This paper illuminates the way multiple narratives concerning urgency for change dynamically interact on different levels and influence change processes in healthcare organizations. It explores the processes of sensemaking and opposing urgency narratives during a period of implementation for new legislation within the Dutch healthcare sector. Building on recent debates on process theory, narratives, and temporality, a new perspective on change urgency is presented, which shows how urgency is not unilaterally created from one position but is produced and reproduced by different editors in a narrative struggle. A temporal framework for change urgency was developed to study these narrative dynamics. Three urgency narratives contested the dominant narrative in the public discourse. The article shows how directors of healthcare organizations, dominated by these narratives, also hold narrative power. Managing change processes implies managing discourse.
Worldwide, healthcare faces challenges due to rising expenditure as populations grow and age, technologies advance, and chronic conditions increase [
Through processes of sensemaking and discursive construction, situations become problems [
Although several studies have contributed to insights on the role of temporality in the unfolding of change [
While narrative analysis focuses on sensemaking and sensegiving, critical discourse analysis focuses on the way power is exercised though language and how some narratives are privileged over others [
This paper takes a “critical-action research approach” [
1) The structure and interrelationships of urgency narratives;
2) Narrative characteristics, focusing on temporal elements and discursive logic;
3) The key producers and editors of these narratives; and
4) Narrative techniques in use.
Following Vaara and Tienari [
Date/Year | Key Events |
---|---|
Prior to 2014 | |
4/2013 | Letter of the minister and secretary of state to parliament to announce the future of long-term health care and a new law (the WLZ) in place for 2015 |
In 2014 | |
4/2014 | Several interest groups of patients, employees, municipalities, and healthcare facilities call for a postponement of the announced changes |
11/4/2014 | Two seniors sound the alarm in a newspaper about the failing of healthcare services for their demented wives. One of them is the father of the secretary of state |
11/4/2014 | One of the seniors debates the secretary of state about on Pauw, a daily talk show, about the present situation in healthcare facilities and the announced changes in long-term healthcare |
11/17/2014 | A parliamentarian of the ruling left-wing party goes on Pauw to debate an opposition parliamentarian and argues that the management in healthcare facilities is to blame for the poor health care provided by such facilities |
1/2015 | Implementation of the new healthcare law WLZ |
provides an overview of the main chronology of events. The research materials were closely read to interpret emergent meanings in the narrative logic [
To further analyze the narratives, we investigated their development and issue attention in the nine newspapers. Because issue attention is crucial for changes in the public domain [
Dutch governmental agencies such as the Ministry of Health, Welfare and Sports, were key producers of the “brink of disaster” narrative (disaster-narrative). The concept concerned the entire system of long-term health care. The subject position of the key producer was the affordability of the current healthcare system in the future and the need for structural change. According to this narrative, because of the growing relative number of pensioners and higher life expectancy, the Dutch healthcare system was becoming too expensive. If no action as taken, health care would quickly become problematic: in other words, the Netherlands was on the brink of disaster. To solve the problem, key editors argued that structural changes in the healthcare sector were necessary. In the government messages, it was clear that there was going to be crisis if there was no response to the urgent situation. Consultancies such as McKinsey also emphasized the problem by explaining how, by doing nothing to cut costs, the Netherlands would end up using roughly one quarter of its GDP and one quarter of the working population to provide curative healthcare (cure) and long-term healthcare (care) [
The tone of this narrative was a little frightening; the whole country was on the brink of disaster, which called for a quick and strong response. In this narrative, the quality of health care was also problematized. In the Pauw broadcast, the secretary of state stressed the aggravation of the level of health care for which the nursery homes were not prepared [
It was important for key editors to stress the autonomy and independence of the patient because the new law was designed so that certain nursing tasks would not be part of the secured health care in the future. As a result, in this narrative the patients’ social networks were considered strong and able to take over these tasks. Moreover, the current system had become a patch for loneliness. In this narrative, the idea was that the Netherlands should not go back to a time when social participation was dependent on charity. At the same time, a society in which loneliness was solved through financed and insured healthcare as unappealing idea in this narrative [
Several stakeholders in the healthcare industry stressed their concern about the tempo of the proposed changes through press releases, petitions, and letters to the Parliament [
Lastly, three political parties―SP, CDA and Groen Links―in the Dutch parliament also wanted the government to postpone the structural changes. Their common argument was to allow more preparation time for the municipalities, but their individual arguments differed. For instance, Mona Keijzer of the CDA argued that the feedback from society hopefully would not fall on deaf ears [
This narrative did not challenge the core elements of the disaster-narrative. The “postpone narrative” (postpone-narrative) focused particularly on the timing and tempo of the implementation of the changes. From a temporality perspective, it is remarkable that the “newly designed” future was portrayed as highly problematic. There were no objects in this narrative, although “vulnerable patients” were mentioned in general. It was important to stress the vulnerability of the patients, because to make this narrative powerful, it was necessary to dramatize the consequences for the people involved.
Key editors of the “shit hits the fan right now” counternarrative (shit-narrative) were two proclaimed whistle-blowers. They shared their story about how poorly their wives were treated in a Dutch nursing home in the newspaper Algemeen Dagblad on November 4, 2014. Several national newspapers and other media organizations picked up the story. The concept in this narrative was the situation in nursing homes. In the Algemeen Dagblad article, the secretary of state’s father explained how his wife received poor supervision and support for her incontinence: “When she stands up, the urine is flowing down her ankles.”
The father of the secretary of state went on to explain that often there was no staff around, especially on weekends. People called him the “servant” because he watched over the patients. Together they expressed their discontent in the paper by explaining that employees did not wait by the patient until the pills were swallowed, because the workers claimed they had no time. The father explained that he found pills in the ashtray or in the pockets of his wife’s trousers, which he thought problematic because she has diabetes and high blood pressure. “Sometimes there is only one nurse who must service three rooms with six patients per room” [
During the broadcast of the talk show Pauw later that evening, the other whistle-blower―in conversation with the secretary of state―emphasized the problematic and inhumane situation in the nursing home where his wife lives. In this broadcast, the shit-narrative encountered the disaster-narrative. The whistle-blower argued that at that moment, the nursing home already had to work with insufficient personnel because of recent budget cuts. He wondered what would happen in 2015, when more budget cuts were planned. In this narrative, the concept of the proposed structural changes was referred to as budget cuts by both the whistle-blower and the opposition parliamentarian [
From the temporality perspective, it is interesting to see how the key editors paid significant attention to the present to explicate their position on the urgency for change. Within the narrative, they used information about structural changes as part of an argument for how the situation would go from bad to worse. The objects are patients, who were portrayed as being dependent and needy. This strongly contradicted the disaster-narrative, in which patients were portrayed as independent, autonomous individuals. Like the postpone-narrative, it was important to dramatize the consequences for people with whom a listener would probably sympathize. One of the whistle-blowers died shortly before the broadcast of Pauw on November 17, and was called a hero and whistle-blower during the talk show.
Another parliamentarian and the secretary of state (both members of the same left-wing party) produced a new counternarrative to respond to the shit-narrative. In this counternarrative, the management of the nursing homes was made a scapegoat, to allow politicians to dodge the blame placed on the government by the shit-narrative. The parliamentarian argued that the story of the whistle-blowers was “unfortunately not a unique situation but an unpleasant reality” [
According to this parliamentarian, low overhead should be the norm: good examples existed, and the focus should be on these organizations. Shortly after November 4, the secretary of state also edited this narrative by taking extra measures and linking them to the development of a law for good management in health care: “Nursing homes where healthcare service is insufficient will receive enhanced surveillance of the inspection for healthcare. Management of organizations that repeatedly do not perform will be addressed. If there are no improvements, another organization should take over the management of the facilities” [
To show how the disaster-narrative and its counternarratives are connected, we draw attention to the four core textual structures and how they relate to one another. The overview of
To analyze how the four narratives developed and declined over time, we examine their issue attention in the nine studied newspapers and then inspect the narrative field and the characteristics of the four narratives. Because the item interviewing a whistle-blower and the secretary of state was published in the Algemeen Dagblad, this newspaper was one of the main editors of this narrative.
When considering the appearance of all news items on the long-term healthcare situation in 2014,
Three of the four narratives peaked in November. The shit-narrative responded to the disaster-narrative and both received attention in the newspapers.
Narrative | Narrative technique |
---|---|
Disaster-narrative | Framing: framing the current long-term health care in a financially problematic way; only a quick response can solve the problem. Fitting facts: using specific data to support the narrative (estimations of the future healthcare costs per family). |
Postpone-narrative | Framing: framing the implementation of the WLZ in a problematic way for the organizations involved; only postponing WLZ implementation will solve the situation. Means-to-aims: while the problem in the disaster-narrative is affordability and the solution is a quick implementation, in this narrative the focus is on the means, that is, the timing and pace, which is problematized. |
Shit-narrative | Framing: framing both current long-term health care and the WLZ in a problematic way for the receiving party: the patients. The WLZ is framed as an additional budget cut. Scapegoating: the government is to blame for the inhumane situation and should stop economizing on health care. |
Scapegoat-narrative | Framing: framing the current situation in health care facilities is caused by the management in these facilities. Omission: to counter the shit-narrative, key elements of the shit-narrative, like the WLZ and budget cuts, are omitted; the current inhumane situation is uncoupled from the healthcare reforms. Scapegoating: the management at the facilities―not the government―is to blame for the inhumane situation and should be removed. |
The narrative analysis shows a polyphonic debate as the different narratives struggled for attention. Three narratives countered the initial disaster-narrative. The narrative struggle reveals how different editors highlighted different aspects of the changes, took different temporal positions, and adopted various narrative techniques. The disaster-narrative resembles Ybema’s postalgia, a dark future contrasting with the problematic present, while the shit-narrative more closely resembles nostalgia. The scapegoat-narrative responded to the problematization of the present and dodged the shit-narrative by scapegoating the management of the nursing homes. Because the shit-narrative was potentially a hiccough for the implementation of the new law, the scapegoat-narrative seems to be designed to defeat the shit-narrative and clear the way for the new law to take effect in January 2015. Moreover, the interests of the editors in the narratives become visible, by which they become power devices. The narratives aimed to win the narrative struggle and shift the field of health care in a direction matching the interests of its stakeholders. For instance, the shit-narrative seems to secure the interests of patients receiving health care today. This narrative was followed by
the scapegoat-narrative, which had significant consequences for people that manage healthcare facilities. The following section allows four healthcare directors to comment on these narratives.
This section presents interpretations of these four narratives by healthcare directors. Four directors were interviewed in retrospect as to whether they recognized and perceived the four macro-level narratives. The focus was on whether they believed these narratives contributed to stability or change, as well as their own personal urgency narrative. All four directors recognized the four narratives as presented in Section 3 of this article; their reactions are summarized for each narrative.
Disaster-narrative. The four directors argue that the affordability of long-term health care was the strongest issue of the narrative. They feel this element of the narrative was eventually neglected by its main editor, the secretary of state. An absent but relevant element of the disaster-narrative was the connection between the aggravating level of health care and education and schooling. Although they all stress the autonomy of patients, they question the assumption that patients possess a strong social network. One director argues that the families of patients are also old and therefore not always capable of taking care of their relatives. All directors recognize this narrative as part of the management discourse, not of the employee discourse. They view this narrative as a change narrative, although they needed to reframe the narrative for their own change agenda.
Postpone-narrative. For the directors, the postpone-narrative contributed to stability. All directors recognize the magnitude of the changes, but they believe the call for postponement did not help overcome the challenges. One director explains how this narrative contributed to doubt among stakeholders, but also among colleagues working in the projects preparing for the implementation of the new law. The main editors of the narrative claimed to represent the workers within the sector, but these directors contest this. One manager suggests that this narrative was the product of power play by some very powerful healthcare directors within the industry organization Actiz.
Shit-narrative. All directors say the shit-narrative contributed to stability and contradicted the disaster-narrative: when you stress patient autonomy and reducing the amount of health care, incidents like those contained in the shit-narrative are a consequence that should not be problematized. Mismanagement of incontinence is part of the life of these patients, they say. Framing these situations as serious incidents contributed to more rules and regulations and less focus on learning and development. Two directors explain how they experienced their own variant of the shit-narrative. With the help of blogs and other media, similar staffing issues in their organization became “incidents” and ultimately led to the directors’ departure. This narrative also made the sector less attractive to work in, while the changes require more and better educated employees. One director argues that employees in his organization felt misunderstood as a result of the way their work was portrayed in the media.
Scapegoat-narrative. Although the directors believe this narrative was very negative and contributed to stability, they all recognized that incidents where directors enrich themselves were a problem. However, this narrative supports the focus on preventing incidents like these from happening. They argue that focusing on control reduces the focus on the autonomy of patients: “Yes, back in the wheelchair Mrs. Jansen” (to prevent her from falling). One director explains how the shit-narrative and the scapegoat-narrative created and still creates a rat race for healthcare directors with winners and losers. Another director believed that in the focus on incidents and management a new type of director arises: the hero that comes to rescue.
The directors formulated their personal urgency narratives as shown in
The personal urgency narratives of the directors are mostly postalgias in which the present is problematized and the horrific future is the subject of fear and anxiety.
In this study, opposing urgency narratives concerning the implementation of new legislation within the Dutch healthcare sector are explored. The focus was on the dynamic interplay of urgency narratives in public and local discourses. The urgency narratives all took a different temporal viewpoint, which intensified the narrative dynamics. The announcement of change by the secretary of state via the disaster-narrative resulted in several counternarratives, but eventually shifted the field. The disaster-narrative had the function of facilitating the implementation of a new law in January 2015. Editors of the postpone- and shit-narrative narratives tried to influence the public discourse by producing alternative urgency narratives that highlighted additional aspects of the situation to win the battle and shift the field in the preferred direction or tempo. In this contest, the postpone- and shit-narratives “died in combat,” while the scapegoat-narrative supported the disaster-narrative.
The Pauw broadcast showed how the system and real world narratives failed to connect. While these institutional changes resulted in significant consequences
Director | Personal Urgency Narrative |
---|---|
1 | The challenge is to make long-term health care more personal instead of one-size-fits-all. To do this, we need to allow teams and employees to do their own decision-making and to improve human relations. Unfortunately, in my organization, my successor is reversing my measures to stimulate learning and development. |
2 | Health care must change because of the problem of affordability. This requires that the whole system changes. The challenge is to get all stakeholders to change. “It’s all about working with checklists of who is good and who is not.”People in the sector that I know are worried about the labor market and the demand for high-level manpower. I am concerned about whether the changes will succeed in the sector. |
3 | The challenge is to get the sector away from checklists and to start trusting each other again. This implies focusing on quality care and outcomes instead of accountability. The way to do this is to start more experiments in rule-free environments. We need all actors to contribute in all areas, including inspection, care agency, the politics, and management of healthcare organizations. “For me it is a culture of distrust. And this is part of the Anglo-Saxon model of control and supervision and if we don’t stop it now, nothing is going to change.” |
4 | The challenge is to create co-responsibility to deliver quality care with all parties in the field. The challenge for leaders is to stand up in the rat race of the long-term healthcare to support this co-responsibility and change, which can be challenging, especially in big organizations. |
for stakeholders, the voice of the narrative objects was limited. These fixated positions in the debate worsened the struggle and were a potential thread for the disaster-narrative. Macro- and micro-level narratives also collide. On the microlevel, directors drew contrary conclusions about the situation in health care, while the macro-level narratives significantly shaped their working environment. The directors were especially critical of the secretary of state―the key producer of the disaster-narrative―for taking an inconsequent position on the shit- and scapegoat-narratives, thus contributing to a rat race of winners and losers. The directors feared an overstrained healthcare sector with a focus on control measures and an inadequate amount of high-quality manpower. Stories like the shit-narrative and scapegoat-narrative make the sector less attractive to future employees. Two of the directors connected their departure to the narratives in the public discourse. These micronarratives show how the working lives of the directors and their employees are shaped by the narratives in the public discourse. However, the directors also hold power in developing alternative logics in narratives that can “survive” the battlefield.
By observing the processes of narrative development on several levels on a specific time frame, this study contributed to an in-depth view of the narrative dynamics in the Dutch healthcare sector. The result of this paper contributes to the debate on narratives and temporality, first by revealing how the temporal positions of the editors play a key role in the struggle of urgency narratives in public and local debates. Second, the results reveal how storytelling on different levels further feeds the dynamic struggle of this change process. This study shows that there are more temporal narrative strategies than nostalgia and postalgia. Since the results of this study point to a broader understanding of temporal interpretations in narrative struggles than postalgia and nostalgia, further research could provide additional insight on the multiple manifestations of urgency narratives in change processes. In terms of power, the urgency narratives in this study contribute to the idea of frameworks of power [
Managing change in complex change processes implies managing discourse. In the battlefields in which urgency narratives compete, only the strongest urgency narratives survive. Manages confronted with change should not focus only on dominant or highly visible urgency narratives, however; micro narratives also contribute to the framework of power and can in time shift an entire organization or field. Managers and policy makers confronted with change should be aware of and sensitive to different temporal interpretations of change urgency. First, a practical suggestion for managers in change processes is to invite input from various voices to discover these diverse temporal interpretations. Second, managing organizational change also requires narrative skills like reframing macro narratives for local change initiatives.
A first limitation of this study is the limited number of stakeholders interviewed. Walgrave and Varone [
The framework of change urgency and the method of issue attention provide a means to study the dynamic development and termination of urgency narratives. Further research could provide additional insight on the distinctive manifestations of urgency narratives. In a way, this study bridges approaches from process theorists [
This study explores processes of sensemaking and sensegiving and analyzes urgency narratives in a period before the implementation of new legislation within the Dutch healthcare sector. The leading question in this paper is: which urgency narratives can be conceptualized and how do they discursively create change urgency in the debate on Dutch long-term health care? A framework was developed to study narrative dynamics. After the announcement of change by the secretary of state via the disaster-narrative, three narratives followed: a postpone-narrative, shit-narrative, and scapegoat-narrative. Although the disaster-narrative was challenged, it eventually succeeded in shifting the field. The narrative struggle in the public debate among these narratives influenced local sensemaking processes. Directors of healthcare organizations are especially critical of the key producer of the disaster-narrative for taking an inconsequent position on the shit- and scapegoat-narratives and thereby contributing to a rat race of winners and losers that strain the healthcare sector with its focus on control measures and insufficient high-quality manpower. Stories like the shit-narrative and the scapegoat-narrative make the sector less attractive to future employees. This paper contributes to theoretical studies of temporality by showing how the temporal positions of narrative editors play a key role in intensifying narrative struggle. This paper also contributes to the idea that managers hold narrative power to develop strong urgency narratives themselves. Managing discourse is an implied necessity for managing change processes.
The authors declare no conflicts of interest regarding the publication of this paper.
van Ooijen, M., van Nistelrooij, A. and Veenswijk, M. (2018) Opposing Views on the Urgency for Healthcare Changes in the Netherlands: A Temporal Narrative Struggle. Journal of Service Science and Management, 11, 343-359. https://doi.org/10.4236/jssm.2018.114024