Learning behavior and flexibility in health care teams
How can, and do teams intervene on unwanted developments in team learning behavior to
attain and maintain flexibility?
Vincent van Kraaij
U1244228
Supervisors:
Drs. Frank van Gool
Prof. Dr. Inge Bongers
Prof. Dr. Richard Janssen
Dr. Joyce Bierbooms
Second reader:
Dr. René Schalk
Master thesis Human Resource Studies
Project theme: Flexibility
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Abstract
In times of budget cuts and fast-changing environments for health care organizations,
there is increased need for flexibility to cope with change. This study is about how teams can
achieve and maintain flexibility by using the flexmonitor. The process of how teams learn and
intervene on learning behavior is central, as learning behavior is key in achieving flexibility.
The sample of the study consists of nine mental health care teams with from each team one
respondent, whilst large teams provided two respondents. A total of 13 individual interviews
were conducted. Data was analyzed using open, axial and selective coding. Purpose of the
analysis was to gain information about which indicators and interventions regarding learning in
teams are mentioned in the research population. This was compared with indicators and
interventions from literature to see whether discrepancies exist between academic work and
health care practice. Main findings regarding indicators of learning consist of positive
interaction and attitudes among members within the team as well as a pleasant and
psychologically safe work climate. Furthermore individual traits such as proactivity and
motivation are important indicators of learning, as well as team-wide behaviors such as team
activity and reflexivity. In terms of which interventions teams used to redirect learning behavior
respondents mention group discussion, team building and feedback, which are in line with
theory. A second group of interventions consists of hidden interventions that have positive
outcomes regarding learning but which respondents are unaware of. In addition to this the use
of the flexmonitor itself proved to be an intervention. Future research can build on current
results and, among other things, could be directed in a longitudinal study of the flexmonitor to
attain more data to provide a deeper insight into how individual teams use the flexmonitor.
Specifically how the process arises in which interventions are created to counter unwanted
developments and which outcomes exist regarding flexibility.
Introduction
In recent times, a need has arisen for increased flexibility in Dutch health care
organizations. This stems from the fact that the health care environment in the Netherlands
changes rapidly, becoming more turbulent and complex (Poiesz and Caris, 2010). One reason
for the increased turbulence is the market oriented reform in 2006, allowing for regulated
competition between health care insurers (Maarse, Jeurissen & Ruwaard 2016). In addition to
this was the Dutch healthcare system decentralized in 2015, transferring responsibility for
health care services from national government to municipalities (Nowak et al., 2015).
Organizations that have become the subject of these profound, ongoing changes have an
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increased need for flexibility in order to thrive in complex environments (Van Gool,
Theunissen, Bierbooms & Bongers, 2016). In other words: in highly turbulent environments,
organizations ought to increase flexibility to increase control (Volberda, 1997). However
seemingly paradoxical, flexibility should always be combined with a degree of stability, as too
much flexibility leads to unfocused actions with possible outcomes such as deconstructive
results and chaos (Volberda, 2004).
The present study is about the development and use of a method that focuses on early
detection of certain team behaviors that enhance or undermine flexibility in health care teams
and guides in intervening to counter certain undermining behaviors. This method is called the
flexmonitor. The purpose of the flexmonitor is to signal trends in team behaviors and to help
intervene on certain unwanted behaviors. The flexmonitor has arisen from practice where self-
management of teams’ increases and a need exists for guidance to cope with the ongoing
changes that teams encounter (Van Gool, Bongers & Bierbooms, 2016). It is used by individual
team members, meaning that individuals are part of the intervention process of changing
behaviors. This implies that the flexmonitor is a bottom-up approach, which increases the
chance of successfully intervening on and changing behavior as opposed to top-down
approaches to change (Collins, 1998).
The flexmonitor is comprised of four dimensions, consisting of learning behavior,
cooperation, decision-making behavior and resilience. In the dissertation of Vink (2017) comes
forth that there is no conclusive evidence from literature for the use of these four specific
dimensions in relation to flexibility. Rather these are based on the experience and knowledge
of Frank van Gool. In the flexmonitor, each dimension consists of statements that teams think
of and use to score their own behavior for a specific dimension. The total score of a dimension
is visualized in a graphical representation which ranges from green to yellow to orange to red,
or in other words from balanced, to first signals, to evident problems, to crisis. See appendix B
for an example. If a negative trend becomes apparent in a team’s flexmonitor, interventions are
implemented to counter trends and maintain flexibility.
In the current study there is a distinct focus on the dimension ‘learning behavior’. The
central research question is: how can, and do teams intervene on unwanted developments in
team learning behavior to attain and maintain flexibility? An in-depth study into indicators and
interventions regarding team learning is done to answer this research question. In addition the
use of the flexmonitor is reviewed, as it provides the framework regarding the aforementioned
indicators and interventions. Indicators represent team learning behavior and a lack of them
represent unwanted developments in team learning. Interventions represent the ways team can
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(literature) and do (practice) intervene on them. Outcomes of the literature study and empirical
findings are compared to increase knowledge on a recently identified gap in literature regarding
difficulties in designing appropriate and achievable interventions in practice (Foster, Lawson,
Wardman, Blythe, Linehan, 2012). An additional outcome of comparing literature to practice
is to be able to provide practical recommendations regarding the creation of indicators and
interventions on a theoretical basis. Furthermore, practical recommendations could improve
future outcomes of using the flexmonitor in the health care sector.
The social relevance of this study and the flexmonitor in general, is grounded in health
care practice, where behaviors of health care staff and teams are directly linked to quality of
care (Burhans & Alligood, 2010). A method like the flexmonitor can support teams in the
complex task to become and remain flexible by functioning as a methodology to monitor
flexibility in a structured manner. In addition to this it provides team members with an
opportunity to participate in the management process of their team, which is linked to better
outcomes (Schneider, Brief & Guzzo, 1996). In terms of scientific relevance the present study
adds to the relatively small body of work in literature in which flexibility is researched as a
team output instead of an organizational output (Li, Chang, Chen & Jiang, 2010). Secondly it
adds to the relatively small body of work that explicates flexibility as a pro-active presence
which arises from continuous learning processes, not merely a temporary input for
organizational change (Van Gool et al., 2016).
Theoretical framework
Flexibility
Flexibility has been defined in several ways in organizational literature. An early
definition is: ‘the extent to which the organization is able to adjust to internally induced change
and to adapt to externally induced change’ (Georgopoulos & Tannenbaum, 1957, p. 536). A
more recent definition is: ‘the ability to recognize and identify a firm’s new market
opportunities, determine the potential strategic importance of these capabilities and resources,
and renew its competencies’ (Wu & Hisa, 2008, p. 99). These definitions of flexibility share
the fact that it is an organizational capability concerned with recognizing change and adapting
accordingly. However, both definitions fail to grasp a second important characteristic of
flexibility, describing it as either a temporary input to induce change or as a constant presence.
As it is proposed that change is continuous, there also is a need to conceptualize organizational
flexibility as a constant (Volberda, 2004). Therefore, the operational definition that is used in
the present study is: ‘flexibility is a permanent pro-active attitude and capability to adapt to the
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changing environment’ (Van Gool, et al., 2016, p. 2). Moreover, flexibility is seen as the
product of change and exists on and affects all organizational levels (Van Gool et al., 2016).
However, in the present study flexibility is specifically viewed upon as a team output, as this
research is into the flexmonitor which focuses specifically on teams. For teams, flexibility is a
key necessity to perform effectively as it adds to a team’s capability to cope with changing
environments (Li, Chang, Chen & Jiang, 2010).
Learning
From the preceding section becomes apparent that flexibility is a key determinant for
team success in turbulent environments. So how can flexibility be achieved? The present study
focuses specifically on learning behavior as the central antecedent of flexibility. In line with
extant literature, learning within organizations is seen as key explanatory variable of how
flexibility arises (Smit & Wandel, 2006). Researchers have argued that learning creates
flexibility because it strengthens an organization’s ability to recognize opportunities and helps
to continuously achieve alignment with the environment (Lumpkin & Lichtenstein, 2005). The
need for learning, specifically for health care organizations, is further stretched by Senge
(1990). As the environments in which these organizations operate in are increasingly
tumultuous and complex, there is a need for organizations to replace standardized
configurations with learning processes to cope with complexity (Senge, 1990). In the present
study, learning within organizations is therefore seen as a mechanism which creates flexibility,
meaning flexibility is an outcome of learning (West-Burnham & O'Sullivan, 1998).
So how does the organizational learning process arise, and in which forms is it most
effective? The organizational learning process can be described as single-loop, double-loop and
deutero learning (Argyris & Schön, 1996), see figure one in the appendix for a visualization.
Single loop learning refers to the correction of errors in reference to a fixed norm, whereas
double loop learning refers to the questioning and changing of this norm (Argyris, 2002).
Finally, deutero learning means: ‘to learn how to carry out single- and double-loop learning’
(Argyris & Schön, 1978, p. 27). Especially double-loop and deutero learning are associated
with flexibility (Staber & Sydow, 2002).
Organizational learning is present on the individual, group and organizational level
(Crossan, Lane & White 1999). These are interdependent, a team affects individual members
and vice versa. Furthermore, organizational characteristics such as organizational structure
affect the team and individual (Kim, 1998). Recently, scholars have argued that the ability of
an organization to improve its outcomes through better knowledge creation is mainly dependent
on the ability of teams to learn. This is because learning in organizations takes place in an
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interpersonal manner and collective learning processes are inherently local (Edmondson, 2002).
In other words, team learning is seen as the principal mechanism within the construct of
organizational learning (Murray & Moses, 2005).
Team learning is about the transformation of knowledge via collective conversational
and thinking skills to explicate knowledge with group members so the intelligence and ability
is greater than the sum of its parts (Senge, 1994). Team learning can be defined as: ‘an ongoing
process of reflection and action characterized by asking questions, seeking feedback,
experimenting, reflecting on results, and discussing errors or unexpected outcomes of actions
(Edmondson, 1999: 353). It is a social process which leads to the development of mutually
shared knowledge and cognition (Van den Bossche, Gijselaers, Segers & Kirschner, 2006).
Through dialogue, discussion and providing feedback within a team, double loop learning
arises, which leads to flexibility (Van den Bossche et al., 2006). The outcome of team learning
is: ‘a relatively permanent change in the team’s collective level of knowledge and skill produced
by the shared experience of the team members’ (Porter, Hollenbeck, Ilgen, Ellis, West & Moon,
2003, p. 822). In other words: the difference between team learning and individual learning is
that, within teams, individuals not only learn from their own experience but also from the
experience of other members by integrating group knowledge (Porter et al., 2003).
Indicators of team learning
There has been increased attention for team learning within organizations (Murray &
Moses, 2005) and also increased attention for the way team learning can be enhanced
(Edmondson 1999). Several underlying team beliefs that serve as facilitators for learning
behavior are discussed in the following section. After that the indicators of actual team learning
behaviors are explained. The relation between the team beliefs and indicators of learning
behavior is two-fold (Decuyper, Dochy and Van den Bossche, (2010). In addition, the different
team beliefs are all interlinked (Van den Bossche, 2006). This is visualized in table two of the
appendix.
Team beliefs. Four distinct underlying team beliefs which can be described as
facilitators of learning behavior are collected from extant literature (Knapp, 2010). The first is
psychological safety. Psychological safety is described as a shared team belief that there is
safety for interpersonal risk taking (Edmondson, 1999). For example, this can emerge as the
belief that mistakes will not be held against you and that it is safe to take a risk (Edmondson,
1999). It is argued that this is mainly induced by team leaders, being either formal leaders or
informal leading members of a team. These individuals should promote the acknowledgement
of fallibility and be accessible to all members (Edmondson, 2002).
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The second team belief of team learning is perceived task cohesion which refers to the
degree of joint commitment that is present in a team to achieve a collective outcome (Van den
Bossche et al., 2006). Task cohesion is a structuring factor in team learning behaviors to foster
collective outcomes (Van den Bossche et al., 2006). When task cohesion is high, groupthink is
prohibited and team learning enhanced (Knapp, 2010).
The third team belief is interdependence, which consists of task and outcome
interdependence (Van der Vegt, Emans, & Van de Vliert, 1998). Task interdependence is about
the level of interconnectedness of tasks in a team and dependency on other team members to
execute one’s work correctly which can lead to more information sharing, communication and
helping behavior (Van der Bossche, 2006). Outcome interdependence is about the level on
which individual team members’ personal outcomes and costs are dependent on team outcomes.
The higher the perceived outcome interdependence, the better members share information and
learn (De Dreu, 2007).
The final facilitating team belief is perceived team efficacy, which is the belief in the
team’s potential by its members (Knapp, 2010). Team potential is defined as “the collective
belief of group members that the group can be effective” (Shea & Guzzo, 1987, p. 26). High
levels of perceived team efficacy lead to enhanced learning (Knapp, 2010).
Next to the aforementioned facilitators in the form of underlying collective beliefs there
is also consensus in literature on several behavioral indicators of team learning. Decuyper,
Dochy and Van den Bossche (2010) came up with an integrative review in which seven distinct
observable team learning behaviors are summed up.
Behavioral indicators. The first indicator of team learning behavior is information
sharing. This relates to the communication of individual knowledge or thoughts to other group
members to increase the collective level of knowledge. Quality of sharing can be determined in
two dimensions namely by the level of detail and through how many team members are
involved in the process (Decuyper, Dochy and Van den Bossche 2010).
The second indicator, co-construction is about the joint process of creating shared
knowledge and meaning between group members, sharing is a prerequisite for co-construction
(Van der Bosssche et al., 2006).
The third indicator of team learning is boundary crossing behavior of team members.
This refers to the crossing of borders that are in place within the system which separates one
person from another person and one group from another (Dechant, Marsick & Kasl, 1993).
Boundary crossing behavior is about the communicative processes of learning across different
team members and the interaction with the environment (Decuyper, Dochy and Van den
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Bossche, 2010).
The fourth indicator of team learning is reflexivity. This occurs when team members
have a clear collective view of how the team is currently performing, what the team’s future
goals are and how to achieve these goals. In other words: team reflectivity is about co-
constructing, de-constructing and re-constructing shared team mental models (TMM) and leads
to double-loop learning (Decuyper, Dochy and Van den Bossche, 2010).
The fifth indicator of team learning is called team activity. This is about working
together and the interaction between team members. Working together almost always leads to
an adaptation of team behaviors into a higher level of efficiency and coordination (Arrow,
McGrath & Berdahl, 2000).
The last two indicators are storage and retrieval. This refers to the collection of shared
ideas, knowledge, procedures, routines and habits which can be saved within a team in such a
way that they can later be retrieved (Decuyper, Dochy and Van den Bossche, 2010). Figure two
in the appendix shows a visual representation of the linkages between indicators of learning
behavior and enhancing team beliefs .
Interventions
The theoretical framework will be concluded by providing information on how teams
can intervene on team learning to restore flexibility. Interventions and characteristics of
interventions are discussed and linked with the aforementioned facilitators in the form of shared
beliefs and behavioral indicators of team learning.
Feedback is mentioned in literature as an important (characteristic of) interventions in
regard to learning as this leads to team learning (Arrow and Cooke, 2008). Furthermore,
feedback is seen as a central intervention mechanism regarding learning, especially in health
care practice (Price, Hopwood, & Pearce, 2000). Moreover, feedback mechanisms within teams
lead to double loop learning as it allows teams for alteration of the normal workflow, which
leads to flexibility (Knapp, 2010). However, feedback should be focused away from personal
characteristics as this would have negative effects on learning behaviors and psychological
safety (Kluger & DeNisi, 1996). Instead, feedback should be focused on desired future
behaviors (Kluger & Nir, 2010). Feedback allows teams to practice critical reflection and
dialogue, and to review shared assumptions by routinely reviewing those (Kluger & Nir, 2010).
Proper feedback mechanisms are linked to behaviors such as information sharing, team
reflexivity and boundary crossing behaviors. In addition to this they can positively enhance the
shared team beliefs of interdependence, team efficacy psychological safety and task cohesion
(Whitworth & Biddle, 2007; Wageman, 1995; Kluger & Nir, 2010).
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A second characteristic that is desirable when intervening on learning behavior is that
the used intervention should induce some sort of change, as this creates flexibility (Arrow &
Cook, 2008). Examples are to create variability in interactions of members and work setting as
this extends a team’s experiences, or to periodically change group membership, either
temporary or permanent (Arrow & Cook, 2008). Change enhances communication between
members via increased debate and new thinking (Gruenfeld, Martorana, & Fan, 2000).
Specifically, change can lead to boundary crossing behaviors as a team connects resources and
people beyond group boundaries (Kerosuo & Engeström, 2003). In addition it can increase
diversity and quantity of information sharing, leading to co-construction and constructive
conflict (Arrow & Cook, 2008).
A desired learning intervention is to increase and facilitate group discussion. This can
enhance idea generation which leads to increased information sharing, storage and retrieval,
reflexivity, boundary crossing behaviors, co construction, constructive conflict, sharing and
storage and retrieval. Furthermore it can increase shared perceptions of task cohesion,
interdependence, psychological safety and team efficacy (Van den Bossche et al., 2006).|
Fourth, a more specific intervention associated with increased learning behaviors in a
team, is leadership development (Edmondson, 2002). Empowering leaders are associated with
better information sharing and greater levels of psychological safety (Nembhard & Edmondson,
2006). Furthermore, empowering leadership is linked to increased constructive conflict and
boundary crossing behaviors as well as increased perceived team efficacy and task cohesion
(Srivastava, Bartol & Locke, 2006).
A final intervention that can increase facilitators in the form of shared beliefs and
behavioral indicators of team learning is team building. This is linked to increased personal
relationships and has an impact on interdependence, team efficacy, psychological safety as well
as task cohesion (Salas, Rozell, Mullen & Driskell, 1999). In addition it is linked to increased
sharing, boundary crossing and reflexivity (Salas et al., 1999).
To conclude, the aforementioned (characteristics of) interventions focused on enhancing
team learning behavior are aimed at indicators of behavior, as well as shared team beliefs. In
other words, interventions are aimed at shaping and enhancing beliefs and behaviors. A visual
representation of the complete framework concerning interventions, indicators and team beliefs
can be seen under figure one on the next page. In this visual representation the many linkages
with the other dimensions of the flexmonitor are also included.
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Figure 1.
Indicators
Team beliefs
Interventions
Team flexibility
Reslilience & Vitality
Cooperation Decision making Learning
Interdependence
Information
sharing
Psychological
safety Task cohesion
Feedback Discussion Team
Building
Co
construction
Team
reflexivity
(Idiosyncratic indicators of
learning behavior
(Storage, Retrieval, Team
activity, Reflexivity)
Idiosyncratic shared team
beliefs in regard to learning
(Group potency)
)
Idiosyncratic interventions
in regard to learning
(Leadership development,
Induce change)
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Methodological framework
Research design
The present study is part of a larger research of the flexmonitor. In the present study the
aim was to examine possibilities teams have to intervene on learning behavior, which is linked to
flexibility. This is represented in the aforementioned research question: How can, and do teams
intervene on unwanted developments in team learning behavior to attain and maintain flexibility?
To answer this research question the focus was on which indicators of team learning exist, a lack
of indicators of team learning represent unwanted developments in the research question.
Subsequently the ways teams intervene on team learning behavior was researched according to
how teams can intervene according to literature, and how they do intervene in practice. Information
from practice and literature was subsequently compared for indicators and interventions to clarify
discrepancies, and to provide teams that use the flexmonitor in the future with recommendations
in regard indicators and interventions based on theory.
A multiple case study design is used which is suitable to answer the research question as it
is aimed to answer a ‘how’ question (Yin, 2003). Furthermore, the research design is cross-
sectional and qualitative. A cross-sectional approach is chosen as the aim of the research is to
explore how interventions are created and which indicators are used to signal team learning
behaviors. The research was jointly conducted by all members of the thesis circle regarding the
project theme ‘flexibility’. Each member had an own focus, namely one of the dimensions of the
flexmonitor. Therefore the methodological framework and the topic list used to structure the
interviews was jointly created. The tasks regarding data gathering and analysis were divided
among researchers in line with each respective dimension.
Research population
All nine teams that at the moment of the research were working with the flexmonitor are
included in the present study. In other words, the total research population is included. Every
individual team specifies its own flexmonitor which leads to a customized flexmonitor with
idiosyncratic contents. The customization arises through the working procedure of the flexmonitor
which can be found under appendix B. The use of the flexmonitor by teams results in a report
which reflects a team’s flexibility. For an example of a report, see Appendix C. The report is an
important tool for the teams, as interventions are based on the results it. The outcomes of the report
can be perceived as the basis of interventions created by the teams.
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The teams included in the flexmonitor pilot study all work in healthcare in a non-profit
organizational context. Teams started on different points in time with the flexmonitor. The first
team started in January 2016 while the last team started in November 2016. Moreover, some teams
initiated use of the flexmonitor themselves whereas other teams were introduced by their
supervisor. In terms of representation, although the research is on team level, it is not possible to
interview complete teams as this would be too time-consuming for the team members. Therefore,
thirteen key representatives that initiate, promote and lead the process of the flexmonitor were
purposefully chosen. Representatives therefore have knowledge about the context, mechanisms
and outcomes regarding the flexmonitor.
Instruments and procedure
This study made use of several data sources. Each data source is made up by specific
instruments and procedures which are explained below.
Preliminary literature research. To provide a scientific basis for future use of the
flexmonitor and to add to the body of literature regarding learning in teams, a systematic literature
study was done to compare literature with practice. The search was done using the search engine
Google Scholar with a focus specifically on team learning to demarcate the search. The following
combination of search terms was used: ‘team learning’ (3.730.000 hits), ‘team learning indicators’
(835.000 hits). As the number of results for articles regarding team learning was high and subjects
very diverse and not focused solely around team learning, a new search term was entered which
was ‘team learning literature study’. The inclusion criterion for literature reviews was that the title
should explicitly refer to team learning as the central concept of the paper. Two studies were
subsequently selected; by Knapp (2010) and by Decuyper, Dochy and van den Bossche (2006).
As the former is most recent this was chosen as the source from which indicators were subtracted.
Interventions were searched by entering the search terms ‘interventions team learning’. As
this gave many results (2.260.000) which were dispersed and seemingly irrelevant, specifically in
regard to team learning in organizations, the literature reviews by Knapp (2010) Decuyper, Dochy
and van den Bossche (2006) were used as a base for relevant articles. This method, called snowball
sampling is scientifically valid (Wohlin, 2014). The papers that were selected from those studies
provided the interventions for the present study were analyzed. The selection criterion to include
an intervention was whether there was a specific link between interventions and team learning.
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Secondary data source. The secondary data source consists of statements that teams have
developed to evaluate their flexibility. An example of a statement that teams thought of regarding
learning behavior is ‘The team creates a safe and optimal climate of learning’. Statements are
scored from one to seven by individual members. Combined scores of statements comprise the
idiosyncratic flexmonitor of every team and by filling them out a team gets scores on the four
dimensions as well as an additional aggregate score of flexibility. Secondary data consist of
outcomes of the flexmonitor of individual teams. Statements of included teams can be found under
appendix E. It is important to note that these statements are not generalizable as the statements are
created by individual teams and not reviewed in literature.
Primary data source. The primary data source consists of data from semi-structured
interviews. The choice for semi-structured interviews was made as it saves enough room for
probing questions (Ritchie & Lewis, 2003). The preparation of the interviews started with creating
a topic list. The construction of the topic list was based on the method by Ritchie and Lewis (2003)
by first putting the respondent at ease with general conversation and by guaranteeing anonymity.
The topic guide was created to go from general to specific topics (Ritchie & Lewis, 2003). It started
with descriptives of the team and the respondent, then the flexmonitor was discussed. After this
the topics that are central in the present study were discussed for each dimension meaning that
indicators were first discussed after which the intervention creation process as well as actual
interventions were discussed. The interview ended by thanking the respondent and reconfirming
anonymity. The topic list can be found in Appendix D. As the topic list shows, the interviews has
two main objectives, namely:
To understand which indicators, beliefs and values are perceived as important for
learning within a team. This was to find out which indicators form the base for detecting
unwanted team developments and implementing team interventions;
To gain in-depth knowledge about what interventions are developed by the different teams
and which characteristics they deem important in developing these interventions. This is to
gain information on how teams intervene on learning behavior.
The following step in the preparation of the interviews was to contact the respondents.
Frank van Gool approached the thirteen key representatives of the teams via email for approval of
participation in this study. Subsequently, the researchers contacted respondents via email to make
an appointment for the interviews. The ethical commission of the Tilburg School of Social
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Behavioral Sciences had given prior approval for this study and for contacting the respondents.
Where most teams were represented by one person, the larger teams were represented by two
persons. These persons were separately interviewed. The interview started by explaining the
objectives of the research to the respondent. This will give the respondent an extensive
understanding of the interview and the research. Subsequently, the interview was introduced by
easing the respondent and emphasizing the confidentially of the research. The first questions had
the function to enlighten present circumstances. Subsequently, the dimensions were discussed.
Although this research focuses on one dimension, namely learning, other dimensions were
included in every interview. In this manner, the interviewee was disturbed only once. Each
dimension was measured in the same way, by asking the same questions. The order of the
dimensions rotated per interview, as the concentration of the interviewee will reduce over time. In
this manner, every dimension received the same amount of attention of the interviewees as a
respondent’s concentration is highest at the start of an interview. Every dimension was discussed
in approximately ten minutes. The interviews with the representatives were divided among the
researchers and conducted in pairs. One interviewer led the conversation with the interviewee and
focus all his or her attention on the conversation, the other person functioned as a gatekeeper. The
gatekeeper kept track of time and supported the interviewer with probing questions. The interviews
were recorded on audio files after permission for this was granted by the interviewees.
Data analysis
Data analysis consists of analyzing secondary and primary data. Secondary data consists
of statements created in the flexmonitor by the teams and primary data consists of transcribed
interviews. Triangulation will take place to increase validity.
Analysis of the secondary data source. The secondary data source consists of statements
devised by the teams that they used to rate their own learning behavior (see appendix E). The
analysis started by labelling statements of the dimension ‘learning behavior’ as indicators. An
example of a statement is “We evaluate situations’’. This statement was subsequently labelled as
indicator ‘information sharing’. In other words: a statement is used by teams to evaluate their
behavior and a label is the indicator that it stands for. The labels were admitted based on literature.
When statements were not compatible to indicators from literature, researchers labelled them as
‘new’ indicators. After all researchers labelled their own dimensions, peer review took place.
Statements and indicators of all dimensions were discussed with fellow researchers in order to
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improve the labelling process. Analysis of the secondary data source was completed after
consensus was reached in group discussion between the researchers. These results can be found
under appendix E.
Analysis of the primary data source. The data analysis of the primary data source started
with the verbatim transcription of the audio files containing the interviews. This was done shortly
after the interviews, which enhanced the quality of future interviews and supports understanding
of the data collected in the interviews (Baker, 1999). In other words, the aim of this process was
to fine-tune the topic list and future interviews to ensure that the appropriate information was
collected and mistakes were not repeated. In order to properly ensure these objectives, the topic
list was evaluated by the four researchers together after two interviews were conducted and
transcribed. If necessary the topic list was adjusted. The following step in the data analysis was
coding the transcribed interviews, which happened according to Strauss and Corbin (1990). Each
researcher coded his or her ‘own’ dimension, after which a second researcher did the same and
provided feedback to minimize the possibility of overlooking important chunks of data and to
ensure that the chunks of data would have the right code. In other words, peer review and peer
debriefing was applied in this phase of the data analysis.
The first step of the coding process started with open coding, which is ‘the analytical
process through which concepts are identified and their properties and dimensions are discovered
in data’ (Service, 2009, p. 101). This formed the foundation for distinct individual codes in the
transcripts and was taken directly from the text without interpretations or expectations by the
researchers. Example of this can be found under appendix F in table F1 and F3.
After this phase, axial coding took place in which the underlying mechanisms and relations
between the different constructs was examined. The different constructs that were identified in the
open coding phase were analyzed and recombined in higher order categories meaning that several
open coding labels were grouped under one ‘axis’ (Strauss & Corbin 1998). Different axial codes
were subsequently grouped under a selected code which can be seen as the emerging theme in the
data. For an example of this see appendix F, table F1 and F3.
Following Strauss and Corbin (1998), the next step was to selectively code the data. Axial
codes determine dimensions within a selectively coded theme which led to the elucidation of
central concepts. The process of selective coding consisted of choosing core categories that serve
as key explanations in the process of intervention creation by teams. This also finalized the data
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analysis and led to a preliminary understanding of how teams use the flexmonitor to create
interventions, which interventions are central and which indicators teams deem important for
learning. The outcomes of the selective coding process are of explanatory value and serve as a
basis to answering the research question of how teams intervene on unwanted team developments
in relation to flexibility.
Results
The following section starts by providing a brief overview in which team descriptives are
presented. Subsequently the results regarding indicators and interventions from the interview data
are presented and compared to literary findings found in the theoretical framework to see whether
overlap or discrepancies exist between the data and see which indicators and interventions are the
most common. In addition are secondary data between dimensions compared to find possible
overlap or discrepancies within dimensions of the flexmonitor.
Descriptives
Several general characteristics of the teams and working situation became apparent from
the interviews. Teams in the sample all work in specialized mental healthcare either in a clinical
setting or ambulant. Five teams are self-organized, the other teams have a manager. The core
business of all teams is guiding and helping clients with mental health issues. The organizations
that teams belong to are fairly large in size with several hundreds of employees. The teams vary
from small to large, the smallest team consists of ten team members and the largest team of 39
team members. In terms of demographics the included teams can be described as predominantly
female (estimates from respondents range from 85 to 55 percent female team members), of Dutch
nationality with the majority of team members being rather young (25 to 40 years). In terms of
skill variety teams can be described as low in diversity. Teams consist of home care supervisors
with a background in social-pedagogy, nursing and social work. Differences exist in being
competent to perform medical procedures which are allowed for people with a nursing
background. In terms of power distance teams are described by the respondents as non-
hierarchical and cohesive. Furthermore, team members are described as (overly) caring for one
another.
In terms of stability differences exist between ambulant and clinical teams. Ambulant teams
are stable according to respondents, whereas stability is low in clinical teams. Team turnover is
perceived as being high and the work situation has changed in previous years as the HIC vision
16
was implemented. This vision is in line with client-focused care and fewer separation measures of
patients. This led to perceived changes in work routines such as increased client population and
fewer measures to confine clients, which subsequently led to a decrease in perceived options to
deal with aggression.
Analysis of statements from the flexmonitor
The secondary data source consists of statements created by teams in the process of filling
out the flexmonitor. The analysis was done by quantifying labelled statements to provide an
overview of the importance of specific indicators and a comparison with literature as well as
between dimensions. The results of the secondary data analysis can be seen in table 1, the most
important indicators are briefly mentioned below table 1.
Table 1. Labelled statements flexmonitor
Statements
dimension Learning Cooperation
Decision
- making
Resilience
& vitality Total
Amount of teams
mentioned
Information
sharing* 9 6 4 19 7
Psychological
safety* 7 3 5 3 18 6
Inspiration to
learn 6 6 5
Motivation to
learn 6 1 7 4
Reflexivity* 4 3 7 6
Proactivity 5 2 7 4
Team activity* 3 1 3 7 3
Learning climate 2 1 3 3
Workload 2 2 1
Formal training 2 2 2
Openness 1 1 1
Peer support 1 1 1
Engagement 1 1 1
Uphold structure 1 1 1
Social support 1 1 1
Vigor 1 1 1
Co construction* 1 4 4 9 5
Storage Retrieval* 1 2 3 3
Team efficacy* 4 4 4
17
Boundary crossing
Behavior* 1 1 1
Interdependency* 3 2 5 3
Cohesion* 2 2 2
Total (54) 24* 23 29 3
*Congruent with learning literature.
When focusing on learning behavior specifically, 24 out of 54 statements are in line with
literature. Information sharing is labelled most often (nine times), psychological safety seven
times, reflexivity five times and team activity three times. In terms of indicators that are not
mentioned in literature both inspiration to learn and motivation to learn are found six times.
Proactivity is mentioned five times. 36 out of 54 learning statements are labelled as the six
aforementioned indicators and are therefore seen as the most important findings from the
secondary data provided by the statements of the flexmonitor.
Interestingly, four indicators from literature are not mentioned under learning behavior but
they are mentioned under the dimension decision-making behavior (storage and retrieval, team
efficacy, boundary crossing behavior and interdependency) and under the dimension cooperation
(cohesion, co-construction, storage and retrieval as well as interdependency). Apparently
respondents associate these indicators with other team behaviors rather than learning, this seems
especially the case for co-construction. Moreover, when comparing dimensions across, it appears
that statements of cooperation, decision-making behavior and learning show strong overlap with
leaning literature, respectively 23, 29 and 24 statements match literature from learning.
Interestingly, decision-making behavior shows more overlap with indicators mentioned in learning
literature than learning itself. The dimension resilience and vitality shows distinctively less overlap
with learning and has three indicators from learning literature, all of which are labelled as
psychological safety.
In summary, all literary indicators were mentioned in the statements, however five were
mentioned within the dimensions cooperation and decision-making behavior. In addition 13 ‘new’
indicators were used to complete the labelling of the statements from learning.
Findings from interview data
The primary data consists of verbatim transcribed interviews which were analyzed using
open, axial and selective coding via which important themes emerged in relation to indicators and
18
interventions of learning. An example of this manner of coding can be found under appendix F in
table F1. The following section consists of the findings regarding indicators of learning which are
presented first in table 2 and subsequently are compared to literature, as well as to the secondary
data from the flexmonitor in the section below table 2.
Table 2. Key indicators from the interview data
*Congruent with literature
Indicator Frequency Individual respondents
Key concepts associated with
indicator
Information
sharing* 15 9
Share knowledge skills, Share
information, communicate, be
knowledgeable about team
Inspiration to
learn 19 8
inspiration by new developments,
inspiration by organization, inspire
each other, training as inspiration,
negativity in team
Learn from each
other 17 11
continuous learning, diffusion
knowledge, learning by modelling
Motivation 15 6
Motivated to learn, effects
demotivation. Misbalance in
motivation team, wanting to
develop
Openness 15 8
being honest, open attitude, being
vulnerable, speak up, open attitude,
Proactivity 10 5
excited new developments, active
contribution, see opportunities,
open attitude, learn from each other
Psychological
safety* 23 10
positive working atmosphere, room
for creativity, time to learn,
accountability, safety to learn, space
to develop
Team activity* 1 1 have contact
Reflexivity* 4 3 reflect on self, evaluate,
Workload
(contra) 14 8
learn in courses, able to participate
in courses, decrease possibilities
schooling, work pressure clients,
work pressure tasks
19
When examining the outcomes from the interviews in relation to indicators that were
mentioned in literature, four out of ten indicators are in line. Of these four indicators that are
congruent with literature, psychological safety and information sharing stand out. These are
mentioned respectively 23 times by 10 different respondents and 15 times by nine respondents.
The other two indicators that are congruent with literature are mentioned distinctively less often,
team activity is mentioned only once and reflexivity is mentioned four times by three respondents.
Furthermore, when comparing findings to literature one might remember the division of team
beliefs and behavioral indicators important for learning in literature. When comparing the data
with beliefs and indicators it appears that one out of four team beliefs mentioned in literature
emerged explicitly, namely psychological safety. Next to this three out of six behavioral indicators
from literature are mentioned, i.e. information sharing, reflexivity and team activity. This
comparison can be found under Table F2 in appendix F.
When looking at indicators that are discordant with literature the most frequently
mentioned indicators are ‘to learn from each other’, by 11 respondents, and inspiration to learn
and openness, which both were mentioned by eight respondents. One contra indicator emerged
from the data which is workload. This was mentioned by eight respondents.
Comparing results from the interviews with results from statements flexmonitor
Table 3. Comparison labelled statements and indicators from interviews
Indicator
Number of learning
statements labelled as
indicator
Amounts of respondents that
mentioned the indicator in the
interviews
Information sharing* 9 9
Psychological safety* 7 10
Inspiration to learn 6 8
Motivation to learn 6 6
Reflexivity* 5 3
Proactivity 5 5
Team activity* 3 1
Workload 2 8
Openness 1 8
*Mentioned in literature
To discover patterns in the data, triangulation between primary and secondary data was
used which lead to the elucidation of the most important indicators. Results are summarized in
20
table 3 which can be found above. First, information sharing and psychological safety are in both
data sources the most frequently mentioned indicators. Motivation and inspiration to learn, as well
as proactivity are mentioned with an average frequency in both data sources. Team activity is
mentioned infrequently in the empirical data.
Indicators that show discrepancies between data sources are workload and openness.
Workload could be explained by the fact that statements from the flexmonitor are meant to be
positively formulated whereas workload is negative. The discrepancy of openness could be
explained by the intangibility of the concept and possible difficulties that teams had to formulate
statements that operationalize openness. Furthermore, it seems that ‘to learn from each other’ does
not come forward in the statements but is nevertheless mentioned during the interviews by eleven
respondents. This could be explained by the fact that it seems obvious that one learns from another
when working in a team. Therefore this concept seems available to recall for respondents which
explains the frequency it was mentioned in the interviews. Moreover, this is in line with the
working definition of team learning provided in the theoretical framework.
Interpreting and classifying indicators from practice
When taking a more in-depth look at the aforementioned indicators, three clusters of
indicators of learning with similar qualities emerge. This provides a preliminary classification into
which indicators exist and represent team learning behavior in practice. These can be viewed upon
as the most important results in terms of indicators. In addition, a lack of the following indicators
represents ‘unwanted developments in team learning behavior’.
The first cluster consists of manners of interacting and work atmosphere. This can be
interpreted as the most important cluster based on frequency from data. Indicators are
psychological safety, information sharing and to a lesser extent openness. Psychological safety is
seen by respondents as a necessary belief to be able to learn and have the confidence that there is
room to make mistakes. ‘I think that safety and openness is the most important thing, then we
learn’. However, the importance of accountability should not be overlooked, which is sometimes
hard in teams where members ‘care too much’, according to respondents. Outcomes of
psychological safety are room for creativity and space for people to develop. Therefore
psychological safety can be seen as a condition in which proper interaction between team members
that leads to learning is possible. One manner of interacting is to actively share knowledge: ‘It is
important to end a shift and to learn from each other, which happens especially when you share
21
knowledge’. In addition, respondents see information sharing also in getting familiar with team
members; ‘listen about how the other experiences things’. When people get acquainted they get
more predictable, cohesion is enhanced which is positive for learning: ‘Yes, it is a condition to be
the team, if I do not know why you do things or how you think and why you act, I do not know you
well’. Information sharing is in line with openness. This is associated with being vulnerable and to
speak up which is more likely to happen when it feels safe to do so.
A second cluster of indicators consists of individual and organizational traits which are
proactivity in learning and motivation. Proactivity is described as: ‘that you see opportunities and
chances and that you take initiative yourself and, for example, send articles to each other’.
Motivation to learn is about individual motivation to learn and subsequently also about differences
in motivation between team members ‘learning behavior is mainly about willingness’. Inspiration
to learn is said to arise from other members ‘I'm also inspired when I see a colleague with someone,
you really can get something out of it’. In addition to inspiration from team members’ respondents
add that the organization also inspires to learn "that the organization also shows that we want to
learn and want to improve ourselves; culture is important to learn’.
A third cluster of indicators is made up of actual team behaviors which are team activity,
reflexivity which lead to learning from each other. These can be described as actual team
behavioral indicators. Respondents mention that they learn from each other. This can happen via
modelling ‘this way you learn from each other and situations, so I always try to attend
intervisions’. Learning is said to be enhanced when strengths, weaknesses and development wishes
are clear and one can: ‘make use of everyone's knowledge and qualities’. This leads to enhanced
opportunities to learn from each other.
In summary, when looking at indicators mentioned in the data, three clusters emerge with
indicators that have overlapping characteristics. The first cluster consists of ways of interacting
and communicating within a team, as well as work atmosphere, these indicators are in line with
literature. The second cluster consists of individual and organizational traits that lead to enhanced
learning within a team, these indicators emerged from the data but were not mentioned in literature
in relation to team learning. This could be explained by the focus on specifically team learning in
the literature search. The third and final cluster consists of actual team behaviors that enhance
learning, these are also mentioned in literature. In the discussion section will be elaborated on the
aforementioned indicators.
22
Interventions
In addition to which indicators practitioners deem important for learning, this research was
also about how teams intervene on them. Several themes came up whilst analyzing the interview
data. An example of how this coding process arose in relation to interventions can be found under
appendix F, table F3. The following section starts with a presentation of the most important themes
summarized in table four. The interventions that were implemented are discussed below table 4.
These interventions came forward from the interviews with the key representatives. After the
interventions are discussed, the process of using the flexmonitor is elaborated on to see how teams
experienced this and to gain more in-depth information about creating and implementing
interventions.
23
Table 4. Interventions, the intervention creation process and use of the flexmonitor
Intervention related dimension
Amount of times
mentioned
Amount of
respondents
mentioned Key concepts associated with dimension
Creating interventions 4 3 collective process, simple, concrete
Data gathering flexmonitor 19 11
Low response, reminders, response
interventions, priorities,
Guidance flexmonitor -
interventions 16 8 signaling, anonymity, guideline
Success factors 18 7
collective process, motivate team, bottom up
approach, explain flexmonitor, guide team,
critical questions
Following through with
interventions 16 7
Resources to act, lose focus, time shortage,
need outcome, implementing difficulties
Flexmonitor as intervention 16 10 signaling, awareness, discussion,
Outcome flexmonitor -
interventions 8 5
increased speed interventions, team day, split
team, improved form of transfer
Hidden interventions 9 6
intervention response, make discussable,
awareness, perceived outcomes,
Feedback 27 9
outcomes, create foundation, ask for
feedback, rules feedback, actual interventions
24
Three clusters emerged in terms of actual interventions. The first cluster is ‘the
flexmonitor as intervention’. Respondents argue that usage of the flexmonitor is an intervention
in itself which is linked to outcomes such as increases awareness, signaling of team behaviors
and discussion. In addition respondents argue that since the flexmonitor has been implemented
it is easier to ask for feedback as: ‘It has become a part of the work’. The flexmonitor seems to
have changed the ways of working and by doing so induced change.
The second group of interventions is about interventions that are deliberate outcomes of
the flexmonitor. Interventions consist of a team day, improved form of transfer, a shift
evaluation routine, intervision, splitting of a team and feedback interventions. These are
concrete outcomes of the flexmonitor. Four individual teams implemented these concrete
outcomes. Moreover, in table three a distinct category is made for feedback. This seems to have
a central role in learning for teams as it is mentioned most often (27 times by nine respondents).
The final group of indicators consists of ‘hidden interventions’. These are interventions
that are not perceived by the team as being so but can still be classified as interventions that
arise via the flexmonitor. Examples are to intervene on low response rate and follow-through
by discussing reasons for it. This creates awareness and enhances discussion, however teams
do not perceive this as an intervention. An explanation can be found in the fact that this is not
a concrete outcome of the flexmonitor but rather something that was needed in order to use the
flexmonitor correctly. Commencing discussion is another example of a hidden intervention:
‘Discussing it was the most important thing, interventions were not needed.’ This shows that
discussion in itself is not seen as an intervention. This could be explained because it is not a
classical intervention such as providing feedback or intervision.
When comparing interventions, four out of five (characteristics of) interventions from
literature recur in practice: feedback, discussion, to induce change and team building. Feedback
is the most obvious category and mentioned most (27 times by nine respondents). Respondents
add that feedback is taught in their education ‘we were bombarded with feedback during
school’. This makes it something that is easily recalled and more tangible. Secondly to induce
change is a characteristic of several interventions even though it was not explicitly mentioned.
The flexmonitor in itself induced change but also specific interventions such as the splitting of
a team changed the working process. Teambuilding has come forward in two teams which
implemented a team day and lastly discussion has come forward from using the flexmonitor
which induced discussion on certain topics such as the statements from the flexmonitor: ‘we
discuss two statements in each meeting, how do you fill this in, how does this live with you?’
25
An intervention from literature that does not reflect in the data is leadership
development. The fact that leadership has not been mentioned, can possibly be explained by the
flexmonitor itself and the perception of it as a bottom-up tool. In addition to this could be argued
that, as teams consist of highly educated professionals that are (to an extent) self-managed, there
is the implicit assumption that leaders are superfluous or that leader’s influence on learning is
marginal.
Using the flexmonitor to counter negative developments
The flexmonitor was central in this study, as it provides the teams guidance in
intervening on unwanted developments in learning behavior to attain flexibility. Therefore its
usage provides an explanation for how teams do intervene on learning. A more in-depth look at
how teams intervene on unwanted developments in learning behavior leads to various
observations which are explained below.
Several success factors that help following through with interventions have come
forward. Respondents argue that motivation by the team to use the flexmonitor, using it
collectively and being critical when reviewing the team are factors that increase success
chances. In addition they add that the fact that one can give an opinion anonymously adds to its
value. Another interesting finding is the way teams that have implemented interventions
perceive this process. When looking at statements by respondents from these teams they do not
find it hard to create and follow through. Respondents from these teams mention that the process
is collective and everybody participates in it. One respondent adds that suggestions for
interventions are concrete: ‘what I really like is that colleagues really state concretely how we
can handle this’. This leads to the possibility of implementing actual interventions.
Next to the aforementioned success factors respondents also mention obstructions in the
usage of the flexmonitor. A first lies in the data collection process which is a crucial first step
and the basis for creating interventions. Eleven respondents mention problems at some point in
time with low response. As it is proposed that teams base interventions on the scores of the
flexmonitor, low response leads to incomplete data or misrepresentation of a team’s sentiment
when not all its members contribute. The consequence of this is that incomplete data is available
to create interventions from. Furthermore, it seems that following through with interventions is
hard. Seven respondents mention that implementing actual interventions is hard. Respondents
mention that priorities are elsewhere due to high work pressure which is why response is low.
Workload is also the reason that was mentioned why teams do not follow through with
interventions. Workload has different dimensions; budget cuts, less manpower and shortage of
26
time and resources. Budget cuts leads to less manpower and fewer schooling opportunities. This
indicates a lack of support and decreases inspiration from the organization. Less manpower is
linked to higher perceived work pressure. Especially when the client population that teams work
with is complex and intense, it is argued that learning is diminished due to preoccupation when
working. Teams mention a shortage of resources and time as reasons that interventions are not
implemented. Furthermore, respondents from two teams that experience difficulties using the
flexmonitor mention the amount of guidance by the facilitator as being too low.
A final set of observations regarding the use of the flexmonitor is about how teams use
it to intervene on negative team behaviors. First, instead of purposefully intervening on certain
developments in team learning, several teams implement general interventions that are
proposed to improve behavior on multiple dimensions at once. ‘We place one intervention that
ought to improve several behaviors’. Meaning that instead of specifically targeting certain
behaviors with certain interventions, a more generic approach is used in practice. Based on this
it can be concluded that in some teams interventions are not targeted specifically on certain
behaviors but are more generic; ‘we have now used a couple of interventions at the same time,
which focused on giving feedback and receiving feedback, is this linked to learning behavior?’.
Furthermore, it seems that teams use interventions to target several dimensions of team behavior
and general flexibility ‘now with regard to flexibility and all dimensions’. Finally it can be noted
that the proposed use of the flexmonitor in regard to different stages that signal the quality of
learning behavior and subsequent interventions did not come across in the data. Meaning that
there is not a one on one relation with unwanted developments and subsequent interventions.
Conclusion
To conclude, the research question is answered ‘how can, and do teams intervene on
unwanted developments in team learning behavior to attain and maintain flexibility’. Firstly,
indicators are mentioned that were found in literature and practice. Indicators are used to see
how a team is performing in regard to team learning. A lack of these represent unwanted
developments in team learning behavior and subsequently a decrease in flexibility. Next, the
possibilities are presented that teams have to intervene according to literature, and how they
intervene in practice using the flexmonitor.
In relation to team learning behavior, ten indicators were found in the literature study.
These consist of psychological safety, interdependence, team efficacy, cohesion, information
sharing, storage, retrieval, team activity, reflexivity and co-construction. In practice several new
indicators emerged. New indicators that came up in both data sources consist of inspiration to
27
learn, motivation to learn, proactivity workload and openness. Moreover, three specific clusters
can be distinguished in practice consisting first of work climate and interaction among
members, second of individual and organizational traits and third of team-level behaviors.
In terms of which interventions exist, two sources were used, scholarly literature and
interview data. In relation to how teams can intervene on learning behavior five interventions
have come forward from literature: feedback, discussion, teambuilding, induce change and
leadership development. To answer the question of how teams do intervene on unwanted
developments it can be concluded that the following interventions have come forward in
practice: the flexmonitor itself being an intervention by raising discussion and signal behaviors,
hidden interventions (interventions that were not recognized by team members consisting of
intervening on the response rate, raising awareness on team developments and making topics
discussable in a team); and lastly a group of interventions that were explicit outcomes of the
flexmonitor consisting of a team day; improved transfer form and shift evaluation to provide
increased feedback. When comparing literary indicators with practice the following are present
in both: feedback, discussion, teambuilding, induce change. The only intervention from
literature that was not mentioned in practice is leadership development. Furthermore it can be
concluded that the flexmonitor has a positive effect on team flexibility as it has increased the
sense of awareness and changed the way work is perceived and executed.
Discussion
Interpreting results. To the best of the researcher’s knowledge there are no similar
studies like the current at the time of the research (mid 2017). Therefore, the findings and
observations done in this study can be used as a first directive to continuous team flexibility
from a practical point of view. In the following section the most important findings are
discussed in a more holistic perspective, not just summing up indicators and interventions but
also evaluating the flexmonitor itself. First discrepancies regarding indicators are mentioned
and placed in the literary context. After this, findings regarding important indicators and
interventions are discussed. This section will be concluded by discussing the flexmonitor, as
this was the central method in intervening on unwanted developments in team learning.
First, a closer look and provision of literary context regarding the discrepancy between
indicators in literature and data is given regarding the following indicators: storage/retrieval,
boundary crossing behavior, co-construction, interdependence and perceived team efficacy.
Regarding boundary crossing behaviors, the goal and composition of the team provide an
explanation. There is relatively low skill and task diversity, combined with low hierarchy in the
28
teams. This makes boundary crossing behaviors unnecessary, as there are few perceived
boundaries within teams. Furthermore, storage and retrieval might be uncommon for
practitioners in mental health care, as the nature of the job, which is guiding and helping clients
with mental health issues, does not ask for the creation of team-wide bits of information which
are stored and retrieved. Rather, health care practitioners learn from each other by doing
(Orland-Barak & Wilhelm, 2005). Regarding co-construction, this might be stronger linked to
cooperation and decision-making, which is understandable as these concepts are also
theoretically linked (Cannon-Bowers, Salas & Converse, 1993; Mathieu, Heffner, Goodwin,
Salas & Cannon-Bowers, 2000). The same applies to the absence of interdependency and team
efficacy under the statements regarding learning whilst they are present at cooperation and
decision-making. Interdependency and team efficacy are both linked in theory with cooperation
and decision-making (Alper, Tjosvold & Law, 1998; Nielsen, Yarker, Randall & Munir, 2009).
In summary it can be concluded that a theoretical overlap exists between dimensions. This has
an impact on participants using the flexmonitor as it is apparently difficult to decide which
dimension an indicator should be placed under, which is understandable as overlap between
constructs is an inherent subject in social sciences (Gerring, 1999).
When looking at which ‘actual’ interventions from literature were implemented, the
following were found: discussion, team building, induce change and feedback. Of these,
feedback is by far the most important group, which is in line with theory. The importance for
feedback, especially in health care practice is underlined in literature, as failure to address
feedback can negatively impact upon clients and can lead to grave consequences for health care
outcomes (Price, Hopwood, & Pearce, 2000). This explains the importance of feedback in
nursing theory and its subsequent principal role that was found in practice.
Furthermore, when looking at the most important indicators of learning behavior and
the most important intervention in practice it can be concluded that these are theoretically
linked. Regarding outcomes of feedback, scholars argue that, next to improving the learning
process, feedback also increases reflexive skills such as sharing information (Peacock, Murray,
Scott & Kelly, 2011). In addition, feedback has a two-way relationship with psychological
safety. Psychological safety leads to behaviors such as asking for feedback in a team
(Edmondson, 2003). In addition feedback also has the potential to positively affect the sense of
psychological safety (Edmondson, Kramer & Cook, 2004). In line with the results from this
study it seems that feedback rightfully is the most important intervention in health care practice.
When taking into account the gap between possibilities of implementing theoretical
interventions in practice described in the introductory section of this study (Foster, et al., 2012),
29
it seems that designing appropriate and achievable interventions is possible. The main
obstruction in creating and implementing interventions in practice is workload and team-wide
support and motivation. However, several teams have shown that creating and implementing
interventions can be done when the flexmonitor is supported and room is created to follow
through with interventions. This therefore seems one of the major driving factors of success in
using the flexmonitor.
When taking a critical perspective towards the research question of how teams intervene
on unwanted developments in their learning behavior and flexibility, it can be concluded that
the use of the flexmonitor differed from the proposed function. First in terms of hidden
interventions, which are not explicit outcomes of the flexmonitor but implicit externalities.
Second because teams did not explicitly use different stages of signaling behavior and
subsequently intervened on unwanted behaviors that were detected. Rather, interventions were
used to counter negative trends in team behavior in a more random way than explicitly on
outcomes of the flexmonitor. In addition respondents mentioned that on several occasions an
intervention was proposed to target several dimensions of behavior. The fact that the process
went like this can be linked to work pressure and limited time for innovative, non-core business
such as use of the flexmonitor (Schippers, West, & Dawson, 2015). In addition, overlap between
dimensions might play a role. Specifically, as teams have difficulties in demarcating indicators
between dimensions, it is difficult to target specific behaviors with specific interventions.
Finally, when looking at how flexibility is enhanced, it seems that the flexmonitor itself proved
to be the most direct link by changing the way that work was executed within teams and by
increased awareness. These two topics are linked to flexibility and thus the flexmonitor provides
teams with the intended outcome.
Limitations
A first limitation lies in the limited generalizability of this study. This is caused by the
fact that the data of the flexmonitor is idiosyncratic to every team which makes individual
outcomes less comparable. Furthermore, the labels that have been used are subjective as they
were chosen by the researchers. However, to minimalize these issues, peer evaluation has taken
place in order to decrease subjectivity. In addition data triangulation was used to ensure the
validity of this study.
A second limitation is related to the data collection. The researcher’s interviewing
experience was limited at the time of the research. This might have led to a suboptimal data
collection, for example via a confirmation bias whilst interviewing respondents. However, the
effects of these limitations were limited by having a second researcher present at the interview
30
to enhance data collection by using probing questions and to have an extra safeguard for
possibly leading questions and confirmatory data collection. Furthermore, possible question-
order bias was reduced by following a topic list which was carefully created to decrease
unwanted effects.
A final limitation comes from the respondents. Because they are self-selected, sponsor
bias might have arisen due to familiarity with the creator of the flexmonitor. In addition to this
it might have led to responding in a socially desirable way in the interviews. By using different
sources of data and triangulating between sources, the results between multiple perspectives
and approaches have been compared, which leads to increased strength of findings and reduces
the aforementioned respondent biases.
Recommendations
Practical recommendations. Based on the outcomes of this study it is recommended
to provide a more strict procedure in using the flexmonitor. The flexmonitor is a tool to provide
flexibility and in its vision it is adaptable to the situation and needs of individual teams.
However, Volberda stated that too much flexibility leads to a loss of identity and chaos
(Volberda, 1997). To prevent this, the flexmonitor itself should maintain its structure and
provide a certain amount of guidance. In practice this could be variable between teams. More
structure and guidance in using the flexmonitor by the team or key representatives might lead
to increased acceptance and collective support. This is subsequently linked to more successful
implementation of interventions.
A second practical recommendation is to have stronger interference by the facilitator.
Whereas one might argue that a facilitator ought to have a very minimal role, one could also
argue that stronger interference leads to improved outcomes of the flexmonitor due to the
expertise and experience of the facilitator. Examples to expand the role of the facilitator could
be to actively seek to provide feedback to a team, and in terms of creating interventions, to
provide stronger guidance. Regarding feedback: this enhances a positive work atmosphere and
is linked to psychological safety. Therefore, a facilitator of the flexmonitor ought to take a
leading role by modelling certain behaviors. This is an opportunity to help enhance the team
processes whilst using the flexmonitor and improve potential outcomes. The rationale is that
health care practitioners learn by doing and copying behaviors as mentioned in literature.
Furthermore, as it has become clear that overlap exists between concepts in the flexmonitor, a
facilitator could use his/her knowledge and experience to guide and advise participants and to
provide a foundation from which the flexmonitor is implemented in a way that is theoretically
31
sound. Finally a facilitator’s role could be more concerned with improving double and deutero
loop learning by steering the discussion about the manner in which a team learns.
The final practical recommendation is about the most important indicators and
intervention. Based on the outcomes it is proposed that psychological safety and information
sharing are the most important team learning indicators. The practical implication that is derived
from this is that these two concepts are the most important indicators of team learning in health
care practice. Psychological safety creates room for creativity and space for people to develop.
Information sharing has a relationship with psychological safety as it is stimulated in safe
environments and leads to increased addressing of behaviors (Zhang, Fang, Wei & Chen, 2010).
Furthermore, these indicators also show overlap with the dimensions cooperation and decision-
making. This leads to the assumption that intervening on these specific indicators might have
positive outcomes in a broader way than just regarding learning behavior but also improve
cooperation as well as decision-making behavior. Feedback is the proposed intervention to
increase the information sharing and psychological safety. However, this should be done in a
controlled and positive manner to diminish possible negative outcomes of feedback (Kluger &
DeNisi, 1996).
Recommendations for future research. The present study serves as a starting point in
researching self-initiated team flexibility and the flexmonitor. Based on the findings in this
study three recommendations for future research are given to gain a deeper understanding of
team learning, continuous flexibility and use of the flexmonitor.
First to research team processes more in-depth. Where the present study is focused on
interventions and indicators of team learning on a more theoretical level, future research could
be directed within teams to see which paradigms are used to create interventions. Proposed
studies into individual team processes should incorporate more respondents per team or focus
groups to also attain an insight into different perspectives within a team. This would lead to a
deeper understanding of how teams create continuous flexibility via learning and the
flexmonitor and which internal forces influence this process. Furthermore, research ought to be
extended into longitudinal design as this would allow for stronger causal inferences about
indicators and subsequent interventions. In addition a longitudinal study would allow for
stronger inferences about flexibility as outcomes in a team can be monitored for a longer period
of time.
A second recommendation for future research is to expand the flexmonitor to other
sectors besides health care. This might provide an increased insight in differences in indicators
and interventions regarding learning in different sectors. It is of value to see what happens in
32
manufacturing teams, R&D teams or in hierarchical organizations and perhaps leads to new
insights on important indicators and interventions regarding learning. Also, in other sectors
besides health care (which is the object of severe budget-cuts), a tool such as the flexmonitor
might lead to different outcomes. Specifically, increased budgets and less work pressure might
add to the possibilities and outcomes the flexmonitor can provide and lead to more specific
interventions regarding developments in team behaviors.
A third and final recommendation for future study is to incorporate organizational and
individual characteristics when researching the effect, response and outcomes of the
flexmonitor. Respondents mention inspiration from the organizational environment, individual
motivation and proactivity as important indicators. Furthermore, in literature these concepts are
theoretically linked to learning within organizations (Garcia-Morales, Llorens-Montes &
Verdú-Jover 2006; Stegers-Jager, Cohen-Schotanus & Themmen, 2012). However, they were
not included in the current study which can be explained by the scope of the present study which
was limited to team learning behavior. As it became apparent that teams view individual and
organizational traits as being important indicators of learning, it would be valuable to see how
these factors influence the process. Suggestions are to incorporate personality and
demographics in terms of individual traits. Organizational characteristics that could be
incorporated are size, financial position, certain mission and vision statements to observe
whether, for example organizational culture and importance of learning within an organization
help teams use the flexmonitor more effectively to achieve better results.
33
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Appendix A: figures and tables - theoretical framework
Figure A1
Figure A2
Adapted from Van den Bossche et al., 2006
40
Appendix B: Process of the flexmonitor
The following text is taken from the article on how the flexmonitor is used (Van Gool, et al.,
n.d.):
The flexmonitor is carried out in the following steps:
1. Introducing the flexmonitor
In a 30 minutes presentation the goals, method and potential value and outcomes were
explained using a PowerPoint presentation. The team members decide whether they
want to use the method or not.
2. Start-session; gathering indicators of flexibility.
In a ‘world café-like’ session (Nistelrooij & de Wilde, 2008) the team collect
indicators of flexibility on the four dimensions learning behaviour, cooperation,
decision-making and vitality. Using these indicators, 24 questions are designed for the
team questionnaire, made in Google Forms.
3. Forming a small workgroup or representatives; one to five workers.
The team chooses at least one representative. These representatives are the linking pin
between researcher and the team. They distribute the questionnaire, send reminders
and reports to all the team members, they stimulate colleagues to submit their
questionnaires and are the initiators and organisers of team activities and
interventions. Some teams designate more representatives determined by the size of
the team or the stage of the proces.
4. The questionnaire is monthly distributed using Google Forms.
5. Adjusting session; after one or two months a session is organised to analyse the first
results. One of the key issues is to evaluate the items and adjust the questionnaire
when needed.
6. One week after the monthly deadline the team members receive a report on the results.
In some teams, the results are briefly discussed in regular team meetings.
The workgroup members or representatives initiate interventions in their teams. Team
3 and 4 choose to work with the whole team in all sessions and they initiate
interventions as a team.
7. Team-sessions were held, for analysing the results, coaching and designing
interventions (pp. 4-5).
41
Figure B1: The flexmonitor (Van Gool et al., n.d., 4-5)
Figure B1 shows a form of the flexmonitor. From green to red indicates a scale in which the teams
experiences more problems regarding their learning behavior Teams fill it out with indicators and
interventions in four stages of team behavior which goes from positive to negative where green is fine
learning and red is a crisis-situation in terms of learning.
42
Appendix C: Example report of the flexmonitor
Table C1: Report of the flexmonitor (Van Gool, Bongers, Janssen & Bierbooms n.d)
Teams receive this report on a monthly basis. The schematic provides a comparison with the last score to see how and in which direction a team
develops itself in regard to the four dimensions.
43
Appendix D: Topic guide
Purpose of the semi-structured interview:
To receive in-depth knowledge about what the team representatives see as important
indicators in the four domains as the base for the interventions;
To gain in-depth knowledge about what interventions are developed by the different teams and
which characteristics do they deem important in developing these interventions;
To understand which indicators, beliefs and values have an influence on the development of
the interventions.
Introduction:
Making general conversation but avoiding the interviewee topics, to make the interviewee
more relaxed.
A brief summary of the topics that will be covered in the interview.
Explaining the confidentially and anonymity of the audio tapes and the analysis of the data.
1. Personal details
a. How many hours are you working in a week?
b. How long are you working for this organization?
c. What is your age (if I may ask)?
2. Team details
a. What is the purpose of the team?
b. How long is this team working in its current composition?
c. How is the cultural diversity in your team?
d. What is the male/female ratio in your team?
e. How would you describe the implicit relationships in your team (e.g. hierarchy and
coalition)?
3. Flexmonitor
a. How did you come across the flexmonitor?
b. Did you voluntary participate or was it obligated?
c. How did you experience the flexmonitor up to this point?
d. Would you recommend the flexmonitor to other departments?
4. Decision behavior
Inducement of the interventions
a. Which values/ team characteristics are important in relationship to decision behavior in
your team?
44
b. Can you recall the statements developed in the first stage of the flexmonitor, which
reflects decision behavior for your team?
Help the interviewee remember the statements, when he or she do not recall this
in order to answer the following question.
c. What is the relationship between the values and the statements that are created?
d. Are there any other factors that would influence decision behavior in your opinion?
e. To what extend do the lowest statements reflect actual problems in your team?
One week after the questionnaires are filled out the team members receive a report
of the results. The report shows the three statements with the highest score and the
three statements with the lowest score.
Interventions
a. Which interventions were developed in your team?
b. Why did you think it was important to implement this intervention?
c. What were the team’s expectations about interventions?
d. What effect had the intervention on the team’s behavior?
What were success factors of the interventions and which features were less
successful
5. Resilience and vitality
Inducement of the interventions
a. Which values/ team characteristics are important in relationship to decision behavior in
your team?
b. Can you recall the statements developed in the first stage of the flexmonitor, which
reflects decision behavior for your team?
Help the interviewee remember the statements, when he or she do not recall this
in order to answer the following question.
c. What is the relationship between the values and the statements that are created?
d. Are there any other factors that would influence decision behavior in your opinion?
e. To what extend do the lowest statements reflect actual problems in your team?
One week after the questionnaires are filled out the team members receive a report
of the results. The report shows the three statements with the highest score and the
three statements with the lowest score.
Interventions
a. Which interventions were developed in your team?
b. Why did you think it was important to implement this intervention?
c. What were the team’s expectations about interventions?
d. What effect had the intervention on the team’s behavior?
45
What were success factors of the interventions and which features were less
successful
6. Cooperation
Inducement of the interventions
a. Which values/ team characteristics are important in relationship to decision behavior in
your team?
b. Can you recall the statements developed in the first stage of the flexmonitor, which
reflects decision behavior for your team?
Help the interviewee remember the statements, when he or she do not recall this
in order to answer the following question.
c. What is the relationship between the values and the statements that are created?
d. Are there any other factors that would influence decision behavior in your opinion?
e. To what extend do the lowest statements reflect actual problems in your team?
One week after the questionnaires are filled out the team members receive a report
of the results. The report shows the three statements with the highest score and the
three statements with the lowest score.
Interventions
a. Which interventions were developed in your team?
b. Why did you think it was important to implement this intervention?
c. What were the team’s expectations about interventions?
d. What effect had the intervention on the team’s behavior?
What were success factors of the interventions and which features were less
successful
7. Learning behavior
Inducement of the interventions
a. Which values/ team characteristics are important in relationship to decision behavior in
your team?
b. Can you recall the statements developed in the first stage of the flexmonitor, which
reflects decision behavior for your team?
Help the interviewee remember the statements, when he or she do not recall this
in order to answer the following question.
c. What is the relationship between the values and the statements that are created?
d. Are there any other factors that would influence decision behavior in your opinion?
e. To what extend do the lowest statements reflect actual problems in your team?
46
One week after the questionnaires are filled out the team members receive a report
of the results. The report shows the three statements with the highest score and the
three statements with the lowest score.
Interventions
a. Which interventions were developed in your team?
b. Why did you think it was important to implement this intervention?
c. What were the team’s expectations about interventions?
d. What effect had the intervention on the team’s behavior?
What were success factors of the interventions and which features were less
successful
After the interview:
The interviewee will be thanked warmly.
Briefly tell the interviewee how their answers will contribute to the research.
Reemphasize the anonymity of the interviewee
47
Appendix E: secondary data provided by statements of the flexmonitor.
Team Dimension Statement flexmonitor Indicator
Concordant
Learning
Concordant
other Cooperation Decision Learning
Resilience
& vitality
A Learning In our team we are interested in each other. social support X X
A Learning There are complaints about the amount of training and courses. workload
A Learning I actively contribute to the knowledge exchange on the ward. Information sharing X X X X X
A Learning The team is curious about new developments. motivation to learn
A Learning I find it hard to give feedback to some of my collegues. information sharing X X x x X
A Learning I take initiative in keeping my skills updated. proactive attitude X
B Learning We learn and develop despite the workload at the HIC (high intensive care ward). team activity X X
B Learning We don't need fixed patterns to sustain in the HIC (high intensive care ward) TMM/co-construction X X X
B Learning We evaluate situations. Team reflexivity X X
B Learning Individual teammembers are open about mistakes. psychological safety X X
B Learning Courses give energy. Vigour X X
B Learning The team creates an safe and optimal climate of learning. psychological safety X X
C Learning I give my collegues feedback when needed. Information sharing X X X X X
C Learning I have at least 2 hours a week to learn. Workload X X
C Learning We are aware of our personal development topics. information sharing X X X X X
C Learning I feel stimulated to learn. Inspiration to learn
C Learning We act accordance the work plan. Uphold structure
C Learning We weekly discuss our learning moment. Team reflexivity X X
D Learning I have enough room for creativity. psychological safety X X
D Learning My team inspires me. Inspiration to learn
D Learning I have enough room to learn. Psychological safety X X
D Learning I'm enthusiastic. motivation to learn
D Learning I have a clear focus. Engagement X X
D Learning I can do something with the feedback of my collegues. Information sharing X X X X X
E Learning I experience joy and enough room for guiding students. Learning climate
E Learning We take time for professional development. motivation to learn
48
E Learning We are enthusiastic for new developments and take time for implementation. motivation to learn
E Learning Interest of the team is paramount. motivation to learn
E Learning I feel positively stimulated for development. Inspiration to learn
E Learning We learn from each other. team activity X X
F Learning I experience joy and enough room for guiding students. Learning climate
F Learning We take time for professional development. Proactivity
F Learning We are enthusiastic for new developments and take time for implementation. proactivity
F Learning Interest of the team is paramount. motivation to learn
F Learning I feel positively stimulated for development. Inspiration to learn
F Learning We learn from each other. team activity X X
G Learning I regularly receive compliments. peer support X X
G Learning I feel room to learn from my mistakes. psychological safety X X
G Learning I feel room to develop myself. psychological safety X X
G Learning There is enthusiasm for knew knowledge, developments and courses. Inspiration to learn
G Learning We actively engage in innovation, change and it's implementation. proactivity
G Learning I have actively taken knew knowledge. Proactivity
H Learning I take relevant courses for me and the ward formal training
H Learning I actively take part to moments of intervision. Team reflexivity X X
H Learning I talk to my collegues about difficult situations. information sharing X X X X
H Learning I have access to current information about developments in my profession. information sharing X X
H
Learning
There is 4 times a year an intervision moment organised, which I follow at least 2
times a year. Team reflexivity X X H
Learning I enjoy and have room for new developments and additional tasks. psychological safety X X I
Learning The team is open for new ideas/ developments. motivation to learn I
Learning Immediatly after the bahavior I give my collegues feedback. Information sharing X X I
Learning Every team member actively contributes to new developments. proactivity I
Learning I share my knowledge (whether or not requested) with collegues. information sharing X X I
Learning I handle offered schooling with a constructive manner. formal training I
Learning I reflect on my own actions. self reflectivity
49
Team Dimension Statement Indicator
Matches
with
literature
dimension
Matches Matches Matches Matches Matches
With
literature
other
dimension
with with with with
Cooperation
Decision
behavior
Learning
behavior
Resilience
and vitality
A Cooperation I experience support from my collegues. Peer support X X
A Cooperation If I have input it will always be listened. Communication X X X X X
A Cooperation I hear collegues complain about each other. Peer support X X
A Cooperation Agreements are often not kept. Loyalty to the
decision X X X X
A Cooperation Within our team there is de excistence of
subgroups. Diversity X X
A Cooperation I have influence on the policy of the team. Empowerment X X
B Cooperation I dare to give feedback to everybody. Psychological
safety X X X X X
B Cooperation
Collegues contribute with positive
communication to a good climate within the
department.
Communication X X
B Cooperation
The HIC (high intensive care ward)has it's own
expertise but actively seeks contact with
ambulant clinicians to determine the treatment
policy.
Information
sharing X X X X X
B Cooperation There is attention from collegues for my own
capacity. peer support X X
50
B Cooperation We take the lead in every situation. Pro active attitude X X
B Cooperation We create time and room to discuss with each
other. information sharing X X X X X
C Cooperation Broadly, I know of every collegue where they
are working on. interconnectiveness X X X X
C Cooperation We have sufficient attunement and coordination
within the team. TMM X X X X
C Cooperation My work is enough documented and
transmissible. interdependence X X
C Cooperation I know who I can go to with work-related
questions.
Organizational
support X X
C Cooperation Qualities are used. Interconnectiveness X X
C Cooperation The atmosphere whithin the team is pleasant. relaxed atmosphere X
D Cooperation I feel heard by my colleagues. Peer system X X
D Cooperation I talk to my collegues on a regular basis. communication X X X X
D Cooperation I can be myself. trust X X X X X
D Cooperation We know of each other where they're coming
from. TMM X X X X
D Cooperation There is a safe atmosphere to give feedback. X X X X X
51
psychological
safety
D Cooperation Work will be handled. helping behavior X
E Cooperation I find the atmosphere within the team pleasant. relaxed atmosphere X
E Cooperation Communication is mainly in relation to the
content of our work. communication X X X X
E Cooperation I get my mail easily updated. workload X
E Cooperation On a organisational level there is flexible
support.
Organizational
support X X
E Cooperation We aim a common objective. TMM X X X X
E Cooperation I feel there is an open way of communication. communication X X
F Cooperation I find the atmosphere within the team pleasant. relaxed atmosphere X
F Cooperation Communication is mainly in relation to the
content of our work. communication X X X X
F Cooperation I get my mail easily updated. workload X
F Cooperation On a organisational level there is flexible
support.
Organizational
support X
52
F Cooperation We aim a common objective. TMM X X X X
F Cooperation I feel there is an open way of communication. communication X X
G Cooperation There is a relaxed atmosphere. relaxed atmosphere X
G Cooperation Agreements that are made are kept. loyalty to the
decision X X X X
G Cooperation There is alignment within the nursing team. communication X X
G Cooperation There is room to give and receive feedback. information sharing
environment X X X X X
G Cooperation I have a positive professional relationship with
all of my collegues. cohesion X X
G Cooperation I feel empowerd by my collegues. empowerment X X
H Cooperation I consult with my collegues. information sharing X X X X X
H Cooperation I have attention for my collegues. peer support X X
H Cooperation During shifts I reflect on situation with my
collegues. communication X X X X
H Cooperation Agreements are well documented and
implemented.
loyalty to the
decision X X
53
H Cooperation I feel safe within the team. psychological
safety X X X X X
H Cooperation I contribute to a relaxed atmosphere. relaxed atmosphere X
I Cooperation I dare to be vulnerable. trust X X
I Cooperation I experience unity in the team. cohesion X X
I Cooperation My job gives me energy. vigor X X
I Cooperation I can participate in policy. empowerment X X X
I Cooperation I'm able to give and receive constructive
feedback. communication X X
I Cooperation We are aware of each others tasks,
responsibilities and competences TMM X X X X
54
Team Dimensie Statement Engels Indicator
Matches
with
literature
dimension
Matches Matches Matches Matches Matches
With
literature
oher
dimension
with with with with
Cooperation
Decision
behavior
Learning
behavior
Resilience
and
vitality
A Decisionmaking In our meetings we make clear agreements. Communication
x x
A Decisionmaking Early signals are quickly picked up in our team. TMM/ storage and retrieval X X
X
A Decisionmaking I experience room and possibilities to make independent decisions. Psychological safety
X
X X X
A Decisionmaking Sometimes I hear collegues react negatively to other co-workers. Emotional stability
X
X
A Decisionmaking Sometimes I make emotional decisions . Emotional stability
X
X
X
A Decisionmaking We work from a strong shared vision. TMM/high involvement X X X X
B Decisionmaking We make informed decisions based on discussion and multiple perspectives.
use of diverse
knowledge or multiple
perspectives
X
X
B Decisionmaking Even when were not involved in the decisonmaking, we take responsibility for
teamdecisions.
High
involvement/loyalty to
the decision
X
X
B Decisionmaking We seamlessly cooperates with other disciplines.
boundary crossing
behavior/information
sharing
X X X X X
B Decisionmaking We base dismissal of a patient only on professional arguments.
Information
sharing/diverse
knowledge
X
X
B Decisionmaking We communicate all decisions directly and completely to our team. communication X X X X
B Decisionmaking We take decisions based on professional arguments. diverse knowledge
X
C Decisionmaking I keep myself actively informed about important issues within the team. high involvement/pro
activity X X
X X
C Decisionmaking There is transparant communication about decisions. communication X X X X
X
C Decisionmaking If needed, I make independent decisions. empowerment X X X X
X
C Decisionmaking I feel responsible for team decisions.
high
involvement/loyalty to
the decision
X
X
C Decisionmaking Each team member has equal input in decision making. diverse knowledge X X
X
C Decisionmaking The team is decisive and comes to action. perceived team efficacy X
X X
D Decisionmaking I may make mistakes. psychological safety/ X X X X X X
D Decisionmaking I agree with team decisions. high
involvement/loyalty X
X
D Decisionmaking I trust the judgement of collegues. trust X X X X
X
D Decisionmaking I dare to make individual decisions. /trust X X X X X
55
D Decisionmaking My opion is heared. communication X X X X X
D Decisionmaking There is room for own initiatives. supportive system/learning environment X
X X
E Decisionmaking People listen to me in (team)meetings. communication
X X X
E Decisionmaking I ensure that me and my collegues are aware of decisions and developments. communication
X X
X
E Decisionmaking We do what we have to do. TMM
X X
X
E Decisionmaking We uphold a decision as a team. loyalty to the decision X X X X X
E Decisionmaking We are a vigorous team. resilience & vitality/ perceived team
efficacy X
X X
E Decisionmaking Our decisions are effective, are extended to a period of time and are evaluated. communication
X X
F Decisionmaking People listen to me in (team)meetings. communication
X X X
F Decisionmaking I ensure that me and my collegues are aware of decisions and developments. communication
X X
X
F Decisionmaking We do what we have to do. TMM
X X
X
F Decisionmaking We uphold a decision as a team. team activity
X
X
F Decisionmaking We are a vigorous team. resilience & vitality/ perceived team
efficacy X
X X
F Decisionmaking Our decisions are effective, are extended to a period of time and are evaluated. communication
X X
G Decisionmaking I can agree with team decisions. Loyalty tot he decision x
X
G Decisionmaking Decisions are quickly an accurately made. quality of decision making/team efficacy X
X X
G Decisionmaking I have enough confidence to make independent decisions in this team. trust X X X X
G Decisionmaking Decisions are made after a peer review by collegues. peer review/diverse
knowledge X X
X
X
G Decisionmaking I make a professional decision in every circumstance. diverse knowledge
X
G Decisionmaking I feel competent to make independent decisions. self esteem
X
H Decisionmaking I feel heard during meetings. communication
X X
H Decisionmaking I actively contribute to decision-making. high involvement X
X
H Decisionmaking I have an pro-active attitude within the multidisciplinary team. high
involvement/proacitivity X X
X X
H Decisionmaking I dare to give my opinion during meetings. psychological safety X X X X X
H Decisionmaking I worked out my work carefully and made it possible to carry it over. storage and retrieval
X
X
H Decisionmaking I have enough energy to process new input vigor
X
I Decisionmaking I feel safe to give my opinion. psychological safety
X X
X X
I Decisionmaking I feel heard by my team. social support
X
I Decisionmaking I experience that decisions are made in consultation. diverse knowledge
X
56
I Decisionmaking I take responsibility in decision making. diverse knowledge/responsibility
X
X
I Decisionmaking There is a productive and enthusiastic attitude. enthusiasm/high involvement
X X
I Decisionmaking I support teamdecisions, even when I wasn't there. TMM X X X
Team Dimension Statement Indicator
Matches
with
literature
dimension
Matches Matches Matches Matches Matches
With
literature
oher
dimension
with with with with
Cooperation
Decision
behavior
Learning
behavior
Resilience
and
vitality
A Resilience
& vitality There is a relaxed atmosphere on our ward. Psychological safety X X
X X
A Resilience
& vitality I adapt easily to new expectations Adaptive personality X
X
A Resilience
& vitality I feel fit and well rested. Vitality X
X
A Resilience
& vitality I feel reluctant towards my job. Engagement X
X
A Resilience
& vitality There are a lot of temporary workers at work.
Social support
system X
X
A Resilience
& vitality I feel proud about our ward. Engagement X
X
B Resilience
& vitality Ik go to work with pleasure. Engagement X
X
B Resilience
& vitality I see problems as a challenge. Vigor X
X
B Resilience
& vitality I feel taken serious, my opinion matters. Pyschological safety. X X X X
B Resilience
& vitality Everyday we give each other feedback.
Team
communication X X x X
B Resilience
& vitality I’m able to make an assessment from different perspectives. Use diverse knowledge X X
B Resilience
& vitality I’m able to perform additional tasks (e.g. commissions) in addition to my job. Engagement/vigor. X X
C Resilience
& vitality I have a daily laugh wit my co-workers. Work atmosphere X X
C Resilience
& vitality The balance between capacity and workload works for me. Vigor X X
C Resilience
& vitality I enjoy going to work. Engagement X X
C Resilience
& vitality I feel room for flexibility regarding my work activities. Empowerment X X
C Resilience
& vitality Work-related absenteeism is low. Engagement X X
C Resilience
& vitality I have a healthy balance between work and private life. Work-live balance X X
D Resilience
& vitality The atmosphere is relaxed. Work atmosphere X X
57
D Resilience
& vitality I go to work with positive energy Vigor X X
D Resilience
& vitality There is room for creativity with work activities Empowerment X X
D Resilience
& vitality The goals are clear TMM X x
D Resilience
& vitality We work and carry the load together. Support system X X
D Resilience
& vitality I experience low pressure by absenteeism. Vigor X X
E Resilience
& vitality I feel fit and like to get to work. Vigor/engagement X X
E Resilience
& vitality I have a balance between main and secondary tasks. Work balance X X
E Resilience
& vitality The department is neat and tidy. Work atmosphere X X
E Resilience
& vitality We are committed and invested in each other. Support system X X
E Resilience
& vitality We can adjust our actions to the situation. Adaptive personality X X
E Resilience
& vitality We can talk about discontent and handle this on a constructive manner.
Team
communication X X
F Resilience
& vitality I feel fit and like to get to work. Vigor/engagement X X
F Resilience
& vitality I have a balance between main and secondary tasks. Work balance X X
F Resilience
& vitality The department is neat and tidy. Work atmosphere X X
F Resilience
& vitality We are committed and invested in each other. Support system X X
F Resilience
& vitality We can adjust our actions to the situation. Adaptive personality X X
F Resilience
& vitality We can talk about discontent and handle this on a constructive manner.
Team
communication X X
G Resilience
& vitality I enjoy going to work. Engagement X X
G Resilience
& vitality I feel fit and like to get to work. Vigor X X
G Resilience
& vitality I feel involved and inspired by the developments within the HIC.
Engagement / high
involvement. X X X X
G Resilience
& vitality We are flexible enough to carry each other’s burdens. Support system X X
G Resilience
& vitality I feel myself appreciated in the team. Support system X X
G Resilience
& vitality The humor is supportive to our job. Work atmosphere X X
H Resilience
& vitality I enjoy going to work. Engagement X X
H Resilience
& vitality I experience no hindrance of the staffing. Workload X X
H Resilience
& vitality I feel fit and rested. Vigor X X
H Resilience
& vitality I’m concerned for the well-being of my colleagues. Support system X X
H Resilience
& vitality They would take care of me when I would need it. Support system X X
58
H Resilience
& vitality On the end of my shift, I have finished my tasks. Workload X X
I Resilience
& vitality I enjoy going to work. Engagement
I Resilience
& vitality I’m satisfied with my work scheduele. Workload
I Resilience
& vitality I find the humor in my team comfortable. Work atmoshpere
I Resilience
& vitality I’m proud of the work I deliver. Engagement
I Resilience
& vitality I experience my team as flexible. Adaptive personality
I Resilience
& vitality I experience a relaxed atmosphere Psych safety X X
59
Appendix F: result
Table F1. Example of the coding process in regard to indicators
The table can be read from left to right. First the citations are mentioned. These were subsequently coded with an open coding which was based
on the textual elements. When everything was coded open axial coding was admitted to group certain clusters of open coded, in this case it is
about dimensions of reflexivity. The coding process concluded by selectively coding the axial coding which allowed for themes to emerge.
Furthermore the axial codes can be seen as different concepts within a major theme which in this case is the indicator reflexivity.
citation open coding axial coding selective coding
eigen handelingen reflecteren reflectie reflect on
self reflexivity
Dus toen zijn we wel kritisch met elkaar gaan
zitten om te kijken wat gebeurt hier nu eigenlijk.
Dus in die zin wordt er dan wel tijd voor
genomen en kritisch na gekeken.
Interventie – Kritisch
overleg Evalueren reflexivity
we bespreken situaties altijd alles bespreken Evalueren reflexivity
te evalueren dan ga ik gewoon vragen, hoe vond
je mijn communicatie met de client, vond je het
correct of had ik wat anders moeten doen. Dat
doen we wel dat is wel echt iets in het team waar
we sterk in zijn, elkaar helpen.
Elkaar helpen Evalueren reflexivity
60
Table F2. Comparison of learning indicators from literature with practice
Team beliefs/indicators Emerged in results Y/N Frequency when mentioned
Psychological safety Y 23
Task cohesion N 0
interdependence N 0
perceived team efficasy N 0
information sharing Y 15
co-construction N 0
boundary crossing behavior N 0
reflexivity Y 4
team activity Y 1
storage/retrieval N 0
Interventions
Feedback Y 28
induce change Y 7
discussion Y 9
leadership development N 0
team building Y 1
61
Table F3. Example of the coding process in regard to interventions
Citation open coding axial coding selective coding
New way of doing the transfer new transfer outcome
flexmonitor Feedback - intervention
Tip and top; focused on asking feedback Characteritics new
transfer
outcome
flexmonitor/ask
for feedback
Feedback - intervention
That you really do it in synergy not like, you drop it at
someone and he has to see what to do with it Ask for feedback
ask for
feedback Feedback - intervention
Start by asking it Ask for feedback ask for
feedback Feedback - intervention
The table can be read from left to right. First the citations are mentioned. These were subsequently coded with an open coding which was based
on the textual elements. When everything was coded openly, axial coding was admitted to group certain clusters of open coded, in this case it is
about dimensions of feedback. The coding process concluded by selectively coding the axial coding which allowed for themes to emerge.
Furthermore the axial codes can be seen as different concepts within a major theme which in this case is the intervention of feedback.
