self-organizing teams, you learn to adopt new dan was het duidelijk los van elkaar geweest. Dat is nu wel
processes yourself, which meant that all trainers-on-the- overal doorgedrongen dat het echt iets anders is. Dat is
job were dismissed. The management, the layer I’m in, door heel veel collega’s opgevangen als dat het een
half of them dismissed. That, the self-organizing teams, verkapte bezuiniging is. Want bij zelforganisatie hoort je
was for employees hard to distinguish from a roostert zelf, alle roosteraars zijn ontslagen. Bij
retrenchment. The board has recognized this and has zelforganisatie hoort dat de kwaliteit van zorg zelf bewaakt
visited all nursing homes a year after the retrenchment, wordt, bijna de hele afdeling kwaliteit is ontslagen. Bij
to explain that the timing wasn't good, but that there zelforganisatie hoort dat je nieuwe processen jezelf eigen
was no other choice. They admitted that it would have maakt, de trainers on-the-job zijn ontslagen
been better to wait for one more year because then it
would have been clear that the self-organizing teams
and the retrenchment are separate from each other.
That is now understood by employees, but at first they
felt as if the Board didn't know how things worked at
ZHGA.

My role as a manager is shifted more and more to the Zeker nu bij zelforganiserende teams wordt mijn rol steeds H3
background due to the self-organizing teams. A bit of meer naar achteren geschoven, beetje coachend en Interview
coaching and facilitating. They have to keep an eye on faciliterend. Ze moeten elkaar dus nu scherp houden.
themselves now.

I think it's very important that the people around them, Ik denk dat het heel belangrijk is dat de mensen eromheen, H3
like me and the policymakers, should take care of the zoals ik en beleidsmakers, dat we met elkaar zorgen dat ze Interview
fact that they create a chance to center the client. de kans krijgen om die cliënt centraal te zetten.

Another manager stated that, apart from a lack of time Maar er is wel behoefte en de zorg vind ik, besteed te H1
to spend on personal attention, change recipients find it weinig aandacht aan mensen. Gewoon aan de mens zelf. Interview
unimportant to bring this personal aspect into their Daar hebben ze nouja, sowieso geen tijd voor zeggen ze.
daily work. Maar vinden ze ook niet zo belangrijk.

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Appendix I: Translations P. Dijkstra

What if your mother lives here, what would you want Zo van, wat als jouw moeder nou de cliënt is wat zou jij M1
then. willen. Ja dan is het al, dan komt het heel dichtbij. Want Interview
dan zou ik het allemaal wel dit en dat.

Is there a lot of space for improvement? Yes, they are Is er veel winst nog te behalen dan? Ja! De medewerkers P7
able to do it much better. kunnen het veel beter doen. Interview

This project hasn't really started yet, and we have little Dat project loopt echt helemaal nog niet, dus we hebben P8
to do with it. er eigenlijk weinig mee te maken. Interview

From there's a lot of pressure by management to Zit er heel veel druk achter vanuit het management om dit H1
implement this project. project door te voeren? Ja behoorlijk wel. Interview

I've heard of it, but don't work with it as far as I know. Ik heb van het project gehoord, maar werk er zelf hier P2
verder niet mee. Niet voor zover ik weet in ieder geval. Interview

I hadn't heard of it, that's why I was very interested to Ik had er nog niet van gehoord, vandaar dat dit me wel P3
talk to you. interessant lijkt. Interview

That project doesn't really ring a bell, but yeah, you hear Het doet niet echt een belletje rinkelen, maar je hoort er P1
a lot about centralizing the client. wel veel over, dat cliënt centraal. Interview

That it would be very sloppy if I wouldn't have known De cliënt centraal staat in onze missie. Dus het zou wel H3
about it, because it's in our mission. heel slordig zijn als ik er niet vanaf had geweten. Interview

That's quite typical, that there's actually no, at least I've Dat is ook wel het typische, dat er eigenlijk geen tenminste P7
never heard of it, that someone said within the ik heb het nog nooit gehoord, nog nooit heeft iemand Interview
healthcare sector that they want more salary. They all gezegd binnen de zorg van ik wil meer salaris, allen zeggen
say that they want an extra person, more colleagues. ze ik wil er wel een poppetje bij. Meer collega's.

It is not something you do for money, but for fun. Het werk doe je niet voor het geld maar omdat je het leuk P2
vindt. Interview

There aren't many changes, the client has always been Er zijn niet zoveel veranderingen, de cliënt staat natuurlijk H1
the core focus. altijd centraal. Dat is niet zo van nu zetten we de cliënten Interview
echt centraal. Daarbij proberen we meer rekening te
houden met de familie en de cliënt, dat vinden de
verzorgers toch nog wel eens lastig.

It's old wine, put into new jars. Het is oude wijn in nieuwe kruiken. H3
Interview

We've always had the client as our main job. Als je eigenlijk al het idee hebt dat je het altijd al hebt P7
gedaan, de bewoners belangrijkste zijn, dat het altijd al zo Interview
geweest is.

If you, often, or daily, don’t sustain the emotional Als je dat heel vaak hebt, als je dat dagelijks hebt, als je dan P1
distance with the client you will end up feeling niet die afstand met de cliënten houdt dan ga je eraan Interview
miserable yourself and you can’t sustain that. I won’t do onderdoor dus houd je het niet vol. Ik doe dat niet, ik kan
it, I can’t handle it. daar niet tegen.

If there’s more time for the client, then we increase our Als er meer tijd is voor de cliënt dan kunnen we meer
attention. Otherwise it’s just washing, showering, aandacht besteden. Anders is het echt alleen maar wassen, H1
dressing up, feed. Where is the actual attention for douchen, aankleden en eten. Waar is dan de Interview
them? daadwerkelijke aandacht

We can never do it as well as the family, cooking that We kunnen het gewoon nooit zo goed doen als de familie. H2
nice, and giving the personal attention. We can't provide Het eten smaakt anders, en de persoonlijke aandacht voelt Interview
that, only within our possibilities. Then you should look anders. Dat kunnen we niet, alleen maar binnen de
for a different nursing home, but they won't give that mogelijkheden. Je zou dan moeten gaan zoeken voor een
either. ander verzorgingshuis, maar zij kunnen dat ook niet hoor.

My mother always wears the same clothes, I want from Ik wil nu dat mijn moeder, ze heeft altijd dezelfde kleren H1
now on that wears other clothing'. But this is what aan. Dat doet die mevrouw, die vist het uit de wasmand en Interview
happens, she grabs these clothes out of the dirty laundry die trekt het dan zelf aan. Wat doe je dan? Of we hebben
basket and puts her dress on. What do you do then? Or ook eens iemand gehad die was gek op hagelslag, en ja. Als
a woman who loved chocolate sprinkles. What happens je hagelslag eet dan zie je er niet altijd, ook al heb je een
when you eat chocolate sprinkles is that, even while servet om, dan ga je wel eens knoeien of het komt op je
wearing a napkin, you spill a bit and might end up on broek en heb je een vieze plek. Op dat moment komt de

67
P. Dijkstra Faculty of Social Sciences

your trousers, causing a dirty spot. At that moment her dochter binnen, WAAAT? Heeft ze helemaal geen schone
daughter comes in and says: ‘WHAT? She is not wearing kleren aan. Ze zit onder de chocola. Dat komt dan door dat
any clean clothes, all covered in chocolate'. Yeah, that is broodje. En wat kies je dan?
because of her sandwich. What should you choose at
this moment?

What happens is that family, for example, thinks that Maar wat er wel gebeurt is dat familie bijvoorbeeld denkt H3
their mother or father still wants to do a lot of things, dat vader of moeder nog van alles kan of wil. Terwijl die Interview
and is able to participate. But that mother or father moeder of vader dat helemaal niet meer wil of kan.
doesn’t want to do that anymore at all.

From then onwards it becomes hard for us because Dat zijn voor ons hele lastige dingen, want uiteindelijk is H3
family has a decisive role and we, as professionals, only het dan ook de familie die doorslaggevend is en hebben wij Interview
an advising role. We try to talk with family members to daar een adviserende rol in. Maar dan gaan we wel het
convince them that the resident is of greatest gesprek aan met familieleden om ze proberen te
importance. overtuigen van het belang van de bewoner want dat staat
voor ons natuurlijk voorop.

It sticks to the interpretation of the children. They say; Het blijft een beetje de interpretatie van kinderen. Dit P7
this is what my mother really likes and dislikes. But yes, vindt mijn moeder prettig, dit vindt mijn vader prettig. Dit Interview
perhaps that has changed over time, you will never niet. Misschien is dat in de tussentijd wel verandert, dat
know. weet je niet.

This image sticks to the relatives. But what if this all Daarnaast geven verwanten hobby's en interesses door van H3
changes and someone wants to start a new hobby? We hun vader/moeder die van oorsprong uit hun goede jaren Interview
have to anticipate to that. komt, dat beeld blijft bestaan. Maar wat als dit ook
allemaal nog verandert en iemand een nieuwe hobby wil
beginnen? Daar moeten wij op in kunnen spelen.

Sometimes they become our extension. Their mother Het ideale is, dat gebeurt ook vaak. Dat de familie gewoon P1
has to go for a walk three times a day, and they are echt een verlengstuk wordt van ons. Mevrouw moet Interview
helpful and come over in the evening” eigenlijk drie keer per dag even een stukje lopen en dan dat
regelen we dan s’avonds even.

If we don’t have information on that person, we can’t Als we die informatie niet hebben kunnen we ook niks. Het P2
provide the best service. Otherwise it’s an endless trail- blijft toch altijd trial en error. We hebben die informatie Interview
error story. We need this information from the family in nodig, maar soms zijn ze gewoon lui en verwachten ze veel
any way possible. But sometimes they are just too lazy van ons. Er kan ook een complete karakterverandering
to provide it and they expect us to know everything and zijn, dus dat kan ook helemaal anders zijn natuurlijk. Het
that we are able to do everything for them. It’s not staat toch niet op hun voorhoofd wat ze willen?
written on their forehead, is it?

Often, for us, it’s not only attention for the resident, but Dus het is vaak voor de zorg niet alleen maar aandacht voor H1
also for the family. Because it’s just like that, the family de bewoner, maar ook vaak aandacht voor de familie. Want Interview
decides. dat is ook gewoon zo. Het is de familie die bepaalt.

Based on the information and stories that I directly get Aan de hand van informatie en verhalen die ik rechtstreeks P9
from family, I know what these people have done and krijg van familie weet ik wat die mensen hebben gedaan en Interview
what they love, and of course what they don't love. waar ze van houden, en natuurlijk waar ze niet van
houden.
Your mother, your father, he or she lives here. We have Uw vader, uw moeder, die woont hier en waar ze behoefte M1
to hear from you which needs and wishes this person aan heeft moeten we van jullie horen. Vertel het ons maar. Interview
has, so tell us!

It's different than let's say ten years ago, where people Het is anders dan pakweg 10 jaar geleden, waar de mensen P9
were in need of basic health care, dressing, showering, de behoefte hadden aan basiszorg, douchen, aankleden, en Informal talk
and other daily tasks. It felt as if this was their home, andere dingen. Dit was hun huis, en de andere bewoners
they were accompanied by people the same age, and hadden dezelfde leeftijd en speelden spelletjes. Nu hebben
they were able to play games. Most of the residents now de meesten dementie, vaak al kritiek, echt een hele nare
are suffering a form of dementia, mostly already in one ziekte. Zodra ze binnenkomen gaat het meteen al zo slecht.
of the last phases of this horrible disease. Once they Ze vinden het lastig om aan te passen, en snappen wat er
enter through the doors, it gets worse very quickly. They gebeurt. Soms is er ook weinig meer te doen om ze te
find it hard to adapt, leaving their own home and not vermaken omdat ze niet eens weten wie ze zijn, dus wie
understanding what is happening to them. There's zijn wij dan nog?
sometimes little to do to entertain these people because
they don't even know who and where they are, so what's
there for us to do?

In some homes, you just can't do it anymore. That Sommige woningen kan het ook gewoon echt niet meer, P3
freedom of choice? We would love to do it, but they are die keuzevrijheid. Soms zouden wij wel heel erg graag Interview

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Appendix I: Translations P. Dijkstra

already in a far state of dementia and therefore it's barely willen, maar dan zijn ze al zo ver in de dementie dat het
possible anymore. This makes it hard because then you gewoon echt niet meer kan. Dan is het wel lastig, want dan
have to make a choice yourself. moet je een keuze maken.

Well, if someone suffers a form of dementia, then this Nou is het zo dat als iemand dementie heeft dan vervalt die H3
self-management sort of expires, but then the relatives regiefunctie natuurlijk heel erg, maar dan hebben die Interview
come up with completely different requirements and kinderen vaak weer heel andere eisen en wensen ten
desires for their beloved ones aanzien van de zorg van hun ouders.

I find it hard when you recognize that there’s no Ik vind dat lastig in die zin dat je merkt dat als er geen P3
decision made by the resident, that they turn restless. beslissing genomen wordt dat mensen met dementie Interview
onrustig gaan worden.

Some just can't tell us anymore, they're not in the Sommigen kunnen het niet meer vertellen, ze zijn niet P8
position. This can be because of all sorts of reasons. We meer in die positie. Dit kan vanwege allemaal dingen, maar Informal talk
try to do it as much as possible at the people who are we doen gewoon ons best voor de mensen die het nog wel
still able. You will ask: ‘What would you like? kunnen. Dan vraag je waar ze behoefte aan hebben?

The client is always number one, always the center of De bewoner gaat altijd voor, de cliënt centraal natuurlijk. H1
our work. The family is, of course, important, as a De familie is wel ook heel belangrijk natuurlijk. Een Interview
daughter is always closer to the client than any nurse. dochter staat uiteindelijke altijd dichterbij dan elke
verpleegster.

Because the book-of-life had to be filled in by family, Omdat het levensboek door familie ingevuld moest H1
including all sorts of photos, images, and all that. They worden met foto's, allerlei plaatjes en dat soort dingen. Dat Interview
found it too much effort. We have the experience that vonden ze te veel werk. De zorg heeft de ervaring dat die
those books end up in a drawer, it was too colossal. boeken in een la belanden, het was te kolossaal. Mensen
People just want a short overview, a short story, like the willen nu gewoon een kort overzicht, een kort verhaal, wie
new project ‘who-am-I'. A few questions, whereas it was ben ik inderdaad. Paar korte vragen, waar het vroeger een
an art product before. People just didn't want that, it was heel museumstuk was. Dat willen mensen gewoon niet, het
too much. The new method is way more practical. was too much. Dit is veel zinvoller.

This in-house support is a blessing, there is more time De woonbegeleiders zijn een zegen, er is meer tijd en rust P9
and peace within the department. We needed this. op de afdeling. Informal talk

The quality framework is the core of project CC at Het kwaliteitskader is de basis voor cliënt centraal bij M2
ZHGA. All information, more or less, necessary for the ZHGA. Alle informatie staat er eigenlijk wel zo in. Dit Informal talk
best service for the client is included in the report. We hebben we nodig omdat het belangrijk is om de beste
give it our own touch. service te verlenen. We geven er onze eigen draai aan.

There was always a heart for the quality of life, but we Er was altijd hart voor kwaliteit van het leven, maar dat H3
filled it in for the residents, even though everyone has vulden wij vervolgens voor hen in terwijl iedereen Interview
different wishes and demands natuurlijk andere mensen heeft.

The entire health sector is based on what we should do Om maar even aan te geven, heel drastisch gezegd, dat en M1
as health care providers to make things more ook de hele manier waarop we het zorgplan hebben Interview
comfortable. We have the care plan, and we provide this opgebouwd is ook heel erg vanuit de zorg bekeken. Want
care. What should we do for the client? It's all about our we hebben het zorgplan van een cliënt en wij gaan zorg
position towards the client, instead of: I'm the client, leveren aan de cliënt. Wat moeten wij dus doen voor de
and I would like to be taken care of by your organization. cliënt? Dus het is allemaal van wij wij wij, naar de cliënt
i.p.v. ik ben de cliënt en ik wil zorg bij jullie.

What people have to learn again is that when you enter Wat mensen weer moeten leren is dat als je bij iemand H1
someone's room, you can say ‘hello' to them, but also binnenkomt kun je ook gewoon groeten, maar ook een Interview
just start a conversation. I can tie your wound, but talk gesprekje beginnen. Ik kan met jou, jouw wond verbinden,
to you at the same time. People have lost that ability, I maar ik kan ook gewoon met jou praten tegelijkertijd. Dat
figured. If I talk with the employees, they just do their zijn heel veel mensen toch verleerd. Dat valt mij op. Als ik
work. ook met de zorg praat, ze doen hun ding.

We have to stop thinking out of systems, but start Ik denk dat onze, dat wij daar gewoon niet heel erg die P8
thinking from the perspective of people that use health mindset voor hebben. Meer methodisch. Wij zijn heel erg Interview
care. gewend van ik bekijk iemand en dan vind ik daar iets van,
en zo benader ik dat.

Back in the days I could still take time for the client, and Vroeger kon ik wel gewoon tijd voor de cliënt nemen, een
play a game. We can’t anymore. Now they have hired spelletje spelen. Dit kan niet meer. Nu hebben ze er P9
someone to do it for us. speciaal iemand voor aangenomen. Informal talk

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We tied people to heaters in the living room when they We bonden mensen vast aan kachels als ze rusteloos H2
were hard to keep an eye on, and they would either walk waren. Dit was makkelijker. Anders zouden ze een gevaar Interview
away or be a risk to others when left untied. kunnen zijn voor zichzelf en anderen.

I definitely think that it's due to the fact it has been in Denk dat het er zeker mee te maken heeft dat er zoveel op P7
the news often, the terrible image within the nursing het nieuws is geweest, dat het zo slecht is binnen de Interview
homes. They have a bad name of course. verpleeghuizen. Zij hebben een slechte naam natuurlijk.

You see this in society, people are more assertive, want Zoals ik zei, mensen worden anders oud. Dit zie je terug in H3
to make their own decisions and all that. de maatschappij. Mensen zijn mondiger, willen zelf keuzes Interview
kunnen maken en alles.

People turn old in a different way than the nursing- Mensen worden anders oud, jazeker. Dit zie je terug in P4
homes and employees are used to. verzorgingshuizen en bij medewerkers, dat is wennen. Informal talk

Most of the times it's the image of nurses who are very Want er ligt ook vaak een beeld van je bent alleen maar P3
busy, running around, and only cleaning poop. This poep aan het ruimen, alleen maar druk, terwijl dat beeld is Informal talk
image is not correct and not how it actually is. But you denk ik niet helemaal terecht en niet helemaal reëel. Maar
can only experience that by visiting one of these nursing dat kan je alleen ervaren door gewoon inderdaad eens rond
homes and to see it by yourself. te kijken op een locatie of op een wooncentrum van goh, is
dat echt zo. Is dat mijn beeld en klopt dat?

Now one of our colleagues has a new cat, a Siamese cat, Nu heeft een van onze collega's een nieuwe poes, een H3
who is called Kees. One of the residents also had a Siamees en die heet Kees. Die collega komt nu elke week Interview
Siamese cat in the past. That colleague will bring her een uurtje met de kat hierheen om met die kat bij haar te
cat, every week, for an hour to sit with the cat next to zitten, als die foto's dan ziet is het gewoon ontroerend. Zo
her. If you see these pictures, they are so heartwarming. blij dat ze is, Kees is er weer!
She’s so happy, yelling: “Kees is here again!”

Then, one of the caregivers already entered the room Een van de medewerkers ging dan eerst even de kamer H2
before the alarm would go off. She would switch on binnen om de wekker af te zetten, en dan zachtjes de Interview
classical music, very quietly, which would wake her up muziek aan, klassiek, heel zacht. Dit zou haar dan wakker
in a very pleasant way. They would leave her in bed for doen worden op een aangename manier. Dan lieten ze haar
another fifteen minutes, so she could cuddle nog even in bed liggen voor een kwartiertje, dan kon ze nog
comfortably. lekker smoezelen.

We will work it out again, one way or another. We doen het wel weer, het gaat lukken, hoe dan ook. P4
Interview
We think this project is a very nice way to let employees Wij denken dat dit project een mooie manier is om M1
think about for example how they build reports and verzorgenden te laten reflecteren, nadenken over hoe zij Interview
question their mindset. Because then they think. Wow rapporteren en afvragen hoe ze hun werk doen. Zo denken
I’ve never thought of that. zij namelijk van: Wow, daar heb ik nog nooit aan gedacht.

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Appendix II: Book-of-Life Form

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Appendix IV: Who-am-I Form

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