U NIVERSITÀ D EGLI S TUDI DEL M OLISE
C AMPO BASSO
DIPARTIMENTO GIURIDICO
_________ ______________ ___________ ____________ _________
Corso di Dottorato di Ricerca in
Innovazione e Gestione delle Risorse Pubbliche
Profilo “Scienze Giuridiche , Organizzative e Man ageria li”
Ciclo XXI X
S.S.D. SECS/P 10
“D EVELOPIN G AND IMPLEMENTIN G ICT I NNOVATI ONS FOR EFFICIENCY ,
QUALI TY AND EFFECTIVENESS I N COMPLE X ORGANIZ ATIONS : A
COMPAR ATIVE AN ALYSIS OF H U MAN R ESOURCE I N FORMATI ON
S YSTEMS I N H EALTHC ARE ”
Coordinatore:
Chiar.mo Prof.
Massim o Franco
Relatore/Tutor:
Chiar.mo Prof.
Massim o Franco
Candidato
Aizhan Tursunbayeva
Matricola n.: 151586
Anno Accademico 2015/2016
II
Executi v e Sum mar y
This interdisciplinary PhD lies at the inte rsection of three domains: Human
Resource (HR) Manage ment, I nformation S y ste ms ( I S) and Health Informatics,
also known as eHea lth. It focuses specifically on Human Resourc e Information
Systems (HRI S ) designed for or used in he alth organizations. The studies
described used both secondar y and empirical res earc h methods to synthesiz e the
existing body of evid ence, generate new eviden ce and advance cu rre nt theoretical
models in this area.
Stud y 1: A methodologically rigorous S y stemat ic L iterature Review captured ,
critically appraised and s y nthes iz ed the exist ing corpus of r esearc h pertinent to
HRIS. It revealed that while some studies of HRIS implementation have
differe ntiat ed between e xpected and realized benefits, none have compared both
of these in the context of healthcare, and none h ave compared HR I S in different
healthcare systems (Tursunbay eva et al., 2016).
Stud y 2: The empirical studies were aimed at addressing this knowledge gap b y
analy sin g the expected and realized benefits from HR I S projects for differe nt
stakeholders within healt hcare or ga nizations in two countries. They also set out to
assess to what extent identified in the s y stematic review sociote chnica l factors o f
influence affected implementation and outcomes in these projects.
The empirical r ese arch foll owed a qu alitative em bedded case stud y desi gn, using
both documentar y anal ysis and stakeholder int erviews. Two case ex amples were
selected for anal y sis - a national and a regional HRI S d eve lopment and
implementation programmes in two differe nt European countries. T he same
commercial HRI S s y stem was procured under p ublic tender and deplo y ed in both
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settings. Data were analyz ed within and ac ross both cases in order to identify their
commonalities and difference s.
The integrated a nal y sis identified a wide range of e xpected bene fits t hat had
driven both projects for different actors . There w as eviden ce o f all the categories
of expected benefit identified in previous HR I S research (see Parr y & T y son,
2011), ex ce pt for improving Or g anizational i mag e. Uniquel y the results indicate
that HRI S projects can be also driven b y organizations’ motivations to benchmark
themselves against the sector le aders and b y particular r equirements of th e health
sector (e .g. improvin g pa tient care).
The comparative ana l y si s of the two case studies also provided clear evidence that
benefits realization takes place not only durin g the I S implementation process, but
also through its use and can be affected b y a wid e range o f sociotechnical factors .
The two case studies analy z ed in this thesis also de monstrate that there are strong
interdepende ncies both across different categories of benefit and between
differe nt actors. Importantl y , the anal y sis also revealed the v ariation between
benefits expected at the outset of the project compared to the outcomes realised
later on.
Stud y 3: In o rder to b etter understand this gap, fu rther anal y sis was und ertaken of
the processes of HR I S d evelopment and implementation that had influenced each
outcome. This used an Institutional Theory lens to explore how different (possibl y
competing) institutional pressures had shaped the d evelopment and
implementation of this “ IS in novation ” within these or ganizational settings ov er
time . The concepts of t he “ organizing vision ” and “ strategic responses ” we re
invoked to understand how differ ent organizational a ctors had interpret ed the
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nature and goals of the innovation and how the y had chosen to respon d to the
various institutional pressures associated with them.
This anal y sis y i elded a framework for describing the process throu gh which soci al
context shapes orga nizat ional I S innovations over time. This framework, and the
taxonom y of ex pec ted and realized benefits from HRIS, contribute meaningfull y
to the development of theor y in thi s area and can inform future HRI S research .
Insights and recommendations from the studies are also valuable for manage rs
planning, delivering or evaluating HR IS development and implementation
projects, which can be complex and challeng in g.
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A ck now ledgements
The dream of pursuing a PhD dates from m y earl y childhood, whe n I observed m y
mother working with PhD candidates and holders at Kazakh Economic
University, where she w as an administrative official in the PhD office. Thus, I
want to thank her for bringing me up in an envi ronment that nurtured m y l ife -long
curiosity, motivation and thirst for acquiring new knowledge, whi ch enco urage d
me to take this challenging PhD pa th as well.
I want to thank m y P hD Supervisor, P rof. Massi mo Franco, who believed in m y
PhD proposal and during the last three years supp orted and shared m y passion for
information system innovations and their effect on Human Resources
transformation. I would also like to thank him for giving me intellectual freedom
in m y work and for his timel y explanation of the importance of academic
publishing.
I would also li ke to thank Dr. Claudia Pagliari and Dr. Raluca Bunduchi who
academically host ed me at the Universit y of Edinburgh, and for the l ast two y ears
dedicated their time and resources to g uiding and challenging me to st rive for
academic excellenc e in a ll resea rch and publishing activities.
I would like to conve y m y sincerest gratitude to the leads o f the HRIS projects I
studied, and all the respondents I interviewed for providing me with access to the
essential projects’ docu mentation th at allowed me to c onduct c omprehensive
analy ses.
I would also like to acknowledge the contribution of the Universit y o f Molise PhD
Committee members, other Universit y of Molise P rofe ssors (whose seminars and
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lectures I attended) and of Administrative Office staff for making my PhD
experience efficie nt, interesting and ver y posi tive.
I would like to thank my husband, who during these three y ea rs has provided
strong emotional support and encourag ed me to c omplete this challenge. He was
and will always be t he fi rst reader and revi ewe r of all m y writings. I would also
like to thank him and his pare nts for helping t o look a fter Zhanel, who grew
alongside my researc h, a nd for giving me an oppo rtunity to focus on m y writings.
Finally , I would like to t hank Barb ara and all m y other f riends who durin g these
three ye ars continued listening with the sincere st i nterest to the primary to pic that
I spoke about - m y PhD - and for providing both moral and practical help. I was
very lucky during these three y ears’ journe y to meet man y new friends and
colleague s, who I woul d also like to thank for stimul ating discussions and for
sharing ou r PhD journeys.
VII
Table of Conten ts
1. Chapter 1: Introduc tion .................................................................................... 1
1.1 Aims and benefits of this re search ............................................................ 3
1.2 Structure of the thesis ................................................................................ 5
2. Chapter 2. Overview of HRM, HRI S and HRIS i n hea lth ............................... 8
2.1 Introduction ............................................................................................... 8
2.2 HRM: Concepts and definitions ................................................................ 8
2.3 HRIS: Conce pts and defi nitions .............................................................. 10
2.4 HRM and HRI S: ori gins and developme nts ................................ ............ 12
2.4.1 Beginning of 20 th ce ntury (Pre-post W orld War I ) .......................... 12
2.4.2 Middle of 20 th century (Pre-post World W ar II ) .............................. 14
2.4.3 End of 20 th century ........................................................................... 14
2.4.4 Millennium and Contemporary Period ............................................ 15
2.5 Health context: overview ........................................................................ 18
2.6 HRIS in Health context: ove rview .......................................................... 19
2.7 Conclusions ............................................................................................. 21
3. Chapter 3. A critical examination of interdisciplinar y literature on HR I S in
health ...................................................................................................................... 23
3.1 Introduction ............................................................................................. 23
3.2 Review objectives ................................................................................... 25
3.3 Systematic litera ture review methodolog y .............................................. 26
3.3.1 Search stra te gy ................................................................................. 26
3.3.2 Article screening a nd se lection ........................................................ 28
3.3.3 Data extraction and a nal y sis ............................................................ 29
3.3.4 Critical appraisal tec hniques ............................................................ 30
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3.4 HRIS in Health: literature sy nthesis ........................................................ 31
3.4.1 Review results .................................................................................. 31
3.4.2 Analy sis of previous studies ............................................................ 48
3.5 Summary of the results ................................................................ ............ 60
3.6 Conclusions ............................................................................................. 63
4. Chapter 4. Conceptual framework ................................................................. 65
4.1 Introduction ............................................................................................. 65
4.2 HRIS be n efits and fac tors shaping IS innovations .................................. 67
4.2.1 Frameworks on HRIS benefits in hea lth settings ............................. 67
4.2.2 Frameworks on factors shaping the out come of IS innovations ...... 71
4.2.3 Summary of conc eptual f ramew orks for HR I S benefits and factors
shaping the outc om e of IS innovations .......................................................... 72
4.3 Institutional theory: I ntroduction ............................................................ 73
4.3.1 Institutional pressures in DiMagg io and Powell (1983) .................. 75
4.3.2 Organizational ac tors’ strate g ic responses to institutional press ures 78
4.3.3 Analy sis of Institutional the or y in IS research ................................. 79
4.4 Conclusion ................................................................ ............................... 84
5. Chapter 5. Methodology ................................................................................ 88
5.1 Introduction ............................................................................................. 88
5.2 Researc h questions .................................................................................. 88
5.3 Researc h m ethodology ............................................................................ 89
5.4 Selection of ca s es .................................................................................... 92
5.4.1 Selection of country ......................................................................... 92
5.4.2 Selection of sec tor ............................................................................ 92
5.4.3 Selection of units of ana l y s is ........................................................... 93
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5.5 Data collection ......................................................................................... 94
5.6 Data analy sis ........................................................................................... 99
5.7 Ethical considera tions: Confidentialit y and sensitivit y ......................... 102
5.8 Critical reflec tions on m y role as a researcher ...................................... 103
5.9 Quality of the stud y ............................................................................... 104
5.9.1 Cr edibility ...................................................................................... 105
5.10 Conclusions ........................................................................................... 107
6. Chapter 6. A comparison of expected ve rsus realized benefits in HRIS
projects in different contexts ................................................................................ 109
6.1 Introduction ........................................................................................... 109
6.2 National case stud y in C ountry 1 .......................................................... 110
6.2.1 National case stud y setti ng : NHO and its HR I S strategy .............. 110
6.2.2 The HRI S project ........................................................................... 111
6.2.3 Expected and realized benefits from HRI S and recipi ents of HRI S
benefits ................................ ........................................................................ 114
6.2.4 Fac tors affec tin g realization of expected HRIS benefits ............... 128
6.3 Regional case stud y in Country 2 .......................................................... 139
6.3.1 Regional case stud y se tti ng : NHO and its HR I S strateg y .............. 139
6.3.2 The HRI S project ........................................................................... 141
6.3.3 Expected and realized benefits fr om HR I S and recipients of HRIS
benefits ................................ ........................................................................ 142
6.3.4 Fac tors affec tin g realization of ex pected HRIS benefits ............... 153
6.4 Discussion ............................................................................................. 161
6.5 Conclusion ................................................................ ............................. 165
7. Chapter 7. A comparative case stud y on the devel opment and
implementation processes of HRI S ...................................................................... 166
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implementation approa ches, reactive a ttitudes towards innovation (Tr oshani ,
Jerram, & Hill , 2011) inc luding “ diffusion difficulties” (McGrath & Zell, 2001)).
Fi nall y , healthcare s y stems, partic ularl y those in the public sector, are highl y
complex organizational settings characterized b y multi ple instituti onal demands
(pressures), which vie for dominance and shape t he adoption, implementation and
use of I S innovat ions (C urrie & Gu ah, 2007; Sherer, Me y e rhoefer, & Peng , 2016).
Healthcare settings therefore also provide fertile g round for investi ga ti ng the
processes throug h which institutional demands influenc e IS innovation.
1.1 A im s and benefits of this resear ch
Building on previous research on the expected and realized benefits from HRIS, I
aimed initi ally to anal y s e the expected and realized benefits from HRIS projects
for different stakeholder s in different contexts, as well as to empirically examine
whether and how identified in the s y stematic r eview socio-technical factors of
influence (Tursunba y eva, Bunduchi, Franco, & Pagliari, 2016) sh aped a ffec ted
these projec ts.
The following specific r esea rch questions were developed in order to achieve the
afore m entioned re s earch objectives:
RQ1: What are the exp ec ted benefits, actual outcomes and u nintended
consequences of introducing a new technological innovation – HRIS?
RQ2: What are the expected b enefits and outcomes for diverse HRIS
project stakeholders and/or user groups?
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RQ3: What are th e fact ors that inf luence th e tr ansformation of expected
HRIS bene fits into reali zed bene fits?
However, as the results of this anal y sis showed a difference between e xpected
benefits as opposed to realised outcomes during the im plementation and early
assimilation of HRI S in the studi ed projects, I the refore developed the further aim
of exploring the processes of HRIS development and implementation in both the
contexts that led to this outcome . He re I used institutional theor y that
conceptua lises or g anizat ional behaviour as the product of the ideas, values and
beliefs embedded in the insti tutional environments in which organiz ations opera te,
and this helped me to explore the processes through which inst itutional pressures
shape the d evelopment and implementation of an ICT innovation within an
organizational setting, particular l y b y examining such influences over time.
The following additional rese arch question was po sed to achieve this objective:
RQ4: How do institutional pressures shape the development and
implementation of an IC T innovation within an organization ’ s setting over
time?
This P hD research aime d to c ontribute to both to the re search and p ractice of
HRIS by:
Addressing an important gap in the interdiscipli nary and international
literature on the expected and realized bene fits from HR I S fo r different
stakeholders, as we ll a s the processes of HR I S development and
implementation that can ca use these outcomes.
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Providing guidance to HR I S proje ct’s stakeholders on how to smooth the
often challenging imple mentation processes, in order to ensure th at these
systems can y ield the benefits the y p romise.
1.2 Structur e of the the sis
This thesis consists of 8 chapters. The complete thesis structure is presented in
Fig u re 1.
Figure 1. Thesis structure
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Chapter 1 is an introduction and Chapter 2 offers a brief synopsis of the evolution
of HRM and the role tha t HR I S has pla y ed in it. It also introduces the h ealthcare
context which was chosen for this stud y . Cha pter 3 provides an overview of the
existing research on H RI S in health, what gaps there a re in it , as well as
discussing pertinent finding s from the s ystematic literature re view on H RIS in
health that I conduc t ed.
Chapter 4 introduces the conceptual (theo retic al) f ra mework for this stud y . I t first
describes generic frameworks for studying benef its from HRI S before mo ving on
to the question of specific benefits from HRIS in health , and exist ing fram ewor ks
for stud y ing f actors shaping I S innovations. Moreover, it also describes three
concepts derived from institutional theory used in this re search (i nstitutional
pressures, or ganizing vision and strategic r esponses), and provides an ov erview of
how institutional theor y has been used in IS r ese arch so far. Thus, both Chapter 3
and 4 reveal gaps in the current literature and c onsequently justif y the research
questions identified.
Chapter 5 describes the research method ology used in this stud y . I t star ts from
specifying how the research design and cases to stud y w ere chosen, as well as
justify ing the approaches to the data collection and anal y sis that have been
adopted. It then describe s data sources used in th is study. Finall y , it provi des an
overview of the ethical issues considered during this researc h, critical reflections
on my role as a rese archer, and on the qualit y of this stud y .
Chapter 6 presents findings flowing from a comparison of the expected versus the
realized benefits in the n ational (Countr y 1) and reg ion al (Countr y 2 ) case studies ,
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while C hapter 7 presents the results of the comparative anal y sis of the
development and implementa tion of HR I S in t he selected health orga nizations.
Chapter 8 discusses the significance of the findings of this research and the
contribution it makes to the ac ademic literature and to potential future practice .
Finally it identifies the l imitations of the r esearch undertaken, and on this basis
suggests area s for fu rther research in future.
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2. Chap ter 2 . Ov ervie w of HR M , HR IS and HRIS in heal th
OVER VI EW OF HR M, HRIS A ND HRIS IN HEA L TH
2.1 Introducti on
Organizations use three main ty p es of resources - ph y sical, orga nization al and
human - in ord er to ma ximize their competitive advantage and achieve desired
profitability (Thite, Kavanagh & Johnson, 2009) . Many scholars have hi ghlighted
the importance that HR h olds among these th ree. Thus, for example, Greer (1995,
p.105) states that “In a growing number of organizations human resources are now
viewed as a sou rce of c ompetitive advantage. T here is greater recognition that
distinctive competencies are obtained throu g h highl y developed emplo y e e skills,
distinctive organizational cultures, management processes, and s ystems. This is in
contrast to the traditional emphasis on transferable resources such as equipment.. .
Increasing l y , it i s being recognized that competitive advantage can be obtained
with a high-qua lit y work forc e that enables organizations to compete on the basis
of market r esponsivene ss , product and servi ce qualit y , dif ferentiated products, and
technolog i cal innovation.”
2.2 H RM : Concepts and definitions
Since HR are so importa nt for organizations, manag ement of HR has also been
recognised as a critical priority . Scholars have provided various definitions of
H RM . For ex ample, Schuler and Jackson (1989) describe HRM practices as “a
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system that attracts, d evelops, motivates, and r etains employ ees to ensure the
effective im plementation and the survival o f the organization and its members”,
while Delery and Dot y (1996) conceptualized it “as a s et of intern ally consistent
policies and prac tices designed and implemented to ensure that a firm’s human
capital contribute to the achievement of it s business objectives”. A more recent
definition by Minba eva ( 2005) refer to HRM practices “as a set of practices used
by organization to manage human resources through facilitating the development
of competencies that are firm specific, produce complex social relati on s and
ge n era te organization al knowledge to susta in competitive advantage”. In this
thesis, I follow one of t he most recent HRM d efinitions by Tan a nd Nasurdin
(2011), whereb y HRM amounts to “spe cific pra ctices, for m al poli cies, and
philosophies that are designed to attract, develop, motivate, and retain employees
who ensure the effec tive functioning and survival of the or g anization ” .
HR mana gers pursue man y organizational roles. Thus, for ex ample, pre vious
research has summarized contemporar y HRM prac tices int o six teen opera tional,
support and value p rocesses that take their ori g in from four str ategic objectives
(see Fig ure 2 adopted f ro m Foster, 2009) .
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Figure 2. The HR/ Payroll proce ss f ramework
Today efficient and effective HRM practices and policies also include the use of
up- to -date and accurate employee data, which can be collected, maintai ned and
reported b y HR I S . Thus, HRIS pla y s a very important role in the management of
organizational HR . However, as the role of HR mana g ers has changed over time,
so ha s the role HRI S play s in supporting it. The next section spe cifies the
definition of HRIS used in t his thesis, followed b y a hi gh-level overview of the
evolution of HRM and the role that HRIS has had in it.
2.3 HRIS : Concepts and definiti ons
A wide variety of termin ologies and definitions have been used in the literature to
describe ICT aimed at s upportin g HRM (Stroh meier, 2007). A consequence of
this is a lack of consistenc y and agreem ent in thi s are a ( Bondarouk & Ruel, 2009).
Such systems have bee n explicitl y referred to as:
HRIS – “the composite of databa ses, computer applications, and hardware
and softwa re necessar y t o collec t/record, stor e, manage , deliver, pr esent,
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and manipulate data for human resour ces ” (Broderick & Boudreau, 1991 ,
p.17) or the “s y stem use d to acquire, store, manipulate, anal y se, ret rieve,
and distribute information regarding an o rg anization’s human resources .
An HRI S is not simpl y computer hardware and associated HR - relate d
software. Although an HRIS includes hardware and software, it also
includes people, forms, policies and p rocedures, and data ” (Kavana g h,
Gueutal & Tannenb aum, 1990, p. 29; Thite et al., 2009, p. 17 ).
Electronic human resource or E -HR system - “created real -time,
information-based, self- service, interactive work environment” ( L engnick -
Hall & Moritz, 2003, p. 365);
Electronic human resource mana g ement or e-HRM sy ste m - “a wa y of
implementing HR strat eg i es, poli cies, and p ractices in or g anizations
through conscious and di rec ted support o f and/or with the full us e of web -
technology- based channels” (Ruel & Bondarouk, 2004, p.365 -366); or
Virtual HRM – technolo gical mediated networks of different int erna l and
external actors providing the firm with the HR services needed without the
further existence of a conventional HR depart ment (Strohmeier, 2007 ,
p.20).
These terms can be used as to refer to standalone IS for HR, as f or I S embedded
within enterprise resource planning (ERP) systems (which is often the case in
complex organizations) (Escobar-Pére z, Esc obar -Rodríguez, & Monge- Lozano,
2010).
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Due to the int erdisc iplina ry nature of thi s re search, in this thesis I refer to an y I CT
aimed at supporting the administration, management and development pract ices of
HR as HRI S.
2.4 HRM and HRIS: origins and developments
HRM is a relativel y new term, which onl y came into common use a few decades
ag o. A range of other terms have histori cally be en used to describe HRM,
reflecting both the role of HR manag ers and the economic and social
environments in which they op era ted. For example, at the be g inning o f the 20 th
century HR p rofessionals were often called welfare wo rkers, while by th e mid dle
of the 20th century they were t y picall y re f erred to as pe rsonnel managers.
The penetration of ICT int o this HRM has made a significant contribution to the
development of the field. The next section will review in detail the evolu tion of
HRM and the role that HRIS playe d in it.
2.4.1 Beginning of 20 th century (Pre-post W orld War I)
There were two major triggers for the birth of HRM d epartments w it hin
organizations. First was the appearance of indus trial welfare work in the 1880s,
when some organizations needed a ne w staf f po sition to reg ulate and m aintain
records on employees ’ hours of work, health and safety issues and pa y r oll (Thite
et al., 2009). Thus in 1916 it became obligator y in man y US factories to have a
welfare worker (Kaufman, 2008). Second there was the establishment of s epara t e
employment offices that aimed to centralize a nd standardize such personnel
administration functions as hirin g or p a y roll ( Kaufman, 2008). Thus F arnham
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and the management of patient records, thereb y increasing transparency a nd
accountability ” .
Health orga nizations are characterized by a dual structure involvin g on the one
hand, clinical functions and on the other business and support functions, and this
is re flected in their I C T (Khatri, 2006). Despite the importance of business and
support s y stems in health organizations very little res ea rch on their adopti on or
impacts exists, compared with other are as in health infor matics and eHe alth
(Menac h emi et al., 2006).
Previous research h as un derlined that HR I S in health contexts is an important area
of stud y due the compl exit y of its governance, technological, and workforce
structures (Bondarouk et al., 2009; Ev ers, 2009) ; and it s comparabilit y with I S
implementation in other complex public s ector organizations, including issues
such as top down implementation a pproaches and reactive attitudes towards
innovation (Troshani et al., 2011) including “dif fusion difficulties” (McGrath &
Ze ll, 2001), which will be discusse d in detail in the following section.
2.6 HRIS in Health cont ext: o v e rview
As mentioned above, since the y are not perceived as li fe critical, HR I S have
rece iv ed ver y li ttle attenti on in the health lite ra ture and their dev elopment,
implementation, use and impacts in health organiz ations are poorl y understood,
compared with clinical sy s tems (e.g. Electronic Health Records).
However, “people costs” can account for 65 - 80% of health organiz ations’ total
operating budgets (Khatri, 2006) . Thus, effective management of HR is es sential,
from both a clinical and a bud g etary p erspective. HR I S can support a v ariety o f
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HRM practices, including r ecruitment and performance man age ment, and provide
health leaders with crucial information that can guide effective c apa cit y p lanning
and re source allocation. Unsurprisingl y , successful implementation of HR I S in
HR departments has been linked to improvements in patient care (Kabene , King,
& Gibson, 2010).
The importance of HRIS, and the data that they ca n generate, has a lso bee n
highlig ht ed b y various global health ini tiatives (e.g. WHO, 2015). For e xample,
the W HO , in their 2006 World He alth report stated that “s y stems for r ecording
and updating h ealth worker numbers oft en do n ot exist , which presents a major
obstacle to d eve loping evidence-b ased policies o n hu man resource development”
(WHO, 2006). Six years later, despite the im portanc e of HRIS for und erpinning
strong health systems, a 2012 review (Riley et al., 2012, as described in Waters et
al., 2013, p.896 ) concluded that “universal understanding of the HR I S use d in
monitoring human resources for health is minimal and baseline info rmation
regarding their scope a nd capabilit y is practically non- existent … the authors
called for more descriptive rese arch of HR I S globall y , including documentation of
impact so as to adv ance the science and eviden ce-based pr actice in this area” .
Some researchers have alre ad y re sponded to this reque st and mad e their
contributions to the in terna tional peer-reviewed literature (e.g . Kumar et al.,
2013). How ever, since this topic lies at th e intersection of informatics,
management, and health, most of the existing HR I S studies in healthcare are
spread across several discipline -specific bodies of knowledge, making it difficult
to obtain a complete picture of the evidence base (Strohmeier, 2007).
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Thus, although forms of HRIS have been use d in healthcare for almost half a
century (Audit Commission, 1995), thi s is still an evolving ar ea for innovation.
Increasing l y sophisticated, modular HRIS are b eing procured and implemented in
health organizations worldwide ( Harris & Spencer, 2015) , often at high expense in
terms of technolo gy , support and change management. While the benefits of these
systems have b een much vaunted b y HR I S vendors (Horowitz, 1996) and polic y
makers (The Scottish Government, 2015), recent years have also seen some
spectacular failures, where lar g e sc ale implementation programs have en countered
huge overspends, weak organizational buy-in or poor interoperabilit y with
existing sy stems (Thite & Sandhu, 2014) . Given the opport unity cost of getting
these projects wrong, de veloper s, procurers, and managers require more guidance
on the usefulness, ef fectivene ss and impleme ntation barriers associated with
HRIS, a s well as how to evaluate them.
2.7 Conclusi ons
As demonstrated in this chapter, the field of HRM has significa ntl y evolved in the
last centur y , and HR I S h as pla y ed a noteworth y r ole in this transformation (Thite
et al., 2009). Adoption of these s y stems by mor e orga nizations, driven by their
expected benefits, has attracted the attention of practitioners and more r ece ntl y
academic scholars (Parr y & Tyson, 2011). However, the available knowl edge on
their development, im plementation, use or impacts is still scarc e or spread across
disciplinary boundaries (Strohmeier, 2007). This i s especiall y tru e for the health
sector, which has traditionally prioritized studies on clinical over administrative I S
(Menac h emi et al., 2006) . However, given th e o pportunity cost of getting HR I S
22
initiatives wrong, developers, procurers, and man agers req uire more guidance on
the usefulness, effectiveness and implementation barriers associa ted with HRI S,
as well as how to evaluate them. The present research aims to close this important
literature ga p.
23
3. Chap ter 3 . A critical examinat ion of interdiscip linar y
literatu re on HR IS in heal th
A CRITICA L EX A MIN A TION OF INTERDISCIPLINA R Y
LITERA TURE ON HRIS IN H E A L TH
3.1 Introducti on
This chapter pre sents the results of a s y stematic litera ture review
1
of HRIS in
health. I ts primar y ai m was to search inter disciplinary academic and gre y
literature to identif y and classify the exist ing evidence on HRIS a doption,
implementation and impact in he alth organizations worldwide , as we ll as to
inform the research str ategies for m y empiric al case studies (see Ch apters 6 and
7). Thus, in addition to documenting and classif y in g the re search on HRIS in
health, this review also sought to understand th e outcomes and im plications of
HRIS implementation in health o rga nizations, the theoretical fram ewor ks used to
study them, and areas for future research.
1
The systematic literature revie w prese nted in this c hapter was conducted in co llaborati on with
Dr. Claudia P agliari (eHe alth Research Group, Uni versity o f Edi nburgh) a nd Dr. Ral uca B unduchi
(Business School, Universit y of Edinburgh) as a part of my re search visit to the Uni versity of
Edinburgh and it s findings have bee n disseminated in the following ways :
Tursunbayeva, A., P agliari, C., B un duchi, R., Fra nco, M. (2 015) Human resource infor m a tion
systems in healthcare: a systematic rev iew. P ROSPERO: CRD4201 5023581.
Tursunbayeva, A ., P agliari, C. , Bunduchi, R., Franco, M. (20 15). Hum an reso urce infor mation
systems in healthcare: a systematic revie w (protoco l). J MIR Res Protoc; 4 (4):e135.
Tursunbayeva, A ., B unduchi, R., Franco, M., P agliar i, C. (2 016). Hum an reso urce infor mation
systems i n health care: a s ystem a tic evide nce review. Jo urnal of Am erica n Med ical
Informatics Associatio n.
24
The need for this sy st ematic literature review emerged from background scoping
work (Tursunbay eva, Pagliari, Bunduchi, & Franco, 2015 ) in which I searched for
and examined existing reviews of HR I S literature. This work revealed that
existent literature reviews on HRI S tend to be discipline-specific, ty p icall y
coming eithe r from a bu siness, social science, or ICT perspective (see Figure 4).
Only a few used a s ystematic approach (Riley et al., 2012; S arkis & Mwanri,
2013; Strohmeier, 2007; Van Geffen, Ruel, & Bondarouk, 2013), and none
encompassed the ICT, s ocial science, business, and h ealth literatures to g ether .
Only two re views looked specificall y at HR I S i n healthcare (Riley et al ., 2012;
Sarkis & Mwanri, 2013), both of which prioritized medical and social scienc e
databases, and were li mited in scope. The first, p ublished in 2012, was aimed at
uncovering bas eline information on the use and capability of HRIS in different
countries, as a means of underst anding the challenges this pres ents for global
health workforce monitoring and d evelopment. The second, published i n 2013,
examined the role of dif fere nt t y p es of innovati ve ICT as a means of enabling
continuing professional development to strengthen HR capacit y in healthcare.
Figure 4. Analysis of existing literature reviews on HRIS
2
2
Overall, si x liter ature re views mentioned in Figure 4 ( Strohmeier, 2007; Van Geffen et al., 2013;
Marler & Fisher, 2013; Bo n darouk & Ru e l, 2009; Bondarouk & Furtmueller, 2012; Ruel &
Bondaro uk , 2 014) w ere adopted from “Orchestratin g t he e - HRM symphony” (Bondar ouk, 2 014),
inaugural lect ure given b y P rof. T . B ondarouk at the U niversity of T wente in December 2 01 4;
others I w as fa miliar with based on background readin gs . No n -syste matic literat ure reviews
(Strohmeier 201 2; Marler & Fisher, 20 13; Ngai & W at, 2006; Bondarouk & R uel, 2009; Sareen &
Subramanian, 2 012; B ondarouk & F urtmueller, 2012 ; Ruel & Bondar ouk, 2 0 14) were classified
accord ing to their refere nces and the jo urnals these reference s w ere p ublished in.
25
3.2 Review objectives
As aforementioned scoping wo rk identified onl y two previous literature r eviews
specifica ll y examining HRIS in health, both of which are limited i n scope
(Tursunbaye va et a l., 2 015), I th erefore set out to conduct an interdisciplinar y
systematic review uti lizing sour ces of evidence f rom the ICT, social science, and
health research literat ures, and encompassi ng an y I CT used for HR
administration, management a nd development pra ctices in he alth organizations.
Although the main aim of this review was to inform the res earch strate g ies for
empirical case studies of m y PhD research, the following spe cific objectives were
also set for guiding it :
Determine the prevalence and scope of existing research and evaluation
pertaining to HR I S in health organizations;
26
Analy s e, classif y , and synthesize ex isting evidence on the processes and
impacts of HRI S develop ment, implementation and use; and
Generate recommendatio ns for HR I S r esearch, pr ac tice, and polic y , with
reference to the nee ds of differe nt stakehold ers and communities o f
practice .
3.3 S y stem atic literatu re review methodolog y
3.3.1 Se arch strategy
A comprehensive s earch strategy was it eratively developed and tested d uring a
scoping phas e (see App endix 1). This was used to interrogate ten international
online databases indexing medical/health (Cochra ne Library, MEDLINE, a nd
EMBASE), social science (AB I / Inform, ASS IA, and Sociological abstracts), ICT
(IEEE Xplore), and multi-disciplinary research (Scopus, Web of S cienc e Core
Collection (W eb of Sci ence CC), and ScienceDirect). Gre y literature sources were
also examined, including reports from the WHO, releva nt prof essional
organizations (e.g. Chartered Institute of Personnel and Development, Societ y for
Human Resource Man agement, Healthcare I nfor mation and Mana gement S y stems
Society) and consulting firms (Deloitte, Ernst & Young , PricewaterhouseCoopers,
KPMG). Aca d emic disse rtations were searched via Google, and the reference lists
of qualify ing articles were “snowballed” to identify additional studi es. No
restrictions were applie d on publication y ear or language.
27
3.3.1.1 Keywords identif ication and se arch stra tegy creation
A comprehensive li st of ke y w ords for this systematic review (Tu rs unbayeva et al.,
2015) was crea ted via the following three main steps:
1. The following t y p es of HR-related terms were identified:
a. HR terminology that the researc h team were familiar with based on the
background rea din g s;
b. Terms that were r eturne d when I s earche d unde r “Human resource” in
the US National L ibrary of Medicine ’s Medic al Subject Headings
browser, such as staff and manpower; and
c. Terms articulated within a highl y -cited expert review analyzing
theoretica l, methodological, and topical aspects of e -HRM, and in the
abstracts of the referenced articles (Strohmeier, 2007) (added during
the “Search Query 2” development stage).
2. The I CT - related terms “information s y stems” and “information technolog y ”
were selected based on the background readings.
3. The research team identified general health termi nology th at w e all were
already familiar with: health, healthcare, hos pital, clinic*, and medic*.
K eywords “ Health care ” and “ care ” were not included, as the y were not
sufficiently sensitive.
I tested three main searc h queries for the identified key words on June 25-26, 2015
(R esults of this testing are provided in Tursunbayeva et al., 2016).
28
3.3.2 Article screening a nd s election
Generated o utputs were stored in EPPI-Reviewer 4 s y stematic review software.
After ini tial scre ening o f titles and abstrac ts the full text of potentially relevant
articles was examined by two reviewers ( Dr. R aluca Bunduchi and m yse lf) to
assess their fit with the inclusi on criteria. Disa g reements we re resolved through
consensus or arbitration by a third reviewer ( Dr. Claudia Pag liari).
3.3.2.1 Inc lusion Criteri a
There were two in clusion criteria :
1. Studies involving a formal or semiformal approach to the investi ga tio n or
evaluation of HR I S , whether led by a ca demi a, industry (e . g . consul ting
sector), or from within the healthcare s ec tor;
2. Studies of broader busi ness/administrative/ERP/Hospital I S that explicitl y
examine their application to HR pra ctices.
3.3.2.2 Exclus ion Criteri a
Descriptive reports, pur e market research, artic les focused on softw are design
issues, studies not primaril y focused on HRIS or which mentioned HRIS without
specifying the health sector, and articles ex amining generic ERP s/H ospital I Ss
without referring to HR functionalities were excluded. Details of th e filters
applied at each s creening stage are included in t he PR I SMA flow dia gram (see
Fig u re 5) .
35
between r oles; System needs to
reflect true work load for users to
be satisfied.
Approaches t o : Technology and
I ndi v idual
S6
Dent, Green,
Sm ith, & Cox,
1991 (N/A)
UK (High) ;
Secondary (>1
Hospitals) (Ded.:
Manpower I S)
To find ou t how the district m anagements had
prepared for, a nd were respond ing to, the
implem entation of three corpo rate com put er
system s.
Qlt.
(5.5)
Implementa tion
Facilita tors: Org anization and
Project
Barriers: O rganization
Approaches to: Project and
Technolog y
Dent, 1991 (SS )
To exam ine t he developm ent of com puting and
ICT strategies within the NH S England and
Wales.
S7
Engbersen, 2010
(N/A)
Netherlands
(High); Secondary
(Hospital) ( Gen. :
I ntranet )
To adv ance understan ding of the special feature s
of e-HRM implem entat ion and to prov ide i n sight
in wha t k ind of influenc es e -H RM has on the
HRM departm ent and the o rganizatio n.
Qlt.
(6.5)
Implementa tion
Recomm endat ions: Individual,
Organiz ation, Project and Task
Use
Barriers: Indiv idual, Task and
Organiz ation
Outcom es>Generic:No change
to Operation al and Stra tegic
S8
Escobar- Perez
and Escoba r-
Rodriguez , 2010
(SS)
Spain (Hig h);
Secondary
(Hospital)
(Gen.:ERP )
To analyse the pro cess of im ple m entation of ER P
system s in ho spitals, as an organization with
divided and heterogeneou s functional areas. To
identify the princ ipal t e chnological objectiv es
that were set in the proce ss of implem entation,
which of those objectives were achieved, and t h e
deficiencies t h at have subsequent ly become
Qlt.
(5.5)
Developmen t
Expected c : Strategic
Generic: Org anization,
Technolog y and Indiv idual
Implementa tion
Generic: I ndividual
Approaches to: I nter -
36
evident.
Organiz ation, Project and
I ndi v idual
Escobar- Perez,
Escobar-
Rodriguez and
Monge- Lozano,
2010 (IC T)
Use
Barriers:P roject and I ndividual
Satisfaction : Varies between
roles
Approaches to: Technolog y
S9
Evers, 2009
(N/A)
Netherlands
(High); Secondary
(Hospital) ( Ded. :
HR Portal)
To assess the contribution of an HR porta l
towards HR pro cesses.
Qlt.
(6.5)
Developmen t
Expected c : Strategic, Serv ice and
Operational
Implementa tion
Recomm endat ions: Pro j ect, T ask
and I ndividual
Realiz ed c : Empowerm ent
Use
Satisfaction : Use rs need t im e to
judge the system ; Strong
relationship between system
ease of use an d user sat isfaction.
Outcom es>Generic:No change
to Operation al and Serv ice
Downside s: Reduced
Operational and Empow erm ent
Recomm endat ions: Project and
Task
S10
Fahey and
Burbridge, 2008
(Health)
USA (Hig h);
Secondary (>1
Hospitals) (Gen.:
To present a case study of a failed attempt to
apply the princip les of diff usion of innovation to
a software prog r am .
Qlt.
(4.5)
Developmen t
Generic: T echnolog y
Implementa tion
37
Daily Staff
Managem ent
System )
Facilita tors: Organiz ati o n
Barriers: Techno logy and
Organiz ation
Use
Facilita tors: Organiz ation
Barriers: O rganization an d Task
S11
Fehse, 2002
(N/A)
Netherlands
(High); Secondary
(Hospital) ( Ded. :
Personnel I S)
To exp lore t o what exten t and how does
organizationa l politics explain IS i mplem entation
outcomes.
Qlt.
(6.5)
Developmen t
Expected c : St rategic
Implementa tion
Facilita tors: Indiv idual
Barriers: Organization, P roject
and I ndividual
Generic: I ndividual and
Organiz ation
Approaches to: Project and
Technolog y
Use
Outcom es>Generic:No change
to Operation al
S12
Gurol, Wolff and
Berki, 2010
(N/A)
Turkey (Upper -
Middle);
Secondary
(Hospital) (D ed.:e-
HRMS)
To investigate several spec ific and critical poin ts
that will contribute to a better und erstanding of
e- HRM and t o provide a m odel for the
implem entation of e- HRM.
Qlt.
(4.5)
Use
Realiz ed c : Opera tional, Strategic
and Em powerment
S13
Hawk er et al.,
1996 (Heal th)
Canada (High) ;
Secondary
(Hospital) ( Gen. :
Workload
To descr ibe the develo pm ent and applicatio n of a
computerized work load measurem ent tool for use
in hospital nur sing educat ion departm ents.
Qlt.
(2.5)
Use
Realiz ed c : Service and St rateg ic
38
Measurem ent
System )
S14
Helfert, 2009
(SS)
I reland (High) ;
NHS (Ded.:
Personnel Pay roll
Attendance and
Recruitment
System )
To outline a framework f or analysing heal thcar e
process m anagem ent projects.
Qlt.
(5.5)
Implementa tion
Barriers: Individual, Pr oject,
Task, I nter - Org anizat ion,
Organiz ation and Techno logy
Approaches to: I nter -
Organiz ation and Pro ject
S15
Kazm i and
Naarano j a, 2014
(SS)
Pakistan (Lower-
Middle);
Secondary
(Hospital) ( Ded. :
HRI S)
To pro pose an evaluation t ha t how in a smal l
business scena rio, the bits and p ieces of
know ledge ca n be seen scattered at differ ent
work location s and how the manag ement can
strategically manag e a viable data resource i n t h e
form of existing knowledge base to be retrieved
as and when r equired.
Qnt.
(4)
Use
Satisfaction : Majority of users
are satisfied w ith the infor mation
system provides
S16
Kumar et al .,
2013 (Heal th)
Pakistan ( Low er-
Middle); NHS
(N.S.: HRI S)
1.To document a s to how H R inform ation i s
currently being collected, manag ed and reported;
2. T o identify t he gaps related to HRH data that
need t o be urgently addressed; 3.To sugg est the
tools and pro cesses for m anaging H R data.
Qnt.
(6.5)
Developmen t
Expected c : Operationa l, Serv ice
and Strateg ic
S17
Lin et al., 2010
(IC T/Health)
Taiwan (High) ;
Secondary
(Hospital)
(Gen.:Nurs ing
Assistants
Managem ent
System )
To compare the re sults of the m anual op eration
and system int e rvention in assigning work to
nursing assistants, i n order to evaluate the
system' s performance.
Mixed
m ethod
(4.5)
Use
Realiz ed c : Operational and
Patient Care
Satisfaction : Different cate gories
of use rs ar e satisfied with the
system
S18
Memel et al.,
2001 (Heal th)
USA (Hig h);
Secondary (>1
To discu ss the specific components of the
inform ation manag ement and ICT infrastruc ture,
Qlt.
(2)
Developmen t
Expected c : Operational
39
Hospitals) (Gen.:
I ntranet )
examples of the impacts they have had on
patients, caregiv ers, and t he or g anization, and
lessons learned .
Use
Realiz ed c : Operational and
Service
Approaches to: Technolog y
S19
Parry and Tyson,
2011 (SS)
UK (High) ;
Secondary (>1
Hospitals) (Ded.:
e-HRM)
To exam ine the goals stated by organizations for
the introduc tion of e-HRM, whether t hese goals
were actually ac hieved, and the factors affecting
this.
Qlt.
(7)
Developmen t
Expected c : Stand ardization,
Operational, Se rvice, Strateg ic,
and Em powerment
Implementa tion
Facilita tors: I ndividual and
Project
Generic: T echnolog y
Use
Realiz ed c : Operational, Serv ice,
Strategic and S tandardiz ation
S20
Pierantoni and
Vianna, 2003
(Health/SS)
Brazil (Upper-
m iddle) ;
Departm ents of
Health (N.S. :
HRI MS)
1.To evaluat e the im plementation of HRI S in
selected Health Departm ents and pr e sent the
implem entation evaluation methodolog y; 2.To
identify the limits and pos sibilities for using the
system as HR planning and manag e m ent tool in
local health sy stem s.
Mixed
m ethod
(5.5)
Developmen t
Expected c : Strategic
Im plementa tion
Facilita tors: Env ironment and
Organiz ation
Barriers: Env ironm ent,
Organiz ation, Technology and
I ndi v idual
Use
Facilita tors: Env ironment and
Organiz ation
Approaches to: Task
S21
PWC, 2010
Queensland,
1.To review the organiz ation of corporate
Report
Developmen t
40
(N/A)
Australia (High);
NHS (Ded.:
Payroll sy stem)
services under t he shared se rv ices m odel to
determ ine the m ost approp riate arrangements f o r
the futu re, and mak e recommendations on t h e
appropriate gov ernance model for share d
services going for wa rd; 2.To pr ov ide
recomm endat ions f or the future rollout of t h e
Corporate Solutions Program and for the m ost
effective way to deliver the Program .
(Qlt.)
(5.5)
Expected c : Strateg ic,
Technolog y, Standardizat ion
Facilita tors: I ndividual and
Project
Recomm endat ions: P ro j ect,
Technolog y, Environment, T ask ,
Organiz ation, and Indiv idual
Approaches to: Environm ent
KPMG,2010a
(N/A)
To summarise the work undertaken to date on the
review o f t he Q ueen sland Health (QH ) Pay roll
implem entation pro j ect.
KPMG,2010b
(N/A)
Implementa tion
Facilita tors: P roject and
I ndi v idual
Barriers: Environment, Inter -
Organiz ation, Organiz ation,
Project, Technology, I ndividual,
and Task
Approaches to : Tec h nolog y,
I nter - Organization and Pro ject
Recomm endat ions: I nte r-
Organiz ation, Project, Task and
Technolog y
KPMG, 2012
(N/A)
To r ev iew the current status, proposed solutions ,
strategies, prog rams of work and gov ernance
framework s in place for t he payroll sy stem.
E&Y, 2010
(N/A)
To con duct a review of pay roll and r os tering
system s, to establish their ongoing suit abil ity for
QH, and to asce rtain what potential op tions ar e
available to r esolve the re cent payro ll problem s.
Auditor- General
of Queens land,
2010 (N/A)
To evalua te the effectiv eness of the Departm en t
of Public Work ’s program and proj e ct
m anagement processes, and QH processes, in
relation to t he business readiness of, and
transition to new sy stems.
Chesterm an,
2013 (N/A)
To present a full and careful i n quiry i nto the
implem entation of the Pay roll Sy stem .
Use
Generic: Organiz ation, Project
and Technolog y
Silva and
Rosemm an,
To propose the approach to repre sent the
dynam ic r e lations betwee n social and mate rial
Qlt.
(5.5)
41
2012 (N/A)
entities wh ere the latter are divided into technic al
and organiz ational enti ties.
Approaches to: Project
Outcom es>Generic: Resignation
of the Minister of Health;
Strikes; Im proved country ICT
strategy and g overnance
procedures
Recomm endat ions: I nter -
Organiz ation, Organiz ation,
Project, Task, Technol ogy, and
I ndi v idual
Eden & Sedera,
2014 (N/A)
1. T o illustrate the factors that contributed to
QH’s disastrous im plementation project; 2. To
understand the broader appl ications of this
project failu re on state and nationa l legislations
as well as in dustry sector s.
Th ite and
Sandhu, 2014
(SS/IC T)
1. T o a scertain the main reasons for t he failure of
the new payrol l implem ent ation pro ject; 2. T o
develop a theoretically and practically derived
system developm ent life cycle model.
S22
Rauhala, 2008
(N/A)
Finland (High) ;
Secondary mixed
(Gen.: Patien t
classification
system )
To evaluate whether t h e patient classification
system was valid and f e asible enough to be used
as a m easurement tool for HRM in nursing in t he
wards of som atic special ized health car e.
Qnt.
(7.5)
Use
Approaches to: Task
Fagerstrom et
al., 2000a
(Health)
Fagerstrom et
al., 2000b
(Health)
Rauhala and
Fagerstrom ,
2004 (Heal th)
Rauhala and
Fagerstrom ,
2007 (Heal th)
Rauhala et al .,
2007 (Heal th)
S23
Fagerstrom ,
2009 (Heal th)
Fi nland (High);
Secondary (>1
To illustr ate how the system can be used to
facilitate ev idence-based HR M.
Qnt.
(6)
Use
Realiz ed c : Strategic
42
Hospitals) (Gen.:
Patient
classification
system )
Approaches to: Task
S24
Rainio and
Ohinm aa, 2005
(Health)
Finland (High);
Secondary
(Hospital) ( Gen. :
Patient
classification
system )
To assess the feasibili ty of the system in nursing
staff m anagem ent, and whether it can be seen as
the transferring of nu rsing resources between
wards acco rding to the in form ation received fro m
nursing care intensity classification.
Qnt.
(5.5)
Use
Approaches to: Technolog y
S25
Riley et al., 2007
(Health)
Kenya (Low er -
Middle); NHS
(Ded.: Nursing
Workforce
database)
To desc ribe the developm ent , initial findings,
and implication s of a national nursing workforce
database sy stem in Keny a.
Mixed
m ethod
(5)
Use
Facilita tors: Env ironment and
Organiz ation
Realiz ed c : Strategic
Approaches to: Technolog y
Recomm endat ions: Technology
S26
Riley et al., 2012
(Health/SS)
I nt.; NHS ( N.S.:
HRI S)
To: (1) review and assess nat ional practices in
HRI S i m plementation worl dwide; (2) identify the
m ain areas o f weak ness in HRIS implementation,
with attention to countries facing acute health
workforce shortages; and ( 3 ) draw upon
documented best pract ices to offer
recomm endat ions to decision and policy m a k ers
on how to improv e the science and applica tion o f
HRI S.
Syst.
Review
(6.5)
Developmen t
Expected c : Strategic
Use
Approaches to: E nvironm ent,
Organiz ation, Technology and
Task
S27
Rodger et al.,
1998a (N/A)
USA (High);
Mixed
(Ded.: HRI S)
To describe t h e effor ts of the HR Departm ent to
redesign its HRI S to better meet enterprise-wide
goals of cos t effectiv eness and efficiency .
Mixed
m ethod
(4.5)
Use
Satisfaction : Users are satisfied
with t he distribut ion of HRI S
Rodger et al.,
43
1998b (SS/I CT)
reports and their confidentiality ,
but no t w ith compl icated
procedures an d form s for HRI S
Approaches t o : Technology and
Task
Recomm endat ions: Pro j ect, T ask
and I ndividual
S28
Ruland, 2001
(IC T/Health)
Norway (High);
Secondary
(Hospital) ( Gen. :
Decision Suppor t
System )
To describe t he system development p rocess.
Mixed
m ethod
(5.5)
Developmen t
Expected c : Strateg ic,
Em powerment and Opera tional
Facilita tors: P roject and
I ndi v idual
Implementa tion
Facilita tors: P roject and
I ndi v idual
Ruland and
Ravn, 2001
(IC T/Health)
To ev aluate system’s ef fect on nursing cost s,
quality of manag ement inform ation; user
satisfaction; and ease o f use; and its usefulness as
decision suppor t for im proved financial
m anagement and decis ion -m a king .
Use
Facilita tors: Org aniz ati on
I ndi v idual, Pro ject and
Technolog y
Realiz ed c : Operational and
Strategic
Satisfaction : Users are satisfied
with the system and i n form ation
it provides
S29
Samm on and
Adam , 2010
(SS/IC T)
I reland (High) ;
NHS (Gen.: ERP)
To conduct an investig ation i nto the manag ers’
level of understanding of ERP project
implem entation and the preparations that should
be made to incr ease the l ikelihood of i ts success.
Qlt.
(6.5)
Developmen t
Expected c : Strategic
Implementa tion
Barriers: P roject
44
Approaches to : Org anization and
Project
S30
Schenck-
Yg lesi as, 2004
(N/A)
Malawi (Low) ;
NHS (Gen.:
HRI S)
To review the av ailability of s taff deploym ent
and training data from routine I S i n Malawi and
to inform the Ministry of Heal th and Po pulat ion
of de ficiencies that would need t o be address ed
to better inform the d evelopm ent, ongoing
m onitor ing and deploy ment of tra ining policie s.
Report
(Qlt.)
(5.5)
Developmen t
Approaches to: I nter -
organization an d Technolo gy
Use
Recomm endat ions: T ask
S31
Shukla et al. d ,
2014 (N/A)
I ndia (Lower-
Middle); NHS
(Ded.: Open
source HRI S)
To review HRI S across all 28 states and 7 union
territories of I ndia to asses s their purpo se, scope,
coverage, software technology , usability, and
sustainability .
Repor t
(Qlt.)
(5.5)
Developmen t
Expected c : Operationa l and
Com pliance
Facilita tors: Projec t
Use
Approaches to: I nter -
Organiz ation, Project, Task and
I ndi v idual
S32
Sm ith, Wigg i ns
and Bird, 1979
(IC T)
USA (High);
Secondary
(Hospital) ( Ded. :
A computer bas ed
scheduling
system )
To discuss three years’ experienc e in computer -
assisted schedu ling of nur sing personnel.
Qlt.
(2.5)
Developmen t
Expected c : Strategic
Implementa tion
Facilita tors: I ndividual and
Project
Approaches t o : Technology and
I ndi v idual
Use
Realiz ed c : Operational and
Em powerment
Satisfaction : Can decline over
time due t o t ec hnical design,
51
Table 2. Theoretical frameworks re ferred to in qu alifying studies
Category
Framework
Study
HR and
HR related
Concept of Ex periential L earning
S3
Central Prin ciples of HR M
S22
Personnel as resource in H RM theory
S23
HRI S i m pact through dr awing from m otivation in
organizationa l behaviour an d theory of w ork
perform ance
S33
Innovation
and
Change
Diffusion of innovation s
S10
Theoretica l models of org anizationa l change
S11
IS and IS
related
I nnoDiff model based on the m odel for I S success
S1
Framework of impacts o f technology implem ent ation
S8
Technolog y Acceptance M odel
S9
Corporate in formation f actory
S18
System developm ent life cycle
S21
Concept of m indfulness to develop the co ncept o f
preparedness in ERP im plem entation
S29
Process- centric role of I CT in term s of its im pact on
business val ue
S36
Specific
combinations
of HR and IS
concepts
Conceptual f ramework developed by WHO Study
Group which l inks 3 com ponents: (1) dec ision-mak in g
in the devel opment of HRH ; (2 ) research, and (3) the IS
S42
The role of H RM in I CT im ple m entation
S3
Framework for goals for I CT use for HR
S19
Framework for IC T ef fect s, enriched w ith the con cept
of organiz ational ob ject, and integrat es perspec tive on
emerg ence and enacted p ractices
S21
Other broad
managemen t
/business
Structuration Theory
S3 ; S7
Managem ent strategies
S6
The gam e - theor etic m odel
S6
Evaluation f ramework for business proc ess projects
S14
Knowledge sha ring concep t
S15
Evidence- based healthcare
S23
Em ancipatory princip les and the princi ples of Cri tical
Social Theory
S38
Does not
specify
S2; S4; S5; S12; S 13; S16; S17; S20; S24 ; S25; S26; S 27; S28; S30 ;
S31; S32; S34 ; S35; S37; S 39; S40; S41
52
3.4.2.5 HRIS typ es and the ir functional ities for HR M practice s
Most qualify in g studies (n= 21) examined dedicated HRI S s y stems, comprising
one or several modules for suppo rting particular HRM p ractices. 16 studi es
focused on generic, i ntegrated or g anizational sy stems, including modules
dedicated to HRM practices. Five did not clarif y whether the HR I S were
dedicated or components of generic sy st ems (see Table 1).
Descriptions of I CT for managing HR in health organizations lacked a common
terminology (see Table 1 ). Organizational s y stems that included HRM functions
were commonl y described as ERP (n=3), patient classification s ystem ( n=3) or
Intranet (n=2). Dedic ated s y stems were described as HR I S (n=7), Pa y rol l/Salary
systems (n=4) or electronic -HRM(S) (n=2). HRIS (n=3) was us ed most frequently
in studies not specify in g whether the s y stem was dedicated or generic.
HRIS support various HRM practic es in health org anizations. However, as shown
in Fig ure 7, most qualifying studi es focus on Operational HRM prac tices (e.g. HR
administration or scheduling).
53
Figure 7. HR M prac tice s exam ined in the include d studies
4
3.4.2.6 HRIS use rs
HRIS are d esigned for a variet y of users. The most commonl y mentio ned user
groups were: health sector leaders/decision -makers (n=6), hospi tal management,
4
* Not m e ntioned i n any o f the qualif ying studies; **Out o f scope of this revie w (ple ase see
Tursunbayeva et al., 2015).
Solid line ova ls: existin g Fos ters’ e -HRM la ndscape categ ories. Dashed li ne ovals, text in Italic:
categories add ed to Fosters’ e -HRM landscape.
54
HR department/HR professionals, nurses, nurse managers/administrators, and
employees (all with n=5). Less commonl y m entioned were health or g aniz ations,
government//profe ssional authorities, line managers (all with n=3), staffing
clerk/coor din ator (n=2), clinicians, donor agency, internal temporar y emplo y ment
agency, rura l p rimary care tea ms and nurse educators (a ll wi th n=1). Seven studies
did not specify an y HRI S user c ate g ories.
3.4.2.7 Innov ation stage s
Innovation stage w as classified based on m y int erpretation of studies’ aims and
findings, rather than authors’ explicit statements, which often bore little
resemblance to the stages described in the stud y .
Half of the studies focused exclusively on a single innovation stage (n=21),
mostl y on HR I S use (n=17), with two studies each focusing on either
development or implem entation. The other hal f (n=21) encompassed several
innovation stages, nine covering development, implementation and use , five
development and use, five implementation and use, and two develop ment and
implementation. Table 3 indicates the innovation stages covered and sho ws that
the studies focused mai nly on : Approaches to HR I S use; Factors of influence
during HRIS implementation; HRIS outcomes, such as rea lized bene fits ; an d
Drivers for HRI S.
55
Table 3. Innovation stages examined in the included studies
Category
Developmen t
Implementati on
Use
Expected Bene fits
S8; S9; S11;
S16; S18; S19 ;
S20; S21; S26 ;
S28; S29; S31 ;
S32; S35; S38 ;
S42
Factors o f
influence
Facilitators
S21; S28; S31 ;
S38; S42
S3; S6; S10; S11;
S19; S20; S21 ;
S28; S32; S37
S3; S4; S10;
S20; S25; S28 ;
S35
Barriers
S35; S38
S1; S3; S5; S6;
S10; S11; S14 ;
S20; S21; S29 ;
S38
S2; S3; S7; S8;
S10; S41
Generic
S8; S10
S5; S8; S11; S19
S21
Approaches to
S21; S30; S38 ;
S42
S6; S8; S11; S14;
S21; S29; S32 ;
S37; S38
S2; S5; S8; S18;
S20; S21; S22 ;
S23; S24; S25 ;
S26; S27; S31 ;
S32; S34; S37
Recommenda tions
S21
S7; S9; S21
S9; S21; S25 ;
S27; S30; S32 ;
S34
Outcomes
Realized
Benefits
S1; S2; S4; S5;
S9; S12; S13 ;
S17; S18; S19 ;
S23; S25; S28 ;
S32; S33; S34 ;
S36; S37; S39 ;
S40
Satisfaction
S5; S8; S9; S15;
S17; S27; S28 ;
S32; S35
Generic
S7; S9; S11;
S21
Do w nsides
S9
56
3.4.2.8 Drive rs and realized benefits
All studies described HR I S implementation as being driven b y expected benefits
or goals. The most com mon related to Strategic Orientation - being able to use
information about HR needs and p erf orman ce for evid enc e -based decision
making, to inform HRM , policy and plannin g, o r as a means of migrating to a
centralized, enterprise-wide HR shared services approach. This was followed by
Operational Effi cienc y - reduction and co ntrol of costs, automation or
aug m entation of manual processes, time saving and reduced bureaucracy.
Improvements in HR Se rvice D elivery were also expected, such as id entif y in g
curre nt levels of provision, resolving issues with external service providers and/or
increasing the qualit y of information in HRIS. Other expectations driving
implementation included Standardization of s y st ems, processes or data,
Empowerment of Man agers and/or Emplo y ees, Compliance with statutory
requirements for workforce data, and he lpin g to manage macro organizati ona l
changes , such as a pla nned hospitals merg er. No evidence w as available to
support the claim that health organizations adopted HRIS to improve their
Organizational Image , as sugge sted in Pa rry & T yson’s (2011) framework.
The most commonl y realized benefits of HR I S implementation related to
Strategic Orientation and Operational Efficiency I mp rovements, followed by the
Empowerment of Man agers and Empl oyee s, I mprovements in Service Delivery ,
Standardization and Compliance with regulator y requirements. Anoth er was
improvement in patient care through facilitating minimum standards of nursing
care (L in et al., 2010) . One stud y reported that hospitals using HR I S had lower
rates of vas cular catheter urinary tract inf ec tion ( Spaulding, 2012). Gener ation of
57
interest from other count ries (I ntraHealth International, I nc., 2009) and im proved
ICT infrast ructure (Altuwaijri & Khorsh eed, 2012) were also reported as
beneficial outcomes.
Only a few studies (n=5) reported whether proje cts had achieved benefits. These
found that HR IS did not influence Operatio nal Effi cienc y (n=3), Strat egic
Orientation (n=1) or Service Delivery (n=1).
Only one stud y (S9) reported adverse effects o f HRIS implement ation within
organizations such as ne ga tive influence on perceptions of HR roles and in creased
time investment for supervisors for associated wit h new HRIS processes, although
one (S21) d escribed a region-wide HR I S project as a “catastrophic failure”
(Chesterman, 2013), wit h negative consequences for contractors and government,
including staff strikes and the Minister of Hea lth’s resignation.
3.4.2.9 User s atisfacti on
A few studies reported use rs being satisfied with the system itself (n=3), its
functions (n=1) and the information it provides (n=4), althoug h one (n=1) noted
dissatisfaction with new HR I S procedures and forms. S eve ral desc ribed HR I S
satisfaction as being dependent upon ease of use (n=2), t y pes of users (n=2),
users’ familiarit y with the s y stem, time required to judge s ystems, whether
systems r efle ct t rue workload, and time - in -use; satisfaction increasing with
evolving user ca pabilit ies and org anizational adaptation (the latter all with n=1).
58
3.4.2.10 F actors shaping HRIS developm ent, implementation and
use
Fac ilitators and barriers were repo rted across innovation stages according to the
Kwon and Zmud (1987) framework (see Table 4). S uccess was influenced
primarily b y project-related factors, includin g governa nce structure, approaches to
project man agement and qualit y of execution, and b y individual fac tors such as
stakeholders’ political behaviours and user involvement. Organizational factors,
including org anizational size, diversity , culture, deg ree of ce ntraliz ation, a nd
availability of resource s, were the most si g nificant barriers. Some studies
described te chnolog ical barriers, includin g breadt h of s y stem functionalit y , degree
of local configuration, and int erope rability. Barriers associated with ex isting HR
processes were also mentioned and several studies recommended simplifying such
processes prior to HR IS introduction, although none reporte d an y evidence of this
having facilitated HR I S projects’ success. Macro -environmen tal influences, suc h
as political refor ms and int er-orga nizational relationships, were considere d very
little.
Table 4. Summ ary of influential factors me ntioned in the included studies
Factors o f
influence
FACILITATORS
Developmen t
Implementa tion
Use
Technology
-
S3
S3; S28; S35
Organization
-
S3; S6; S10; S20
S3; S10; S20 ;
S25; S28
Project
S21; S28;
S31; S38
S6; S19; S21 ; S28; S32
S4; S28; S35
Environment
S42
S20
S20; S25
Task
-
-
-
59
Inter-
Organization
-
-
-
Individual
S21; S28
S3; S11; S19 ; S21;
S28; S32; S37
S3; S28
BARRIERS
Technology
-
S10; S14; S20 ; S21
-
Organization
S35; S38
S3; S5; S6; S10; S 11;
S14; S20; S21 ; S38
S3; S7; S10;
S41
Project
-
S1; S11; S14 ; S21; S29
S2; S7; S8
Environment
-
S20; S21
S2
Task
S38
S14; S21
S7; S10; S41
Inter-
Organization
S38
S14; S21; S38
-
Individual
S35
S1; S3; S11; S14; S20;
S21
S2; S3; S7; S8;
S41
GENE RIC
Technology
S8; S10
S19
S21
Organization
S8
S11
S21
Project
-
S5
S21
Environment
-
-
-
Task
-
-
-
Inter-
Organization
-
-
-
Individual
S8
S5; S8; S11
-
APPROAC HES TO
Technology
S30
S6; S11; S21 ; S32; S38
S2; S5; S8;
S18; S24; S25 ;
S26; S27; S32 ;
S34; S37
Organization
-
S29
S26
Project
S38
S6; S8; S11; S14; S21;
S29; S38
S21; S31
Environment
S21; S42
-
S26
Task
-
S37
S20; S22; S23 ;
60
S26; S27; S31
Inter-
Organization
S30; S38;
S42
S8; S14; S21
S31
Individual
-
S8; S32
S5; S31; S32
RECOMMEN DATIONS
Technology
S21
S21
S21; S25; S34
Organization
S21
S7
S21; S32
Project
S21
S7; S9; S21
S9; S21; S27 ;
S32
Environment
S21
-
S32
Task
S21
S7; S9; S21
S9; S21; S27 ;
S30
Inter-
Organization
-
S21
S21
Individual
S21
S7; S9
S21; S27
3.5 Summar y of the re sults
The primary aim of t his review was to inform the research strategies for
conducting empiric al ca se studi es for m y Ph D res earch. Thus, it h elped to
discover that research in thi s area ranges across disciplines and va ries widel y in
terms of its obje ctives, methods, theoretical orientation, quality and language. As
was expected, the evid ence-base is sparse compared w ith clinical IS research.
Most studies foc us, some what uncritica ll y, on the use and rea lized benefits of
HRIS in pr ac tice, rather than socio -contextual or technological f ac tors in fluenc in g
their development, implementation success, or impacts on strategic de cision-
making or cost- effectiveness. Most research comes from higher income countries
and examines small-scale s y stems in individual hospital s ettings. N evertheless,
severa l hi g her qualit y studies were found, including one national p rogram
evaluation. It was possib le to adapt and apply exist ing theor etica l frameworks to
67
4.2 HRIS be nefits and factors shaping IS i nnovations
Organizational scholars have become interested in understanding the influence of
technology on organizati ons since 1960 th (Orlikowski & Barle y , 2001), whil e the
interest in stud y ing benefits of IS and factors that influence their im plementation
started growing since th e early 80s.
Some of these scholars have started exploring specifically the effects that I S has
on HR (e.g . Lepak & Snell, 1998). Thus, in order to explore the benefits (whether
expected or realized) associated with the adoption of HR IS I d raw sp ecifically
from the HR I S r esearc h i n general, and from the sy stematic r eview of research on
HRIS in h eal thcare context. In order to examine the fa ctors that influence the
adoption of HR IS I draw on factors of influence frameworks that are widel y used
in generic I S research.
4.2.1 Framew orks on HRIS benefits in health settings
HRIS r esearc h has identified a n umber of be n efits specific to HRIS in cluding
strategic ori entation, operational efficiency, improving s ervice deliver y ,
empowering managers and employ ees to perform some of the HR functions
(Lepak & S nell, 1998 ) and standardization of H R processes across o r g aniz ation
(Ruel et al., 2004). A more recent stud y involved t he empirical evaluation of these
expected and realiz ed HR I S benefit categories i n ten organizations from diverse
sectors in the UK and added a further category - im proving of organi zational
ima g e benefit (Parr y & T y s on, 2011) (see Table 5 ).
HRIS introduction, ho weve r, can also cause unintended consequences. Such
consequences can be eit her positive, reflecting a benefit for the organiz ation that
68
was not foreseen prior to adoption, for example an orga nization that pla nned to
achieve onl y cost savin g, standardized also HR processes due to the new HR I S
introduction, or ne gative such as, for example, decrease in int erna l customer
satisfaction level due to depersonalization of HR services provision cause d b y the
introduction of HRI S self service module (Parr y & Tyson, 2011).
The s y stematic literature re view of HR IS in hea lth desc ribed in the previous
chapter confirmed the generic expected and realised benefit categories from Parry
and T y son’s (2 011 ) fram ewor k, and identified t wo further categories of ex pected
benefits including compliance with reg ul atory require ments (e.g. for reporting
workforce information), and help in manag ement of macro organiz ational change s
(e.g. planned hospitals merger). Moreover, it also identified four further categories
of realized benefits, including compliance with regulatory requir ements,
improvement in patient care throu g h facilitating minimum standards of nursing
care (Lin et al., 2010) and reduce d rates of v ascular cathe ter urinar y tra ct infection
in the hospitals with H R I S (Spaulding, 2012), generation of intere st from other
countries (IntraHealth International, Inc ., 2009) and improved ICT infrastructure
(Altuwaijri & Khorsheed, 2012).
The final structure of ex pected an d realised b enefits as identified based on the
conducted litera tu re review is depicted in Table 5.
69
Table 5. HRIS benefits and recipients of HRIS benefits
Literature
Sources
Expected
Benefits
Realized Benefits
Main
benefit
recip ients ’
in focus
Lepak and
Snell
(1998)
Strategic O rientation
Operational E fficiency
Service De livery
Em powerment of manag ers and/or em ployees
HR
m anagers
Ruel and
colleagues
(2004)
+
Standardiz ation
HR
Departm ent
;
Em ployees
Parry and
Tyson
(2011)
+
Imp roving Organizatio nal Im age
Organiz atio
n
Systematic
Review on
HRIS in
Health
Com pliance
with
regulatory
requirements
Managem ent
of macro
organizationa l
changes
Com pliance with
regulatory
requirements
Im provement in
patient care
Generation of
interest from other
countries
Im proved ICT
infrastructu re
A g reat
variety of
users/user
groups
The finding s of the s y stematic li terature review also revealed that rese arc h on
expected and realized b ene fits is often isolated in ex isting literature (Me y e r &
Goes, 1988). This reluctance to engag e in a cl ear evaluation of the outcomes of I S
innovation highlights how challenging it is to asse ss the realized benefits of I T
innovation. As such, I set out to address this rese arch ga p and examine the
expected benefits of intro ducing a new technological innovation – HRIS – to the
actual outcomes a nd unin tended c onsequences achieved (RQ1).
70
Finally , the r esults of the conducted s y stematic literature review revealed that both
HRIS and the data generated from the implementation of H R I S in health
organizations can be used b y a great variet y of users/user groups ranging from
hospital managers, clinicians, nurses and/or HR prof essionals. As the tasks
performe d b y thes e audiences vary, it is likely to suppose that the diff erent
audience s would form their own perceptions of the benefits associated wit h HR I S.
However, ex isting research on HR IS benefits (Lepak & Snell, 1998; P arry &
Tyson, 2011; Ruel et al ., 2004) generall y either fa ils to differentiates b etwee n
differe nt users, or t end t o f ocus almost ex clusively on a particular user category .
For example, Parr y and Tyson (2011) identified HR I S goals and outcom es at the
organizations level without distinguishing be tw ee n the ty pes of ac to rs , while
Le pak and S nell (1998) , and Ruel and colleagu es (2004) fo cused p rimarily on HR
professionals, mentioni ng onl y in passing the benefits a ccrued by employees
(Ruel et al., 2004). W hile such studies advanced our understanding concerning the
benefits associated with HR I S implementation, th ey do not provid e us full picture
on the ex pected and r ealized benefits for diffe rent stakeholders. Understanding
whether and how the p erceptions of HRIS benefits var y a ccording to the type of
stakeholder is important to clarif y the kind of ex pected be nefits that motivate
differe nt stakeholders to accept HRIS initiatives, and the kind o f realized benefits
and actual beneficiaries of these initiatives. In order to address this ga p, the
second re s earch objec tiv e of this researc h is to differentia t e the identifie d e xpected
benefits and pil ot outco mes according to the various HRIS project stakeholders
and/or user groups (RQ2).
71
4.2.2 Framew orks on factors shaping the outco me of IS i nnov a tions
The most comprehensive framework for examining the factors that influence the
adoption of technologies in organizations is the TOE framework (DePietro et al.,
1990). TOE differentia tes between three categories of factors:
Technology, including specific features of the technolog y ;
Organization, including the c haracteristics and nature of the adopting
organizations; and
Environment, including t he characteristics of the macro level at which the
technology is adopt ed.
In th e context of IS, in a manner similar to the T OE appro ac h, Kwon and Zmud
(1987) identif y five categories of factors t hat shape I S adoption in organiz ations :
three sim ilar to the TOE framework includin g en vironmental, technolo g ical and
structural (similar to the organizational factors in the TOE framework) ; individual
factors, such as characte ristics of the individual involved in th e adoption of the
technology ; and task fac tors, such as the nature of the tasks for which the IS is
used (Cooper & Zmud, 1990). Overall, De Pietro et al.’s (1990) TOE fra mework,
and more rarel y the Kwo n and Zmud (1987 ) expanded version, is common in the
IS literature ( Bunduc hi & Smart, 2010), and has previousl y been applied t o HRIS
adoption generall y confirming the applicabilit y o f the framework to res earch on
HRIS (e.g. Trosha ni et al., 2011) .
Similarly , the results of the s y st ematic literature review on H RIS i n health
confirmed the application of the expanded Kwon and Zmud (1987) f ramework to
HRIS in health. I n addition, this review identified two further factors that affect ed
the adoption of HR I S projects in health or g aniz ations: (1) int er-org aniz ational
72
factors such as the relati onship between the adopting health organization and the
HRIS vendor (e.g. W aring, 2000), and (2) HR I S project factors including project
character istics such as governance structure, approaches to project management
and quality of execution (Parr y & T yson, 2011). While all of the aforementioned
factors have been shown to influence the adoption of I S in general ( and H RIS in
health in particular), it is still unknown which of these fac tors influence the
transformation of exp ected into realized benefits. I thus draw from an ex panded
version of K won and Zmud’s (1987) framew or k a nd augment it with t he two
factors identified from m y s ystematic literature review in order to ex amine the
factors that influence the transformation of ex pected H RIS benefits into realized
benefits (RQ3).
4.2.3 Summa ry of conceptual framew orks for HRIS benefits and
factors shaping the outcome of IS innov ations
The aforementioned theoretical frameworks and r esea rch questions should help to
evaluate th e expected benefits from HR I S projects, assess their actual
consequences, and explore the socio-technical fa ctors that influence this
transition. Howe ver, previous re search in the field of Science and Technology
recognized that in order to effectivel y compare ex pected benefits versus actual
outcomes - which is the focus of thi s stud y - the processes of HR I S development
and im plementation should also be examined using a theoreticall y -driven and
context-sensitive approach that can take int o account the interaction betwe en
technolog i cal, socia l and organiz ational sy stems (see Robert et al., 2009).
73
Th e nex t sections will introduc e the theoretical framew ork -instituti onal theory-
adopted to examine the processes of HR I S d evelopment and implementation that
led to the results present ed in this thesis, stating also the main rea sons wh y it was
found suitable.
4.3 Institutio nal theor y : Introduction
While the economic and resource-dep ende nc y theories that I considered adopting
for this part of m y r esearch explain organizational behaviour in t erms of rational
self-intere st c alculations, inst itutional theory con ceptualises it as the product of
the ideas, v alues and beliefs embedd ed in the instituti on al environments in which
organizations operate (DiMaggio & Powell, 1983). It posits that, in orde r to gain
legitimacy , pr estige , stab ilit y , r esources or even t o survive in these environments,
organizations and their personnel oft en act a ccording to what is p erceived to be
legitimate, rather what is perceived as rational in terms of efficienc y and
performa nce (M eyer & Rowan, 1977). Therefore, organizations conform to the
rules im posed b y powerf ul institutions, which are often d efined as re g ulator y
structures, g overnmental agencies, laws, courts, professions, interest groups and
public opinion (Oliver, 1 991). These rules are also known as inst itutional
pressures, and institutional scholars also highlighted that the y can cause si milarity
between diff ere nt organizations that are aiming to obtain legitimacy (Di Magg io
and Powell, 1983 ).
Mey er and Rowan ’s (19 77) influential article re -emphasized the complexit y of
institutional processes (Greenwood, Ra y nard, Kodeih, Micelotta, & Lounsbury ,
2011) and p rompted a new approach to institutional anal y sis . This approac h gave
74
birth to a “new” institutionalism paradigm t hat stressed that “sources of
rationalized my ths [ pressure s] may be in competition if not in conf li ct” (Scott,
1991, p. 167) and that “expectations of powerful external [institutions] actors are
often conflicting , v ague and in flux” (Elsbach & Sutton, 1992 , p. 700; as cited in
Greenwood et al., 2011 ). This has started to s hed light on the im portance of
institutional environments to orga nizational behaviour prompting scholars to
study the so ciotechnical factors that can affect organizations and organizationa l
processes.
Other theoretical frameworks that I considered using in m y r esearc h include
critical manage ment theories that also challenge previous beliefs that
organizational decision making is driven only b y rational aims to achieve
organizational effici enc y primarily because it “is an approach to underst anding
organizations and manage m ent prac tices as the produc t of social rather than
ec onomic pressure s. It ha s become a popular perspective within management
theory because of its abilit y to explain organi zational behaviors that def y
econ omic r ationality ” (S uddaby , 2014 , p. 379). H oweve r, I chose to proceed with
institutional theor y : first because the focus of critical management studies is on
“the social injustice and environmental destructiveness of the b roader soc ial and
economic s y stems that mana g ers and or ga nizations serve and reproduce” (Adle r,
Fo rbes, & Willmott, 2007, p. 119) which was not the main focus of my stud y ;
second because institutional theory was found t o be suitable to respond to the
identified research questions inasmuch as it helped me to explore the processes
through which institutional pressures shape the development and implementation
of an I CT innovation w ithin an organizational setting. I was con firmed in thi s
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decision by the fact that previous scholars have already identified institutional
theory as a suitable “critical” (Strohmeier, 2007) theoretical approach.
In fac t, in the last f ew deca des instituti onal theory has become diffused throughout
various disciplines, suc h as sociolog y (e.g. Meyer & Rowan, 197 7) and
organizational studi es (e.g. DiMaggio & Pow ell, 1983). Recentl y, institutional
theory has also prov ed h elpful in understanding the development, implementation
and use of I S in organiz ations and how these are affected b y dive rse insti tutiona l
force s.
4.3.1 Ins titut ional pressures in DiMaggio and Po w ell (1 983)
Several instituti onal scholars have expressed their views on inst itutional norms
and requir ements – pressures (e.g. DiMa gg io & Powell, 1983; Me y e r & Rowan,
1977; S cott, 1995;) and how the y cause similarit y (also known as homogeneit y ) in
an institutional field. In this section I will provide an overview of the way
institutional pressures are conceived in the work of DiMaggio and Powell (1983),
chosen for this research because of its suit ability to ex plain the data and previou s
successful a pplication in I S r esearc h.
DiMaggio and Powell (1 983) describe three ke y s ou rce s of instituti onal pressures
- coercive, mimetic and normative - that can be imposed on organizations b y
powerful institutions, and cause their similarit y.
Coercive pressur es arise from the fo rmal and informal rul es, stand ards or
regulations imposed b y insti tutional actors in the wider envi ronment surrounding
organizations, such as th e need to comply with standards and regulations, or to
conform to top-down strategies, such as g ov ernme nt deadlines or targe ts.
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Examples of coercive pressures ma y include government mandates or regulatory
agencies. This kind of pressures can either force, persuade or invite organizations
to adhere to the instituti onal re quirements.
Mimetic pressures arise from the motivation to imitate other orga niz ations that are
perce iv ed to be successf ul in a similar environment. Thus, it has been observed
that or g anizations tr y to reproduce th e behav iour of othe r similar or ganizations
from their sec tor at times of uncertaint y or when the goals of a projec t are too
ambiguous. Interestingly, previous research has observe d that even inno vations
are affected b y conscious or unconscious or ganizational eff orts to imitate the
behaviour of others. For example, “ Whil e there certainl y are those who
consciously innov ate, there are thos e who, in their imperfect attempts to imit at e
others, unconsciousl y innovate b y unwittingl y acquiring some unexpected or
unsought unique attribut es which under the prevailing circumstances prove partl y
responsible fo r the success. Others, in turn, will atte mpt to cop y th e uniq ueness,
and the innovation- imitation process continues. ” ( Alchian, 1950; as cited in
DiMaggio & Powell, 1983, p. 151 ).
Normative pre ssure chiefly comes from the informal social norms operating
within profe ssional groups. DiMaggio and Powell’s (1983, p.152) interpre tation
of professionalization concludes that it is a “ collective struggle o f member s of an
occupati on to define the conditions and methods of their work… and to es tablish a
cog nitive base and le g itimation for their o ccupational autonom y ”, and also states
that professions ca n also be influe nced b y coercive and mimetic pressures.
Ruef and Scott (1998), in their longitudinal study using data from 143 hospitals in
the US, differentiate bet ween two t y pes of normative pressure: mana gerial norms
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retarded institutionalisation of some innovations during the later st age s ( Currie,
2004; Swanson & Ramiller, 2004).
Thus, i n contrast to the previous belief that “earl y adoption of inno vations is based
on local, rational organiz ational choice, while later adoption is instit utiona lized
and follows taken-for- granted assumptions about what constitutes proper practice”
(Tolbert & Zucker, 1983 ; as cited in S wanson & Ramiller, 1997), Swanson and
Ramiller (1997) argue th at organizations create a n image for the innovation the y
are planning to adopt (e.g. how innovation shoul d be used within the organiz atio n
or what kind of benefits it will bring for diffe rent categories of stak eholders) earl y
in the beginning of the in novation adoption process. Thus, they also stat e th at “An
interorganizational com munity , comprised of a heterogeneous network o f parties
with a variet y o f mate rial interests in an I S innovation, collec tivel y creates and
employs an or ga nizing vision of the innov ation that is central to de cisions and
actions affecting its developm ent and diffusion. That organizing vision represents
the produ ct of the efforts of the members of that communit y to make sense
(Weick, 1995) of the innovation as an organizational opportunit y . In so making
sense of the innovation, the communit y in effect also defines it and creates it ”
(Swanson & Ra miller, 1997, p.459).
This or g anizing visi on is created and used b y a w ide range o f inter-or g aniz ational
actors, who can continue to shape it throughout the li fe -c y cl e of innovation, and if
“The or ganizing visi on remains underdeveloped after early adoption, later
diffusion and institutionalization of the innovation is lik el y to be retarded”
(Swanson & Ramiller, 1997, p.458). The orga nizing vision is ty p ically
underdeve lop ed at the early stages of a new project, and develops as the
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technology and actors’ und erstanding of its possibilit ies co-evolve. An or g anizing
vision facilitates the interpretation of the innovation by actors tasked with
delivering it, helps to legitimise the innovation within the organizational context,
and helps to mobilise support for realising the ef fec tive deliver y and ado ption of
the innovation (Swanson & Ra miller, 1997).
“ Orga nizing vision ” includes the business pro blematic, or the organiz ational
issues that the innovation is supposed to solve, the core te chnology itself, and the
organizational practices associated with the innovation. Marsan, Pare and Beaudry
(2012) found that when organizational stakehold ers have a positive image about
innovation, the organizations are most ly in f avour of pursuing inn ovation
adoption. Finally , Bunduchi and colleagues (2015) argue that co mpeting
organizing visions c an be created between different or ganizational fi elds whe n
differe nt stakeholders for m differe nt expectations about the adopting innovation.
This concept was initi all y applied to understand the development of technology at
the level of the institutional field. However, recently, it has also been empl oye d to
explain the adoption of innovation at in ter-org anizational (Lyytinen &
Damsgaard, 2011) and o rganizational (Bunduc hi et al., 2015) levels. I emplo y th e
latter approach in my research because I fo cus on the components of the
organizing vision that actors within the studi ed health organizations cr ea ted
regarding the HRI S in qu estion.
4.4 Conclusi on
Existing li tera ture on generic HR IS , as discussed above, tend s either to focus on
user expectations from HR I S or on achieved benefits of implemented HR I S
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innovation. This is also true for r esearch on HR IS in health (Tursunbayeva et al.,
2016). Therefore, in m y research I a im ed to ad dress this research gap and ex amine
not only the expected b enefits of int roducing HR I S but also the actual project
outcomes and unint ended consequenc es (RQ1 ). Moreover, as previous studies that
focused spe cifica ll y on b enefits from HR IS do no t provide the full picture on the
expected and r ealized benefits for di fferent st akeholders, there is a lac k of
understanding regardin g what kind of ex pected benefits motivate different
stakeholders to accept and proceed with HR I S ini tiatives and what kind of
benefits these ini tiatives actuall y ac hieve (especially in the he alth sector) . Thus,
the sec ond research qu estion (RQ2) that I set out serve s to diffe rentiate the
identified expected be nefits and actual project outcomes acc ording to diverse
HRIS project stake holders and/or user groups.
It is alread y known that adoption of technology innovation in organizations is
influenced b y five facto rs related to the technology, organization, environment,
task and indi viduals. Ho weve r, the results of th e s y stematic literature review on
HRIS in health identifie d in seven factors that can affect HR I S projects i n health
organizations, the two additional factors b eing inter-organizational (e.g.
relationship between implementing organization with vendors and suppliers ) and
project-related (e.g. governance structure, approaches to project management, and
quality of execution ) matters. Thus, in order to enhance the current understanding
of the adoption of HRIS in g eneral, as well as HRI S in hea lth organizati ons in
particular, I aimed to empirically examine the fac tors that can influe nce the
realization of initially envisi oned HRI S benefits (RQ3).
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Finally , a s recognised in the field of Science and Technolog y studies, in order to
effectively examine the processes of IS development and im plementation that led
to these outcomes, I used a theoretica ll y-drive n and context-sensitive approach
(see Robert et al., 2009), i.e. I draw on institut ional theor y to ex amine the role of
context in shaping HRI S innovations .
As discussed earlier, developments in instit u tional theor y ov er the past 30 y ears
have provided a much more nuanced understan ding of or g aniz ational behaviour,
recognising both the ex istenc e of multiple a nd often conflicting institutional
demands (F riedland & Alford, 1991; Pache & Santos, 2010) and the ag enc y of
individuals and teams capable of actions to retain, adopt or discard the norms,
values and ex pectations influencing their or g anizational behaviours (Greenwood
& Hinings, 1996; Greenwood , Díaz, Li, & L orente, 2010). Ho wever, onl y a
handful of IS studies consider changes in responses over ti me (Standin g et al.,
2009), examining how innovations are sh aped b y conflictin g institutional
pressures embedded in different instituti onal logics (Currie & Guah, 2 007) or
investigate how actors r espond to multiple or conflicting institutional pressures
(e.g. B unduchi et al., 201 5).
Thus in my research I also set out to contribute to institutional liter ature b y
exploring the processes through which insti tutional pressures shape the
development and im plementation of an I CT innovation within an organizational
setting over time (RQ4). I also draw on the concepts of the organizing vis ion (at
an or g anizational leve l) and strateg ic responses, in order to understand how
organizational actors interpret the nature and goals of the innovation and respond
to the various institutional pressures associated with them. Here I dr aw on the four
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stage model of I S innovation (comprehension, adoption, im plementation a nd
assimilation) which has been su ccessfully adapt ed for studies examining IS from
an I nstitutional Theor y perspective (Mignerat & Rivard, 2009). However, since
one of m y case stud ies concerns a multi-site IS programme that has not yet been
fully implemented I focused on the first three of these stages: intention to adopt,
adoption and implementation.
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5. Chap ter 5 . Methodology
METHODOL OGY
5.1 Introducti on
Th is chapter discusses the methodology emplo yed in this stud y , and describes
how it was used to apply th e conceptual (theoretical) frameworks outl ined in the
previous chapter (C hapter 4). It also specifies how the research design and cases
for study were chosen, as well as gives reasons for th e approaches adopted to data
collection and ana l y sis . Moreover, it includes conside rations on ethical issues
relevant to this re search, and, last, some critical reflec tions on m y role as a
researcher, a nd on the qualit y of this stud y .
5.2 Research qu estions
The main objective of this resea rch is to compare the e xpected and pilot outcomes
of two HRIS projects, and empiric ally to ex amine the impact of the fa ctors
identified as li kely influences on these in the sy stematic review. I also aim to
examine the processes of HRI S development and implementation in both
contexts.
The following specific r esearch questions were set out in order to ac hieve the
afore m entioned re search objectives:
RQ1: What are the expected benefits, actual outcomes and unint ended
consequences of introducing a new technological innovation – HRIS?
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RQ2: What are the expected b enefits and outcomes for diverse HRIS
project stakeholders and/or user groups?
RQ3: What are th e fact ors that influence the tr ansformation of expected
HRIS bene fits into rea lized benefits?
RQ4: How do institutional pressures shape the dev elopment and
implementation ove r time of an ICT innovation w ithin an organization ’s
setting over time?
5.3 Research m ethodolog y
There are two primar y research paradigms th at differ in th eir philosophi ca l
worldview, unde rstanding of the social (e.g. in a foc us on facts or o n their
meaning) and technical methods (e.g. whether samples are lar ge or small) : the
former is often dubbed positivi st and the latter non -positivist, roughly equivalent
to the distinction betwe en quantitative and qualitative research (Creswell, 1997 ;
Easterby-Smith, Thorpe, & Lowe, 1991). Thus, an y empirical research should
start from choosing whi ch of these p aradigms to follow. This decision mainly
relates to the nature of the research and its research questions. A positivist
approac h should b e adopted when the focus is on the facts, the causal
relationships between phenomena, and t esting h ypotheses, while a non-p ositivist
approac h is appropriate prima ril y when the fo cus is on meanings, and on an
understanding of the role play ed b y ac tors’ interpretations of, and motivations
regarding , the processes in which the y are involved (Stake, 1995).
The majorit y of ex isting studi es on I CT follow the positivist paradig m (Kauber,
1986). However, the y are often criticized because they neglect the contex t in
90
which the y are situated (Cucciniello, 2011), whereas it has been widel y
recognized that the uses and consequences of technological innovations emerge
unpredictably throu gh compl ex social interactions amongst the actors invol ved,
their responses to and interac tions with the innovation, and the organiz ational
context in which they a re situated (Robert et al., 2009).
As such, previous research on I S (Bunduchi, 2004) underlined the importance of
deciding on the research paradig m to follow early on, as any stud y has to reflect
the identified research st ra teg y and questions. As the aim of m y research was to
understand the expected a nd actual outcomes of HR I S projects in diffe rent
contexts, as well as to examine the associated pro cesses of HRIS development and
implementation, I adopted a non-positivist ic, qualitative researc h paradigm.
Among the diverse t y pes of qualitative research availa ble (e .g. ethnograph y or
phenomenology ), I chose to adopt a qualitative case stud y approach beca use it is
“an empiric al enquir y that investiga t es a contemporar y phenomenon within its
real-life contex t, especially when the boundar ies between phenomen on and
context are not cl early ev ident….[and it]…relies on multip le source s of evidence”
(Yin, 2003, p.). I t also allows access to rich and detailed contextualiz ed data and
has been used successfull y to stud y oth er top -down technology im plementation
projects in complex healthcare contex ts (Cucciniello, La psle y , Nasi & P ag liari,
2015; Scott, Ruef, Mendel & Caronna, 2000).
This stud y focused on international ana l y sis of two HR I S projects in rather
differe nt European countries. The case stud y in the first European countr y
(Country 1) focused on a national-wide project, while the case stud y in the second
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European country (Countr y 2) invol ved a region-wide project of development and
implementation of the same HRI S s y stem.
Previous research h as sta ted that studies using mu ltiple cases can “predict similar
results (literal re plication) or produce contra stin g results for predictable reasons
(theoretical replication)” (Yin, 2003, p. 47). In this way it can “strengthen research
findings in the wa y that mul tiple experiments strengthen research fi ndings”
(Darke, Shanks, & Broadbent, 1 998, p.6). Thus, although each of thes e two case
studies was conducted independently, the smaller-scale region- wide HR I S
development and imple mentation project in Co untry 2 wa s studi ed in order to
assess the replicability o f the methodological an d theoreti cal approach chosen in
the case stud y of Country 1. Here the data collected from the second case stud y in
Country 2 wa s critical in enhancing th e theoretical framew ork and research
strategy.
As the nation-wide program of HRIS development and implementatio n in Countr y
1 was ve ry big and comp lex I adopted an embedded case stud y approach, where I
first studied the program at the national level (the wider unit of analy sis) b y
focusing on the national project team, and t hen ex amined ei g ht individual
Regional Health Or ganizations (RHO) in depth as embedded cases (sub-units).
This approach was chosen to allow comparison across the eight embedded units of
analy sis and to provide opportunities to ex amine both shared and context -spec ific
themes (cf. Y in, 2009 ).
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5.4 Selection of c ases
5.4.1 Se lection of country
The idea o f conductin g multiple case studies in two selected Eu ropea n countries
was triggered b y the out comes of previous research on te chnology initiat ives in
healthcare contexts , which compared impleme ntation of Electronic Medical
Record in the same European countries (e. g . Cucciniello, 2011). Moreover, these
two countries were foun d suit able for this case stud y , as the y are both part of the
European Union (EU), have national h ealth systems, and historicall y th e health
system in Country 2 was modelled after the health s y stem in Countr y 1
(Cucciniello, 2011).
Finally , C ountry 1 w as selected be cause it had a national health service that was
suitable for m y r esearch, and was in the process of im plementing a nation -wide
HRIS system. Thus, I arranged for a six months’ research visit to the Universit y of
Edinburgh in orde r to stud y this pr oject. Countr y 2 was selected be cause it is the
country of m y re sidence and the countr y where I was pursuing my PhD.
5.4.2 Se lection of sector
The title of m y P hD program is “Innovation and Man a gement o f Publi c
Resources” . The main aim of this program is to improve the qu ality of s ervic es
offered b y public sector organizations, as well as their efficienc y and productivit y .
Therefore, it was im portant that my P hD research focused on organization/s from
the public sector. As my resea rc h interest has been alwa y s in HR I S and their
impacts, readings of r elevant int erdisciplinary literature su ggested that very little
is known about the development, implementation, use or impacts of HRIS in
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attended several initial interviews, and on e group interview to ensure th at I felt
comfortable and confid ent interviewing s enior respondents. This was done
following obs ervations o f previous qu alitative studi es (e.g. Pa yne, 2000) , which
noted both that interviewing in qu alitative research is a complex assi gnme nt, and
that it can nonetheless be learnt.
Respondents were selected based on their k nowledge of and involvemen t in the
HRIS p rojects in question . P otential bias in selec ting r espondents w as addressed
by the dive rsified sampl ing strategy. Interviewees were either recommended b y
th e ke y contacts in th e st udied organizations , snowball sampled (e.g. inter viewe es
were asked to recommend other project stakeholders who could contribute to the
study) or volunte ere d to participate in m y re s ea rc h.
Interviews lasted 50 min utes on average (r ange 22-100 min) and were re corded,
transcribed verbatim, anonymized and sent to respondents for verification and
clarification where necessar y .
5.6 Data anal y sis
Data analy sis was mainl y informed by the qualitati ve approach described by Miles
and Huberman (1994), and involved the following three main activities :
Data reduction or dat a coding where d ata was or ga nized and grouped int o
common themes;
Data display wh ere anal y z ed data was organized in a format that would
help understanding of the studied phenomenon; and
Verifying data and drawing conclusions on re lationships, patterns and
explanations for them.
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Thus, data anal y sis in my research started wit h data coding, where an “o pen ”
coding approach (Glaser & Str auss, 1967) to dat a analy sis was first adopted in
order to elicit preliminary cate g ories and the mes, re flecting as faithfully as
possible the terminology of the re spondents. To o ptimize int er-consistency, one of
the richest tr anscripts was first open coded independentl y b y t wo r esearchers (Dr.
Raluca Bunduchi, and my self), who iterativel y reviewed their emergent c odes.
Analy sis then moved to the interpretation sta ge , searching for patterns and
relationships and d eveloping the coding frame work. Interpretation invol ved a
highly iterative process of going back and forth from the data to the li terature to
explore concepts, seek i nterpre tations and identif y patterns that could illuminate
the actor’ s b ehavior and the c haracteristics of the IS innovation process.
At this stage building on previous research, data related to HRIS expected benefits
and outcomes we re coded either according to (1) HRIS benefits identifie d i n
previous research (see Table 5 ) o r (2) addition al expected and realized benefit
categorie s for HRIS in h ealth that I identified in my s ystematic literature review
(see Table 5 ). Data that did not fit into any of th ese categories was then grouped
separa t ely . Finall y , data re lated to f actors that prevented benefits from being
achieve d were also cl assified according to ca t egorie s from previous resea rc h,
which were summ arized in the findings of the systema tic literature review on
HRIS in health (Environ mental, I nter-O rganizational, Organizational, Individual,
and Task, Technology- or Project-related).
This coding app roach he lped to classif y the data on the Expected HR I S Benefits,
Outcomes and Factors of Influence according to the categorie s from generic and
Health HR I S res ea rch, and to identif y additional categories o f ben efits that
101
emerge d from the d ata. However, a s durin g this anal y sis I discov ered tha t not all
of the envisioned expected benefits were achieve d, I also set out to examine the
HRIS development and implementation process that led to these outcomes.
Thus, during the int erpretation stage o f dat a ana ly sis the concept of insti tutional
force s, in particular c oercive pressure from government, seemed to provide a
powerful ex planation for changes in the innovation process du ring its early stages .
This prompted me to ex plore institutional theory as a means of enriching th e
interpretive framework for m y obse rva tions. Further investigation of data revealed
other instituti onal concepts as pow erful lens to ex amine the data, in particular
organizing visions (to e xplain changes in the p rocess of the innovation at each
stage) and strategic res ponses (to explain the innovation outcomes). Thus, I
revisited and re-coded the data with reference to the institutional pr essures
(coercive, normative ma nage rial, normative t ec hnical, and mi metic), organizing
visions (business problematic, core te chnology and organizational processes) and
strategic responses (acquiescence, compromise, avoidance, defiance and
manipulation) characterizing the innovation st ages of comprehension, a doption
and implementation that also emerg ed from the anal y z ed data.
Although both of the afore m entioned coding framew o rks (on ex pected and
realized benefits, and on institutional pressures, organizing vision and strategic
responses) structured the data, the initi al open data coding ensured t hat no
important emerging theme was missed or neglecte d.
All stages of d ata coding mad e use of th e Nviv o qualitative anal y sis software
package.
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5.7 Ethical considerati ons: Confidenti ality and sensiti vity
Part of m y r esearch was conducted du ring m y six months’ resea rch visit to the
University of Edinburgh, where I was co-supervised b y two Senior Lecturers.
Thus, Universit y of Edinburgh Board of Eth ics approval was sou ght (see
Appendix 4) and obtained (“Level 2 Ethics approva l: non-intervention research
where you h ave the consent of the particip ants a nd data subje cts” (Universit y of
Edinburgh, 2016 )) for conducting this stud y. Overall, the n ece ssit y of obtaining
ethical a pproval prompted me to consider ver y seriously various issues (e .g.
anony mit y and confidentialit y ) , which was reflected in the creation of the r esearch
strategy (e .g. to anon y miz ation of study participants).
Before c onducting the case stud y in Country 1, I also contacted the Research
Ethics Office o f the studied NHO, and inquired regarding the ne cessity to obtain
their ethical approval for my research. However, I w as advised that it was not
essential, as m y data collection strate gy did not invol ve interviewing pat ients. I
was also not asked to obtain an y ethical approval from the University of Molise or
the studied RHO in Country 2. However, I still followed the same ethical
guidelines as in the Country 1 in order to ensure consistenc y (anonymit y and
confidentiality for the res pondents) ac ross both cases ).
Relationships of trust were established with the st udy participants, and sometimes
they sha red sensitive and confidential information regarding the projects studi ed .
Thus, to maintain their confidentialit y, the names of participants and organizations
studied were anon ymized and any identif y in g in formation was removed in this
thesis and any r eleva nt publi ca tions. I have also always stored both soft an d hard
copies of recorded interviews and doc umentation received in a secure place.
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Overall, if I had an y con cerns about ethical issue s, I alwa y s addressed the m with
my Universit y of Edinburgh co-supervisors or checked the Univ ersit y of
Edinburgh website for further guidance.
5.8 Critical reflection s on m y role as a res earcher
My educational background is in eng ineerin g and IS , and m y p rofessional
background is in HRM. I often mention ed these educational and professi onal
experiences to interviewees. This increased m y credibility as a researcher and
enabled them to use I S a nd HR terminology freely , a s I was familiar with it . I n the
initial interviews, I also tol d them that I used to work in an international, p rivate
bank. However, I observed that the study parti cipants did not consider this an
asset in m y research, and so I did not mention it in later interviews, unless I was
specifica ll y a sked about my pre vious wo rk e x perience .
I also had experience of conductin g res ea rch in the health sector ( an enterprise
project for my M aster’s degree at McM aster Uni versity , Canada). However, m y
knowledge of the studied health contexts was initia ll y ver y limited. Thus, I always
had to prepare fo r the initial interviews (e. g. read about how health s y stem s in the
studied countries work) and ask m y supervisors and occasionally even stud y
respondents for cl arifications, which in some cases increased the duration of the
conducted interviews.
While gathering and anal y zin g the dat a for my PhD research, I tried to be open
minded and aware o f an y assumptions, stere ot y pes and biases that were shaped b y
my b ackg round and espe cially working experience in the private sector, although
I recognize that thes e to ge th er with th e influenc e of th e research background of
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my PhD Supervisor at the University of Molise and host co-supervisors at the
University of Edinburgh most li kely affected m y research strateg y ( Mauthner &
Doucet, 2003).
Finally , I believe that t he most important lesson that I le arned during m y PhD is
not to make an y assumptions while anal y z ing data , as I tended to do initia lly, but
to ex amine it with a ver y c ritical e y e. This helped me to avoid jumping to
conclusions, and to do my best in ensuring that my data anal y sis is reliable, as
also discussed in the next section.
5.9 Qualit y of the stud y
Qualitative research h as to meet s eve ral criteri a to r eassure readers t hat its
conclusions can be t rusted. There are several ap proac hes to ass essing the qualit y
of qualitative research (e .g . Yin, 2003). I adopted the following approach that had
already been used successfully in previous qualitati ve resea rch on HR I S in health
(Stringer, 1999, p. 176; as cited in Waring, 2000):
“ Credibility – e stablished by p rolonged engagement with participants ;
multiple sources of data for triangulation purposes; participants check and
verify the a ccuracy o f d ata and inform ation recorded; peer debriefin g which
allows the researc her to reflect on research processes with a colleague.
Transferability - established b y describing the means for appl y in g the rese arc h
findings to other contexts. This is done b y giving d etailed descriptions that
enable th e readers to id entify similarities be tween the research settin gs and
other contexts.
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Dependability and confirmability - readers should be abl e to se e an audit trail
that clearly de scribes the processes of data collection and analysis.”
Moreover, while writing this thesis, I also followed the CASP qualitative r esearch
checklist (that I also used to assess the qualit y of the qualif y ing studies in m y
systematic literature review) to ensu re that no important research qu ality-related
points were missed.
5.9.1 Credibili ty
The transcribed inte rviews were sent to appropri ate respondents fo r review . Some
confirmed that the transcripts p rovided an accura te representation of the
conducted interviews, w hile others added to their transcripts missing infor mation
or essential clarifications . "Multiple data sources (e.g. semi-structured interviews
and public or int erna l documentation) w ere anal yz ed in my case st udies to
increase their reliability, althoug h potentially observations on the behaviour of
study participants coul d have added additional credibilit y and ensured full
triangulation."
I established and maintai ned good collaborative relatio nships with key contacts in
the health organizations studied in both countries, and the y confirmed that m y
observations and conclusions were accurate for the time when the data was
collected (e.g. when I sh ared with them conference p ape rs concerning the ir case).
Moreover, the res earch strateg y , as w ell as the preliminar y research findings were
constantly sha red and discussed with m y PhD supervisor as well as with hosting
co -supervisors at the University of Edinbur g h to identify an y emerging issues, and
to address them in a timel y mann er. Finall y , p reliminar y res ea rch resu lts were
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discussed at various interdisciplinar y (e.g. health informatics, organizational
studies or HR) wo rkshops (e.g. Strategic HRM workshop) and conferences ( e.g.
European Group for Organizational S tudies or Farr Institute Health Informatics
Conference) in order to obtain feedback on the rese arch methodolog y and
theoretica l concepts adopted. The full list of confe rences, symposiums and
workshops were research results were presented and discussed is presented in
Appendix 5.
5.9.1.1 Tran sferability
Qualitative research has been often criticized for not offering th e same
ge n era lizabilit y of findings as quantitative studies (Mason, 2002). There are some
recommenda tions on h ow to address this li mitatio n b y s ampling “typical
organizati ons/cases” (e.g. Fl y vbjer g , 2006; Cress well, 2011). In m y research this
constraint wa s principall y addressed b y employing a “ multiple case study ”
approac h (Stake, 1995), where the case stud y in Country 2 was conducted in order
to identif y wh ether the case stud y results regarding Countr y 1 were replicable and
thus potentially generalizable to other health or public sector organizations .
5.9.1.2 Dependab ility and c o nf irmability
Previous research has underlined that “convincing the r e ader of the validi ty of
case stud y r esearc h is a s much a matter of rh etorical st y l e and flair as it is of
accuracy and care in m atters of th eory and met hod” (Walsham, 1995, p.79; as
cited in Darke et al., 199 8, p.288), and that publi cations on case studie s “must be
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composed in an engaging mann er…tha t constantl y entices the reader to c ontinue
reading” ( Yin, 2009).
In this study , I have done m y best to des cribe my re search strategy in detail ,
support m y ar g uments w ith sufficient evidence a nd present m y rese arch findings
in tabular format, as was recommended for qualitative case studies b y Darke and
colleague s (1998). F inall y , I have also tried to present m y case stud y “as an
interesting and c onvincin g stor y ” ( Darke et al., 1998, p. 287).
5.9.1.3 CA SP Check list
CASP checklist was used to assess the quality of qualifying studies in my
systematic liter ature review on HR I S in h ealth. It was sele cted as it is commonl y
used to assess the quality of qualitative research (e.g. D y ba & Dingso y r , 2008 ;
Sheikh et al., 2013 ). Ho wever, I also adopted it as an essential point of reference
to buil d this thesis. Thus, I used it in order to ensure that all c ritical methodolog y
and qualit y- related point s have been thoroughl y addressed, but not to assess the
overall quality of this di ssertation.
5.10 Conclusion s
This chapter has outl ined the research questions set out for empirical st udy and
has justified the chosen research desi gn. It has also described and aimed to
validate methodolo gica l choice s made throughout thi s stud y (e.g . selection of
cases to stud y or approaches to data collection/analysis). Furthermore, it has
provided critical reflections on ethic al issues, m y role as a researcher and th e
quality of this re s ea rch.
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In summar y , qualitative multi -ca se study design wa s adopted, whe re the ca se
study in Countr y 1 is focused on nation-wide, and the case stud y in Countr y 2 on
region-wide pro g ramme of HR I S dev elopment and implementation . Th e reason
for conductin g case study 2 was to examine whether the findings from the case
study 1 would be replicable, and thus potentially transferable/ge neralizable to
other hea lth or public sector or ganizations. Semi-structured interviews were
chosen as the primary d ata sou rce, but they were complemented with
documentary analy sis to increase the validit y of this stud y . Data anal y sis was
mainly informed b y the qualitative approach described by Miles and Huberma n
(1994). The results of this data anal y sis will be presented in the following cha pters
together with rich descriptions of each of the studied cases.
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when the data were collected, while the proje ct has had some unexpected
consequences.
6.2.3.1 Operati onal Go al and Effic iency
Expected
Government expectations for qualit y improvement in the health service are
constantly increasin g while the budgets available for public service s in Europe are
decreasing. Therefore, it was/is especially importa nt for the Government to ensure
that all resource s, and es pecially thos e related to workforce – which can a ccount
for between 65-80% of total operating bud g ets of health organizations (Khatri,
2006) – are p roperly pla nned and spent. Thus, the ke y driver that prompted the
implementation of this c ountrywide HRIS, which was also incorpora t ed into
numerous Government s trategic do cuments, was the need for the Govern ment to
be able to quickly obtain, and conseque ntl y for NHO and RHO to quickl y provide,
workforce data to enable the creation and imple mentation of effective w orkforce
and health policies.
“There was a kind of belief that it’s the best thing for [NHO ] to have this kind of
information, a single business system, it’s huge it really is, a huge lot of data and
a huge information and very, very helpful for everybody from management and
HR corporately up to [ RHOs ] and up to the [Government] ” . (National Project
Team re spond ent 2)
The HR professionals int erviewe d - even those with advanc ed pre-existent HRI S -
reported that the y were looking forward to havin g a new HR I S, as it was promised
to them that the new single instance HR I S w ould be integrated into other national
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(e.g. Pa y roll) and regional (e.g. rostering) s ystems. This was suppo sed to
eliminate the need for multiple data entry acro ss various s y stems, to streamline
associated processes, red uce bureaucrac y and ena ble preparati on of efficient and
consistent statutory workforce reports.
“I think it was going to be quicker. The system was meant to take away a lot of
the paperwork side from us…Also we were tol d that it would generate the letters
so a lot of the admin si de would b e taken away because it w ould generate the
letters we would just have to print it off and send” . (HR Professional, RHO 7)
Moreover, the national HR I S s y stem w as suppose d to allow data sharing b etwee n
all country RHOs, which would in principle ease int er- organizational transfers for
health professionals and reduce the work associat ed with it for HR professionals
(e.g. it would be possi ble to transfer an employee record inst ead of creatin g a new
one).
“The primary goal was to try an d do things onc e across [the Country ] and have a
single system that would allow us to move off where we moved people around …
The [RHOs ] are individual e mployers. But every time so mebody re -join ed the
[RHO ] we start again, so we might get some payroll i nformation from a previous
[RH O] , that’s it ; we then set up new files, n ew sense data, etc., in that individual.
So the goal was, as we have a [NHO ] , then we would be able to transfer data
across ” . (Senior HR Executive, RHO 3)
Finally , HR Professional s also remarked that the studied HR I S project has never
aimed to reduce staffing withi n RHOs or to achieve financial savings.
“The idea of the system was not brought in to drive forward fi nancial savings ” .
(Senior HR Executive, RHO 2)
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The expected benefit for Managers and Employees , as reported b y the eHealth
respondent and some HR Professionals, was to automate some of the pre -existent
paper HR processes, which as a result would make these processes e asier, save
Managers and Employ ees ti me and re duce the paper used.
“Any approvals and thi ngs like that will be done on -line so, you know, it reduces
paper, reduces a lot of t hat, but equall y it reduces the labour process ” . ( eHe alth
respondent)
It should be noted that although HRIS Team Members also reporte d reduced paper
work a s an expected benefit, however, the y hi ghlighted that eliminating paper
processes w ould require t ra nsferring all the data into the new HRI S first.
“It’s going to take away a lot of paperwork, a lot of the r isk in losing that
paperwork, that trai l’s is going to be stored w i thin the system ” . (HR I S Team
Member)
Realized
Some HR Professional s reported that the new s ystem has been set up to require
less approvals (e .g. two instead of three or four) compared to their pre-ex istent
paper b ased processes. Thus , it was perceived tha t the new HRIS simplified and
speeded up some proce ss es, while a lso reducing bureaucrac y .
“I think it’s a lot quicker, even with putting things on to be advertised, especially,
like I think that part is much quicker, it’s just o ne thing just what I need t o do
rather than back and forward ” . (HR Professionals, RHO 7)
However, HR Professionals also suggested that the HR I S implementation project
caused more work for th em. This was mainly associated with the data migration
or data catching up pro cesses that “…l ed [them ] to manual entry of data once the
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initial uploads were done which [they ] hadn’t done in the past” . (Senior HR
Executive, RHO 3)
The interviewed Manager was ver y positive abo ut realized pilot benefits, which
she summarized as an autom ated and quicker recruitment process, as well as the
empowerment that she felt b y being able to access and monitor her tea ms’
employment da t a without re l y in g on HR.
“ In the old system I only had the date that the me mber of staff was hired for this
organization, but you could never see when they moved to thi s part icular role and
I had to go to HR, they had to go to their manual copies, they had to fi nd the date
and send it to me. N ow, you go into the system and you can see all of the dates.
Every single date of when a person had changed ” . (Manag er User, RHO 7)
However, she also reported that HR in her RHO had established additional levels
of c ontrols in the s ystem to e nsure that managers make accurate records (e.g.
accurate feedback notes that are sent to inte rviewe d can didates), which caused
some unexpected delays in the rec ruitment processes.
The interviewed Employee did not report an y a chieve d pilot benefits, although
some HR professionals claimed that users liked that the y could add/ch ange th eir
personal deta ils in t he system, which enabled marginal time and paper saving s.
“To a small extent in some of the departments that are using it for annual leave
recording are not filling out annual leave reque st bits of paper and e xchanging
those and filing those and that sort of nonsense. So there’s probably a marginal
paper saving and time saving in that, but then y ou need to extend that int o all
your other busi ness process as well to get the full benefit ” . (Senior HR Executive,
RHO 6)
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None of the respondents reported an y op erational efficiency-related realized
benefits fo r the Gove rn ment , NHO or RHO at the time the interviews were
conducted.
6.2.3.2 Service D elivery
Expected
For HR Professionals the new s y stem was supposed to expand pre-existent
services the y provided for th eir internal cust omers such as Managers and
Employees ( e.g. creating notification about new job opportunities) , which a s a
result was suppos ed to also have a positive impac t on their work (e.g. to increase
candidate’s pool for recruitment and thus to enable quicker filling of vacant
positions).
“One of the w onderful things I think about the recruitment side of things … if
people have r egistered and said ‘I'm inter ested i n midwifery jobs’ you can send
them all e- mails saying ‘here’s a job come up’ an d suddenly you ’ve got this huge
number of pe opl e that y ou could ne ver g et hold of before. You could put an
advert in the paper or y ou could put things on I nternet sit es but if th ey don’t go
and look at it, now you can actually send stuff out ” . (National Project Team
Re spondent 2)
Interviewed respondents did not re port a ny expected Service De liver y related
benefits for the Government, NHO or RHOs .
Realized
Some HR Professionals reported that the new HR I S contains b etter quality
information, and that they and Managers in thei r RHOs ar e benefitting f rom the
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reports they can generate from it. This was also confirmed b y the interviewed Line
Manager .
“Definitely more quality info rmation that’s coming out of it ” . (HR Professional,
RHO 7)
However, according to s ome HR E xec utives , an increase in the amount o f work
associated with the n ew HR I S implementation affected the level of serv ice that
HR departments provide d to their int erna l customers, as staff responsible for day-
to -day HR practices such as recruitment, were pull ed from these activities in order
to help with the local RHO ’ s sy stem implementati on ac tivities.
No service deliver y ben efits were reported for t he Government, NHO, RHO or
Employees at the time the intervie ws were conducted.
6.2.3.3 Stand ardization
Expected
NHO alread y had a standard electronic s y stem to support its pay roll
administration activities on a national lev el, however, there was no consistency
across the HR processes and HRIS s y stems used withi n the individual RHOs, and
consequently across the workforce reports the y pr ovided to the Governme nt.
“Some people had quite sophisti cated systems, but it meant if y ou w ere the
[Governme nt ’s ] health department and you're asking for reports, then you would
have got the reports in different ways ” . (Senior HR Executive, RHO 2)
Thus, in 2007 an int erna l NHO survey re v ea l ed a wide variety of computer,
access/sprea dsheet and paper-based s y st ems to support HR a ctivities across the
country ; onl y 60 % of 42 surveye d R HOs had HR sy stems, and these systems were
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provided by nine diffe rent companies. Therefore, the NHO ’s vision was to have
one standardized, n ational HRI S that would replace the diverse IS used across the
RHOs, and consequently would allow pr eparation and submission of workforce
reports in a in a uniform format.
“Having one sy stem that’ s maintained that information. That’s one of the key
benefits for the [NHO ] a s a whole, I would say ” . (HR Professional, RHO 7)
There w as also a long -term visi on that b y im plementing nationwide HRIS, some
of the most critical HR pro cesses, such as recruitment, could be standa rdized.
Overall, the medical recruitment process has been identified by the Government
as a critical priority to meet the demand for hig h qualit y health care deliver y
across the whole of NHO. C onsequently , the expectations of HR Professionals for
the recruitment module of the ne w s y stem were also elevated.
“So I think the recruitment process is quite complex but we also have ch allenges
within rec ruiting clinicians and folk all around [the country ] , so it was really
bringing in a standardised way of doing that ” . (eHealth Respondent)
No expected standa rdization related benefits were reported for the RHOs,
managers and employee s .
Realized
HR Professionals mentioned that the new HR I S assisted in standardization of the
NHO’s p re -e xist ent HR processes su ch as posting RHO s ’ job announcements in a
unified format. Moreover, the process of implementation of the new HRIS opened
up a dialogue between R HOs about reconsidering their operatin g pro cedures, and
triggered a n opportunity to move towards standardizing NHO’s HR practices
across all RHOs.
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“It’s a way of working w e’re trying to do across [NHO ] , which is just shari ng
services and doing things differently. So we’ve got, [many RHOs ] a ll doing
recruitment at the moment, but we actually thi nk, well, maybe three or four bigger
[RHOs ] should just do the recruitment on b ehalf of all the [R HOs ] or something,
rather than us doing it. Because it must be mor e cost effective that way, but…
We’re sti ll at early door s with that discussion, but it ’s certainly being looked at.
And hav ing a national HR sy stem would help us with a ll of that discussion,
because everybody would be able to acc ess all the different bit s of information,
etc. So it’ s quite critical to all of that ” . (Senior HR Executive, RHO 8)
No standardization related bene fits were report ed for the Government, NHO ,
RHOs or Employees at the time the interviews were conducted.
6.2.3.4 Strateg ic benefits
Expected
Government envisioned t hat in the lon ger term, once var y ing HR processes across
R HOs had been standardiz ed, some of these HR processes potentiall y could also
be centralized, and shared betwee n individual RHOs. For example, selected RHOs
could become responsi ble for different HR processes (e.g. recruitme nt) and
perform them for all RHOs in the countr y .
“The overall directives come from the [Government ] and they’re looking to have
shared services w ithin HR, so we all need to be working off the one sys te m and
working in the same way ” . (I mplementation Team Member, RHO 8)
For N HO and RHO ac cess to up- to -date and accurate workforce data was
expected to allow better workforce plannin g , whi ch as a result could help RHOs
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and NHO to achieve their strategic organiz ational objectives such as i mproved
patient care or an inc reased level of patient safety which wa s reported to be
challenge d by hi gh levels of absence a mong m edica l prof essionals or turnover
across the c ountr y.
“So there’s some k ey drivers around how it ties i n with patient safety, ho w it ties
in with workforce planning” . (Senior HR Professional, RHO 2)
For HR Professionals the new HR I S p romised automation of sim ple
administrative tasks such as posting announcements about vacant positi ons to the
Internet, which was envisioned as a great strategic benefit that would allow HR
Professionals to catch up on their work, and more importantly focus on more
complex HRM practices such as performance management.
“It would enable the HR de partment to concentrate on other work that they
should be doing ” . (HR Profe ssionals, RHO 5)
This functionality w as es pecially want ed b y the RHOs without pre- existent HRI S,
which were looking to replace and/or automat e existing paper or sp readsheet-
based processes with the help of the new HRI S.
No expected strategic benefits were reported for Managers and Employees .
Realized
No realized strategic benefits were reported for an y st akeholder at the time the
interviews were conducted.
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6.2.3.5 Em powerment
Expected
The interviewed Line Manager reported that the ex pec ted benefit for her and her
team was to have a single inst ance HR I S that would record and maintain all sta ff
information, so that the y could focus on their pri mary job responsibilit ies instead
of spending time on ad ministrative tasks such a s inputting their informa tion into
various IS .
“ W hy now you ha ve to p ush [employees] and tell them ‘go into the other system
and please log your training courses and put every thing that you have done’ and
when you are very bus y throughout the day you might not find that is absolutely
important and you find that most of them don't d o it, which is a bit -, so you don't
have a full [Personal Development Plans] . So I' m hoping that because this system
will be a bit automated and you could do on-line and you could see that it will be
a lot easier to actually be able to have a record ” . (Mana g er User, RHO 7)
This is in line with the re sponses of the interviewed HR Professionals who
reported that the new s y stem was supposed to reduce their manual and
administrative work b y giving responsibility to m anag ers for some HR pr ocesses
related to the m anage ment of their teams, and to employ ees for keepin g their
personal data up - to -da te.
“If we can promote and get staff to do that [change their information by
themselves, etc ] , ins tead of phoning up [HR] and doing a change for them. Let
them just go into the syst em and change it, and it’ s done” . (Senior HR Executive,
RHO 8)
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Therefore, th e intervie wed HR Professionals reported that the y did not have
confidence in rolling out to managers and employees the new s y stem sin ce it did
not have accurate and up - to -date data; at the time of data collection the new HR I S
was used mostly by pilot departments within RHOs.
6.2.4.2 Inter-or ganizational
The HR I S s y stem wa s developed and is licensed b y a US -base d mul tinational
computer technolo gy corporation (s y stem supplier), with a very stron g reputation
for working in complex organizations from various sectors. However, the system
was procured from an int erna tional ICT vendor ha d already p rovided NHO with a
number of other national-level ICT services.
The i nterviewed r espondents reported that alt hough this vendor al rea d y p rovides
and supports diverse clinical and workforce s y s tems for NHO, the y were not
happy with how the y executed this particular HR IS project. Th e y reported that the
vendor was distracted by other projects the y were invol ved in, had a ve ry high
turnover of th eir ke y p roject participants, and as claimed b y respondents also had
little pre vious experienc e of working with the HR I S s y stem supplier. These
factors combined significantly a ffected the project delivery, c ausing delay and a
reduction in NHO’s stak eholders’ satisfaction with the qualit y o f project d elivery
and support the vendor provided.
6.2.4.3 Organi zational
The NHO is characterized b y a great diversity of individual RHOs in terms of
size, geographical location, procedures and pr actice s, composition of staff,
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availability and accessibilit y of computers, staff computer literac y , HR I S systems
used, and HR professionals ’ and staff ’s ex perience of ope rating these s y stems.
These diversities significantly affected the new HR I S impleme ntation project. For
example, I observed a variet y in the RHOs’ attitudes towards the new HR I S .
Thus, RHOs without pre -existent HR systems were enthusiastic about the new
system and very positive about its expected benefits. In contrast, RHOs which
were alread y usin g another HR I S, in most cases bespoke s ystems developed long
ag o thou gh a bottom -up process, reported in all cases a positive ex perience with
their ex isting HRIS, and were in contr ast highl y cautious about the new system.
These RHOs were concerned about th e changes t hat the ne w HRIS would bring to
their existing processes and pra ctice s, about the relative p erf ormance of the new
system compared with their existing HR sy stems, and about the abilit y of the new
HRIS to allow them to continue to provide the kind of HR services that the
RHO’s employ ees were used to.
6.2.4.4 Indiv idual
The feedback from the s y stem us ers w as v aried and depended greatl y on their
individual characteristics. Some users were very positive, actively defending the
system, whilst others viewed the s y stem as co mplicated and non -user friendl y .
The former tended to be relatively new in their p ositions withi n the health sector
and/or with prior work ex perienc e in the private sector. As y et unacclimatiz ed to
the healthcare sector culture, these users p erceived the new s y stem as mod ern and
in keeping with their expectations of what an information sy stem should look like.
Such users also found t he system’s op erational logic and the stru cture of the
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processes that it was impos ing appropriate, and helpful in enabling them to
conduct their work. I n contrast, the users who had worked in the studied NHO for
some time tended to describe the new s y stem as both non-user-friendly and as not
conforming to their underlying assumptions and expectations about what HR
working proce ss es should entail.
Overall, the us e of the new s ystem across the RHOs was v ery limited at the ti me
of the data collection. Thus, it was reported to be used mostl y either withi n HR
departments, with som e rare exceptions when the s y ste m was piloted by oth er
departments outsi de HR . This resistance to adoption of the new sy ste m at the
individual level was caused across the RHOs by the users’ gradually d ecreasing
lack of confidence in the s y stem, which was further au g mented a cross the proj ect
hierarchy b y the n egative “wo rd of mouth” caused b y the s y stem ’s t echnical and
functionality issues and by project dela y s.
6.2.4.5 Task
The s ystem development and configuration processes were significantly
complicated by the v arie t y of pre-existing HR working practice s across the RHOs,
as an y configuration tended to raise the questio n of which RHO ’s best prac tice
should be followed whe n adaptin g th e s y st em. Thus, for example, anal y z ed data
revea ls a marked reluctance within most RHOs to abandon their existing HR
working practices a nd/or HRIS. This resistan ce to change was first manifested
during the de velopment of the initial specifica tions b y the central proj ect team,
which was in formed b y ex tensive consultation with a wide range of
repre s entatives from the various RHOs.
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The reluctance to change ex isting processes and practices also manifested at
various hiera rchical levels and across different departments within RHOs, but was
less noticeable among HR professionals, primarily lo cal HR leaders. Some of the
central te am respondents mentioned that this mi ght be because ve ry few s y stem
users outside of HR par ticipated in the consultative proc ess du ring the sy stem
development and implementation stages and as such their feedback has not been
sufficiently t ake n into ac count during the implementation of the s y st em.
On a positive note, the process of configuring the s y st em opened up a dialogue
between RHOs on re considering their operating procedures, and triggered an
opportunity to move stan dardizing NHO HR pr actices. This was widel y pe rceived
by the central team as actually a significant step forward towards the vision for
transforming the national HR operating framework and fo r creating the model of
shared services across NHO ’s HR that was e nvisag ed in the Government’s
political discourse.
6.2.4.6 Technol ogy
The design of the HR IS s y st em itself embeds a set of assumpti ons about the
working practices, procedures and activities that sy stem users will engage in.
According to the re spo ndents who we re involved in the proje ct develop ment
stage , these are consiste nt with the private secto r and the US national co ntext in
which the s y stem was developed by its US -based vendor. In contrast, most of the
respondents, be they developers, implementers or s y stem us ers, perce iv ed that
these assumptions were clashing with the no rms, values and practices that
character ized their own, public sector and Europe an contex t of use. For ex ample,
135
many respondents claimed that this s y stem was desig ned for private US, global
companies and as such the practices and termin ology embedded in the s y stem
were incompatible with the studied NHO, or public sector environment in which
they opera ted.
The normative difficulties associated with the re conciliation of the operating logic
embedded in the system, versus the context of use, were exacerbated by the
technical di fficulties associated with confi g uring the s ystem to suit the studied
NHO. Althou g h the s y stem was r ecog nized as having a reputation for working in
complex orga nizations across the globe, thi s was an off -the-shelf s y stem, and as
such inflex ible and difficult to adjust to local contexts of use. This inflexibilit y
was in contrast to the experience that some of t he R HOs had with their current
bespoke HRIS which allowed wide customiz atio n to local workin g pra ctices and
conditions. This clash betwee n the new, off -the-shelf HRIS and the existing,
bespoke HRIS in use, exace rbated the frustratio ns of the loca l RHOs with the
prolonged and difficult process of tr y in g to find wa y s of adapting the ne w s y stem
to the curre nt and varied working prac tices w ithin the RHOs. Moreove r, the
contract precluded customiz ation of the s y stem (i.e. cha nges in coding ), and
accommodated onl y high level config urations of the system which led to the
RHOs having to find work-arounds to make the s y stem usable. Following
numerous RHOs’ complaints, signific ant time, effort, and resou rces w ere i nvested
in configuring this off -the- shelf s y stem to better suit the NHO’ s working
procedures and practice s. This prolonge d confi g uration process led to further
delay s in the impleme n tation process, a nd to confusion between the d iffere nt
stage s involved in the development, implementation and , in some R HOs, t he use
136
of the s y stem. Overall, t he dela y s, the work- arounds to adapt the s ystem t o NHO
practice s, and the con fusion between stages had negative consequences for the
system’s performance , fu rther increa sin g the project’s costs and delays.
In view of the se difficulti es, man y of the respondents thought that the ori g inal off-
the-shelf s ystem should first h ave been rolled ou t, before investing in extensive
efforts to adapt it to the require ments of individual R HOs.
A further difficult y raised b y the respond ents involved overlap ping of
functionalities between t he new sy stem and ex isting , nation-wide, NHO IS. For
example, some of the NHO’s existing workforce sy stems already perform some of
the activities enabled b y the new HR s ystem, s uch as requesting annual leave.
Such overlapping mi ght generate a potential conflict between various systems in
use in the future, as well as raising uncertaint y about which system should be used
to perform this activity to avoid duplication of effort.
Moreover, it was originally envisioned that this new HR sy stem would be
integrated with other already ex isting NHO IS ( e.g. the alread y suc cessful Pay roll
sy stem); however, int egration proved to be another challenging exercise, as the
systems w ere not full y compatible, nor w ere the teams supporting these systems
able to prioritize interfacing with the new HRI S.
La st but not l east, some respondents believed that the perception of the HR system
as merel y administ ra tive, might have put it at a disadvantage compared to clinical
projects when competing for scarce resources from the centra l org anizat ion and
stressed the need to argue for it s strategic importance .
Due to all of the aforementioned technica l and functionalit y issues encountered
some RHOs adopted the new s y stem onl y pa rtly such as adopting onl y t he core
137
HR and Employ e e Relations and/or L earning Management modules, with many of
the R HOs refusing to adopt the iRecruitment modul e until more evidence can b e
provided b y the central project team concerning t he new HRI S s y st em’s technical
feasibility. I n extreme cases, some RHOs with existing HRIS even withdr ew from
the planned impl ementation of the ne w s y stem as soon as the first te chnical iss ues
and project dela y s app eared, and/or were considering other alternatives to the
system modules the y were not h app y with (e.g. to continue using a particular
module of their existing s y stem). RHO s which withdrew preferred to wait for later
stage s of the project implementation, once other RHOs had demonstrated that the
new s y stem is full y funct ioning and fit for purpose. These differences of approach
to adoption of the new system among RHOs si g nifi cantly af fec t ed the deli very of
the expected benefits, as the y challen g ed two co mponents that were ke y to the
new s ystem delivering its benefits, includin g the condition that all the new s y st em
modules would be used equally by a ll RHOs.
6.2.4.7 Project
The new HRIS project was executed in accordance with pre -existent NHO norms.
Thus, for e xample, the c entral development team engaged in extensive
consultative proc esses throughout the N HO that are t y pic al for health sector
projects with a variety o f stakeholders i n an effort to ge nerate consensus around
the reduced system specification and thus buy-in to the system.
The project governance structure wa s ori g inally set up with a relativel y small
national level project team tasked with the coordination of centra lized activities
(e.g. data mi gration pro ce sses b etween the RHOs and th e vendor), while each
138
individual RHO would have full responsibilit y for loc al implementation. This
approac h a ssumed that the costs of local implementation would be covered b y
R HOs’ ex isting b udge ts. This set- up ini tially had the support of the RH Os’ HR
Directors. However, the financial crisis resulted in reductions in the resources
available fo r the publi c sector in genera l, and th e NHO in particular. As such,
when the RHOs began local implementation, res ources th at had b een ant icipated
were no lon ge r available. Therefore, fo r most RHOs, HR professionals with
existing full ti me job responsibilities and without special project management
training nor experience of running complex projects of thi s nature were assigne d
to take responsibility for this project.
During s ystem implem entation, RHOs had re ce ived similar instructions and
support from the national project implementation team. However, most o f them
either adopted th eir own implementation st rateg ies, with widel y dif fering l evels of
success, or c hallenged some of the proposed so lutions, arguing that the y were
incompatible with local proce dures.
Due to all of the ch allenge s that the project faced, the RHOs using HR I S
demanded more evidence from the central project team concerning the new HRIS
system’s technical feasibil ity . As the project was being stalled b y technical
problems a nd lac k of willing ness of R HOs to engage in implementation , the
central team responde d by arranging to launch a “pilo t projec t”, where three
selected RHOs would implement the new s y stem with the aim of validating all
transactions within the system, compiling a central resource of standard operating
procedures, developing essential training materials and creating a “lesso ns
learned” report. How ever, most of the respondents stated that this pilot project
139
should have been conducted e arlier, either before or during phase one
implementation. This would have helped resolve all the technical and
functionality issues during the p ilot, and to g enerate and shar e best practice
regarding s ystem imple mentation before be g inning to roll out the s y stem across
the individual RHOs. Although a post -implementation sharing of lessons learned
after each phase h ad be en in realit y pl anned from th e outset of the project, it was
not fully realized be cause ea ch pha se implementation wa s taking longer than
expected and some RHOs were postponing their implementations. These delays
were due to the unforeseen techni cal difficulties associated with develop ing the
system to fulfil the NH O requirements, and the strong r esistance to change th at
the system m et at during the implementation. T hese dela y s led to an ov erlap in
implementation phases b etwee n RHOs, which meant that the problems ide ntified
at earlier stages were not resolved befor e the s y stem was rolled out to the RHOs in
the next phase. This problem was visible to the RHOs and further eroded their
confidence in the project.
6.3 Regional case study in Cou ntr y 2
6.3.1 Regional case study se tting: NHO and its HRIS strategy
The RHO in conce rn is one of the biggest RHOs in the studi ed EU country . It
serves a very la rge and geographical dispers ed territory , counting more than
500,000 residents. It incl udes 2 major hospitals, 5 district hospitals and 13 health
districts. I t also h as established rel ationships with numerous priv ate and
residential care homes. I t has more than 1,800 patient beds, circ a 8,000
employees, a nd circa 1,000 interns and contractors.
140
In the last decade, the studied RHO has experienced a phase of rapid growth (e.g .
budge t increase f rom 630 to 1,000 million euro and 5.3% headcount increa se
between 2006-2009). This growth has ca lled for a change in the organizational
processes and IS in ord er to ensure that the health services provided b y t he RHO
mat ch the grow in g expe ctations of citiz ens. Thus, the RHO created a “S trategic
Business Development P lan” which also included changes to the HRM processes
and the I S that are supposed to support them. In particular, it underlin ed the
importance of health work force skills for delivering a hi gh qualit y of patient care.
This crea t ed the foundation for the “HR Development Program” that incl uded the
transformation o f the HR department, and d evelopment of strategic HRM
practice s such as cr ea tin g a structured s y stem of organizational roles or improving
employee development and career support services. Finally , the design of an I S to
support these new HRM practices was identified as an important compo nent of
this program. D etailed in formation about th e “ HR Deve lopment P rogra m” and its
components is presented in the Table 10.
Table 10. Main content of the HR Development Pr ogra m
Duration
Project
description
Content
Circa 10
m onths
Organiz ational
design
Analysing HR Processes (as is - to be)
Designing RHO’s professional’s model
(organization, roles, peop le)
Testing t he new competence dev elopment
m odel for the sele cted roles (Head of
Medical Uni t, Chief Nurse )
Developing spe c ification f or the new
HRI S
>20 m onths*
Change
m anagement
Aligning processes and organiz ation
Ex tending the com petence model to o ther
roles
243
suggested adaptations that may be required for stud y in g HRIS in hea lthcare.
Institutional theor y also proved a valuable tool for int erpreting the unex pected
difficulties that the h ea lt h organizations encountered during the implementation of
an innovation that had been strongly supported at the outset.
Finally , although eac h of two case studies was conduc ted independentl y , the
smaller scale regional HR I S development and im plementation project in Country
2 made it possible to assess the replicabilit y of th e methodological and theoretical
approac h used for th e c ase stud y in Countr y 1, and the results further enhanced the
analy ti cal appr oach taken and the the oretical innovation arising from the research.
The results of m y r esearch, and the un answered questions remaining, indicate the
importance of HRIS to the e ffective and effi cient functioning of healthcare
systems, and su gge st the need for more interdisci plinary res ea rch, en compassing
economic evaluations, s ociotechnica l anal y s es, studi es of information flows, and
systematic assessments of the impacts of better workforce information o n health
care ef ficiency, qualit y, safe t y , and patient care, as well as new explorator y
research to understand th e value of information for drivin g a nal y ti cs in sup port of
sustainable and effective health sy stems.
244
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A ppendices
A pp endix 1. S y ste matic literature re view search strateg y
*CIPD, Deloitte, Ernst & Young, PWC, KPM G, Societ y for Human Resource
Management (SHRM), Towers Watson, Mc Kinsey & Compan y, Boston
Consulting Group and Sier ra -Ceda r.
1. Search query: free field -form a t
(Health OR Healthcare OR Hospital* OR Clinic* OR Medic*) AN D ("HR
management s y stem*" OR "Human r esource management s ystem*" O R
"Workforce managemen t s y stem* " OR "Personnel manage ment system*" OR
"Manpower manage ment s y stem*" OR "Employee management system*" OR
"Staff mana ge ment s y stem*" OR "E-HR" OR "e-HRM" OR eHRM OR HR I S OR
“elec troni c Human re source ” OR “ HR inf ormation system* ” OR "HR
technolog * " OR "HR management information s ystem*" OR "HR administration
system*" OR “Human resource information s ystem*” OR "Human resource
management information s y stem*" OR "Human r esource administration system*"
OR "Workforce info rmation s y stem* " OR "Workforce technolo g * " OR
"Personne l information s y stem* " OR "Personnel manag ement information
system*" OR " Personnel administration sy stem*" OR "Manpower info rmation
system*" OR "Manpower management information s y stem* " OR "Emplo y e e
265
information s y stem*" OR "Employee management information s y ste m*" OR
"Staff information system*" OR "Staff mana g ement information system*" OR
"Staff administration sy s tem*" OR “HR information technolog*” O R "HR
management technolog*" OR “Hum an resource information techn olog*” OR
"Human resource management technolo g *" OR "Human resource* technolog*"
OR " Personnel Staffing and Sche duling I nform ation S y stems" OR " electronic
HRM" OR "Virtual HRM" OR "Web-based H RM" OR "HR Portal" OR "HR
Online" OR "HR I ntran et" OR "E-recruit*" OR "Electronic r ecruit*" OR "E-
employment" OR "Virtual HR" OR "Web-bas ed HR" OR "Business- to -emplo y ee"
OR "Employ ee s elf se rvice " )
b) Search query: M edli ne form at
1. He alth.mp. or Health/
2. He althcare.mp. or "Delivery of Health Care" /
3. Hospita l.mp. or Hospitals/
4. Clinic*.mp.
5. Me dic*.mp.
6. 1 or 2 or 3 or 4 or 5
7. " HR management s y stem*".mp.
8. " Personnel Staffing and Scheduling Information S y stems"/
9. " Human resource management system*".mp.
10. "Workforce management system*".mp.
11. "Personne l man agement sy stem* " .mp.
12. "Manpower management sy stem* " .mp.
13. "Employ ee mana g ement s y stem*".mp.
14. "Staff ma na ge ment s y stem*".mp.
15. "E -HR".mp.
16. eHRM.mp.
17. “e - HRM”.mp
18. HRIS.mp.
19. electronic Human re sou rce.mp.
20. HR information system.mp.
266
21. HR technology .mp.
22. "HR management information system*".mp.
23. "HR administration sy ste m*".mp.
24. Human resource information sy st em.mp.
25. "Human resource management information sy st em".mp.
26. "Human resource a dmini stration sy stem* ".mp.
27. "Workforce infor mation sy stem* " .mp.
28. "Workforce tec hnolog y ".mp.
29. "Personne l information system".mp.
30. "Personne l mana g ement information s y stem".mp.
31. "Personne l administration sy stem".mp.
32. "Manpower information sy stem " .mp.
33. "Manpower management information system".mp.
34. "Employ ee information system".mp.
35. "Employ ee mana g ement information s y stem ".mp.
36. "Staff inf o rmation sy stem".mp.
37. "Staff ma na ge ment infor mation system" .mp.
38. "Staff administration sy st em" .mp.
39. HR information technology .mp.
40. HR management tec hnolog y .mp.
41. Human resource information technology.mp.
42. Human resource management technology .mp.
43. "Human resource tec hnolog y ".mp.
44. "Elec t ronic HRM" .mp.
45. "Virtual HRM".mp.
46. "Web base d HRM".mp.
47. "HR Portal" .mp.
48. "HR Online".mp.
49. "HR Intranet".mp.
50. E-recruiting .mp.
51. Electronic recruiting.mp.
52. "E -emplo y ment".mp.
267
53. "Virtual HR".mp.
54. "Web-based HR" .mp.
55. "Business- to -e mplo yee" .mp.
56. "Employ ee self service " .mp.
57. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20
or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34
or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48
or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56
58. 6 and 5
268
A pp endix 2. St udy information sh eet
Human Resources (HR) s y st em rollout case stud y - in formation
letter
I am asking if you would ag ree to take part i n a research projec t ai ming to
examine the development, implementation and usage of the new HR s y ste m.
What is the purpose of this resear ch?
The research examines the process through which HR s y stems are dev eloped,
implemented and used within large and complex organizations, and what kind of
impacts the y can have. We bel ieve that insi ghts from thi s case will provide
valuable lessons for d ecision makers and m anage rs considerin g or alread y
implementing HR sy stems and encour age new rese arc h on this topic.
Why have I been asked to take par t?
You have been asked t o take part in this research beca us e y ou have play ed a
significa nt role during the deve lopment, implementation or usage of the HR
system.
What will happen next if I agree to take part in the study?
Following y ou r c onsent, an interview will take place. The aim of th e
interview is to map the development, implementation and usage of the HR
system since it s inception to present da y . Questions will focus on
organizational factors and stakeholders th at affected the de cision to
implement this HR system, change man agement s trateg ies used t o
implement this s y stem in different boa rds, as well as the challenges and
facilitators face d during impl ementation.
With y our permission, the int ervie w will be audio -rec orded. Othe rwise,
the researcher will be taking notes. After the interview, the interview will
be transcribed and the transcription will be emailed ba ck to y ou for
verifica tion. Th e interview transcription is anonymized, unless y ou give
consent otherwise.
275
Management in Healthcare . University of Edinburgh Business School
Workshop on “Organizational and I nstitutional Change”, Edinburg h, UK.
3. Tursunbayeva, A., Pag li ari, C., Bunduchi, R., Franc o, M. (2015). HR I S in
Healthcare. Fa rr I nstitute Health Informatics Conference, St. Andrews, UK.
4. Tursunbayeva, A. (2015). P oster for “HRIS in Healthcare: S ystematic
Review”. Farr Institute PhD Sy mpo sium, Manchester, UK.
