Improvisational theatre as a viable path? Exploring interaction antecedents in public service innovation processes attempting to implement and sustain eHealth solutions

ABSTRACT

This article aims to explore interaction antecedents in public sector innovation processes attempting to implement and sustain eHealth solutions through co-creative planning and extensive training. Whilst there is a growing body of literature on innovation antecedents, there is an incomplete understanding of interaction-related antecedents. Our multiple case study explores innovation processes with varying complexity and success in three healthcare organizations in Denmark and Norway. From a symbolic interactionist perspective, the results reveal that some interaction barriers are frontstage performance, idealization and audience segregation. Mediators and service specialists may overcome these barriers and enhance interaction between collaborating actors.

KEYWORDS:

• eHealth solutions
• innovation processes
• interaction antecedents

Introduction

One of the critical challenges facing European societies is the ageing population and the lack of healthcare staff (World Health Organization 2016). Combined with the politically decided decentralization of care and healthcare services, ensuring accessible healthcare and maintaining high-quality healthcare practices is challenging (Mort, Roberts, and Callén 2013; Peine et al. 2015; Procter et al. 2014). In this regard, there is an increased focus on innovation as a way forward for the public sector to meet these challenges (European Commission 2015; Osborne and Brown 2011).

There is an excessive optimism that innovative eHealth solutions in healthcare services are one of the solutions (NOU 2023; Regeringen and Landsforening 2022; World Health Organization 2019) as eHealth solutions can increase efficiency, quality of care and patient security (Berge 2017; Dugstad et al. 2019). However, despite the strong policy push to implement eHealth solutions, authorities acknowledge that the potential benefits are yet to be realized (Landsforening 2016; NOU 2023) and public sector innovation processes attempting to implement eHealth solutions have a high failure rate (Cresswell and Sheikh 2013; Greenhalgh et al. 2020; Mair et al. 2012; Standing et al. 2018). Various antecedents affect the outcome of these innovation processes, and depending on their level and specific context, they can be either a driver or a barrier (De Vries, Bekkers, and Tummers 2016). The greater the context complexity and the innovation, the more barriers are anticipated (Greenhalgh et al. 2020; Torugsa and Arundel 2016). Research has shown that contextual barriers decrease as the innovation process progresses. However, interaction-related barriers increase as the innovation process progresses and are most influential in the implementation and sustainment phase due to the growing number of collaborating actors (Cinar, Trott, and Simms 2019). Interaction-related barriers are barriers that hinder communication, collaboration and effective problem-solving among actors and could, for example, be related to poor communication channels, lack of trust, resistance to change, silos and departmental boundaries, cultural differences, limited resources and technological challenges.

Research on innovation processes in health care points towards several contextual barriers, such as establishing new workflows and organizational routines, poor management, a risk-averse culture, formal rules, laws, regulations and hierarchical command systems, lack of technical support, lack of resources and lack of training (Cinar, Trott, and Simms 2019; Cresswell and Sheikh 2013; Cucciniello and Nasi 2017; Mair et al. 2012; S. Borins 2001; Scott Kruse et al. 2018; Sligo et al. 2017; Standing et al. 2018; World Health Organization 2019.

Research has shown that it is not straightforward to coordinate interaction and dialogue among various actors (Hartley, Sørensen, and Torfing 2013). This challenge is particularly difficult in the healthcare sector (Cucciniello et al. 2015), where the complexity arising from diverse social identities and institutional cultures results in insufficient knowledge sharing and communication, ineffective network governance, as well as a lack of engagement and accountability from end-users and staff members (Cinar, Trott, and Simms 2019, 2021). Research shows that individuals tend to negotiate according to their own interests and ignore common goals, visions and decisions, which hampers a shared understanding that is crucial for successful innovation processes (Torfing, Sørensen, and Røiseland 2019; Tuckman 1965). This ‘self-centred’ behaviour among collaborating actors is an old issue, and despite a range of models to support the handling of such behaviour (Bennis and Shepard 1956; Gersick 1988; Tuckman 1965), it still remains a barrier in public sector innovation processes.

Some scholars claim that there is a need to broaden the horizon of the conventional view on innovation barriers (S. F. Borins 2014; Torugsa and Arundel 2016). Barriers are dynamic and evolve throughout the process (Hadjimanolis 2003). They may also be regarded as opportunities and not necessarily perceived as disadvantageous. Barriers may adjust the innovation to become more appropriate and beneficial to the context (S. F. Borins 2014; Nilsen et al. 2016; Torugsa and Arundel 2016).

Even though the barrier approach to innovation is not new (Hadjimanolis 2003) and relatively well established within the sphere of public sector innovation (Cinar, Trott, and Simms 2019), there is little in-depth knowledge about interaction-related barriers, how they occur, and how they can be overcome (Cinar, Trott, and Simms 2019). With many failed innovation processes (Cresswell and Sheikh 2013; Greenhalgh et al. 2018; Mair et al. 2012; Standing et al. 2018) and with increasing numbers of actors attempting to build collaborations to innovate (Torfing, Sørensen, and Røiseland 2019), research should focus on how collaborating actors can achieve a shared understanding and why the support from end users and staff members is inadequate. Further, research should focus on why communication and knowledge sharing between collaborating actors are inadequate to improve innovation processes.

Against this backdrop, this paper aims to explore interaction antecedents and provide theoretical and empirical insights into how interaction antecedents influence the implementation and sustainment phase in public sector innovation processes. We address this aim alongside an EU innovation project and base our analysis on a qualitative study exploring three cases with varying degrees of complexity attempting to implement and sustain innovative eHealth solutions with varying degrees of success. Here, success refers to the adoption of eHealth solutions among healthcare professionals. With a focus on interaction antecedents, we refer to Erving Goffman’s dramaturgical approach (Goffman 1959) when attempting to provide answers to the following questions:

How do actors interact, negotiate, and position themselves on different scenes in the innovation process? How do their performance and reasoning about the eHealth solutions change when they interact with others through experiences and events, and how does this dynamic process influence the implementation and sustainment phase?

The dramaturgical approach

We address the research questions in this paper by using Erving Goffman’s dramaturgical approach (Goffman 1959) as an analytical lens to the empirical material. The approach provides theatrical terms to describe and analyse the meaning and process of interaction. Goffman suggests that individuals shape their identity based on interactions, exchanging information to create more precise definitions of identity and behaviour in a given situation. Often, individuals collaborate in a team to perform a routine, as the definition of the situation provided by a specific actor is typically an integral part of an image maintained through close collaboration with more than one actor. Role-playing, self-presentation, and impression management are closely linked to establishing identity and defining the situation, which, according to Goffman, are fundamental features of society (Goffman 1959). It is through these features that we shape society and create order in our interactions. The theatrical terms used in this paper are primarily frontstage and backstage, impression management, and discrepant roles.

Frontstage is a region where a performance is or may be in progress. The frontstage performance is shaped by the environment and the present ‘audience’ and is constructed to provide others with impressions consistent with an actor’s desired goals. Goffman refers to the backstage as a region where action related to a frontstage performance occurs but is inconsistent with the appearance fostered by the performance. The language of behaviour backstage is relatively informal as opposed to the language of behaviour in the frontstage region. Backstage language may consist of reciprocal first naming and collaborative decision-making. Yet, it may also consist of profanity, sub-standard speech, mumbling, playful aggressivity, and ‘kidding’. Backstage performance generally allows minor acts that might symbolize intimacy or disrespect for others present, as well as on the scene. However, frontstage performance disallows such behaviour. A scene where a performance occurs is often identified as frontstage or backstage based on what it is regularly associated with. Still, the function of the scene varies. In one sense, a scene that functions as a frontstage may, at another time, function as a backstage. Whether a scene is frontstage or backstage often depends on the present audience.

Sometimes, it may be appropriate to control access to backstage and frontstage by managing the impression of others. If one fails to manage the impression of others, one may also fail to define the situation. Such dramaturgical difficulties may arise when lacking control of the audience. One way to manage impressions is to segregate the audience by playing one role for one audience and other roles for other audiences. According to Goffman, people have a reason to mobilize their activity to give an impression to others that it is in their interest to give. Here, he presents the concept of idealization, where a performance is socialized, moulded, and modified to fit society’s understanding and expectations (Goffman 1959). Therefore, actual or ‘real’ attitudes, beliefs, and emotions can only be discovered indirectly through people’s claims or through what appears to be involuntary expressive behaviour.

Goffman also refers to various ‘discrepant’ roles with particular characteristics. Those elaborated on here are the mediator and the service specialist. The mediator role goes in between and may function as someone who enables two ‘hostile’ teams to reach a mutually beneficial agreement. The mediator does this by learning the secrets of each side and by giving each side the impression that he will keep their secrets, but tending to give each side the impression of being more loyal to one than the other. As such, the mediator may function as someone who gives each side a distorted version of the other to establish a closer relationship between the two sides.

Service specialists specialize in constructing, repairing, and maintaining performances. As such, they function as’ scene workers’, allowing actors to perform roles and define situations successfully without dramaturgical difficulties.

Materials and methods

The study has an exploratory case study design that follows the principles of multiple holistic case study design (Yin 2009), in which each case comprises a unit of analysis. The exploratory case study is an empirical inquiry that explores processes and addresses mechanisms of a contemporary phenomenon within its real-life context (Flyvbjerg 2006; Yin 2009). This mode of inquiry applies to our research design as we seek to gain insight into interaction antecedents by exploring how individuals and groups interact, negotiate and position themselves during three different innovation processes and how appearances and reasoning change in interaction with others through experiences and events.

In the analysis, we have used Erving Goffman’s dramaturgical perspective (Goffman 1959) as sensitizing concepts. We view sensitizing concepts as interpretive devices that guide us to see, organize, and understand the data, providing a starting point to build the analysis (Blumer 1954). Sensitizing concepts are valuable in studies set in complex and emerging fields and are particularly applicable to this study as sensitizing concepts draw attention to essential features of social interaction (Bowen 2006).

Case selection and data collection

The three selected cases in this study participated in the DISH project, an EU innovation project on digital skills and innovation readiness. As a part of an upcoming innovation process aiming to implement an eHealth solution, all three cases tested three tools developed through the DISH project. The three tools supported digital skills acquisition, co-creative implementation planning, evaluation, and competence assessment. The choice of cases was pragmatic as the selection of cases in the EU innovation project was limited, resulting in three cases with varying complexity. Case A is a nursing home in a rural municipality in the county of Western Norway attempting to implement a patient warning system and digital supervision. Case B is a home care service in another rural municipality in Western Norway implementing electronic door locks (e-locks) in care recipients’ homes. Case C is a cross-sectoral collaboration between a hospital and a municipal home care service in Southern Denmark, implementing discharge conferences through video consultations. In contrast to case C, cases A and B are more similar and less complex as the innovation process consists of implementing an eHealth solution in one organization involving a few categories of employees. The empirical material in the three cases includes document analysis, participant observations, semi-structured individual interviews and focus groups (see Table 1 for an overview of the three cases). This data triangulation prompted interesting insights into interaction antecedents, which eventually led us to the dramaturgical approach by Erving Goffman. For instance, did quotes from the interviews not always correspond with what was observed during the participant observations. Some quotes during interviews seemed to be an idealized version of what was actually going on during the innovation process. In addition, did the interviewees often tell different stories about the same innovation process in the different interviews. Also, the team members were often unaware of each other’s challenging issues. Many interesting insights were found between the ‘lines’ and in the the unsaid.

Table 1. Case descriptions.

Case	A	B	C
Country	Norway	Norway	Denmark
Organisation	Nursing home	Home care service	Home care service and hospital
Employees	60	50	8100*
Care recipients	41	150	225 000
eHealth solution	Patient warning system and digital supervision	Electronic door locks	Video consultations
The objective of implementing the eHealth solution	Increased efficiency and patient security	Increased efficiency and patient security	Increased efficiency, cross-sectoral collaboration, and coherent care
No. of interviews	5	4	3
No. of interviewees	8	8	12
Role of interviewees	Healthcare professionals (2) Unit managers (3) Project manager Project coordinator Nursing home manager	Healthcare professionals (3) Janitor Department manager of technical operations Department Manager of Health Project manager Home care service manager	Municipal leaders (3) Municipal middle managers (3) Municipal case worker Municipal eHealth consultant Municipal IT specialist Hospital unit manager Hospital nurses (2)
Number (hours) of participant observations	1 (2)	–	5 (4–7)

*8100: 2600 employees at the hospital and 5500 employees in the municipality.

The data was collected between 2020–2022, during and after the testing phase of the three tools. The data was collected in person or online (using Zoom, Microsoft Teams, or Cisco Webex Meetings) by SE, CØ, or AMD. In cases A and B, a project manager from each case was our contact person. With help from the project managers, respondents involved in planning and training were invited to participate. To recruit the respondents in case C, we contacted those responsible for the training at the hospitals, and one of the trainers became our main point of contact. All respondents received informed consent, which included an overview of the study project.

Analyses

NVivo 12 software was used to analyse verbatim transcriptions of audio-recorded interviews. The content analyses in this study have a directed approach (Hsieh and Shannon 2005), as the dramaturgical perspective (Goffman 1959) guided us in identifying key concepts as initial coding categories. As this study aims to explore interaction antecedents, we sought to identify and categorize all instances of interaction by reading the transcripts and highlighting all text that, on first impression, appeared to represent interaction-related drivers or barriers. Next, we coded all highlighted passages using predetermined codes guided by the theatrical terms (Goffman 1959). Text that could not be categorized with the initial coding scheme was given a new code. The coded material for each case was read separately. Next, the coded material across the three cases was compared and contrasted to highlight similarities and differences (Falzon 2009).

Results

We have organized the presentation of our findings into three sections. These are based on an analytical distinction between three different innovation processes, metaphorically labelled according to Goffman’s dramaturgical approach. First is the successful improvisational theatre, next is the mediocre theatre, and last is the failed theatre. In the following section, the analysis is presented.

Case A: the successful improvisational theatre

Case A is a nursing home in a rural municipality in Western Norway, offering 24-hour health and care services to care recipients staying in the nursing home for a shorter or longer period. The nursing home has 41 residents and 60 employees, including one leader and 4 unit managers. Since 2017, the municipality has worked on replacing old and outdated equipment with new eHealth solutions, e.g. electronic medicine dispensers and safety alarms. At the time of the data collection, the nursing home implemented a new patient monitoring system, including digital supervision. The objectives were to provide more efficient services and to provide patient security. The project manager initiated the planning of the implementation and involved IT and technical operations, the fire department, the estate department, the eHealth solution provider, and a union representative.

This case is labelled as a successful improvisational theatre, as it, according to all interviewees, successfully implemented and sustained a patient warning system and digital supervision through an interactive relationship between a team of ‘performers’, ‘audience’, and ‘scene workers’. Throughout the process, the performers received solicited suggestions from the audience as a source of inspiration. As such, the performers, the audience, and the scene workers worked together responsively to define the parameters and actions of the scene in a co-creation process.

The process sounds harmonious. However, according to the project manager, the process was not without bumps in the road. There were some initial organizational barriers, according to the project manager:

I was well prepared when it came to the patient warning system. I involved all stakeholders I believed should be involved: technical, fire, the eHealth solution supplier, and the union representative. Everything was in place, including ICT. And then, I sat there and kind of owned the whole project by myself. Even though they’ve been involved, participated in the meetings, and received information, they still don’t take the responsibility I expected they would.

The project assistant agreed with the project manager:

[the ICT department] pulled out quickly because they did not want to be responsible for anything. We have struggled to get the ICT department on board again. We’ve been the ICT department. They did not feel they had control, even though we wanted to invite them in. But they don’t want to be responsible for anything.

Since the other departments did not take responsibility and were not involved, the project management took extra responsibility: ‘Now I am the ICT department. I go into the computer cabinet myself and connect things’. The project management took a discrepant role, labelled as a ‘service specialist’, essential in constructing, repairing, and maintaining the actors’ performance before others (Goffman 1959). The project management, therefore, served as service specialists for the nursing home. Hence, the lack of responsibility from the other departments, initially seen as an organizational barrier, became a driver and an advantage for the staff that could perform without dramaturgical difficulties:

I think that they have visited us umpteen times. They come immediately if something happens. They make a big difference. I think they are amazing, and asking them for help is easy. […] It would be challenging without them. They make our everyday work easier. I think we use less time on frustrations. Technology is not my field. Health is my field. The technology support eases my day.

Service specialists are often invited backstage by the performers and can mix frontstage with backstage (Goffman 1959). Both leaders and staff appreciated the service specialists’ proximity and presence. For example, through their participation in evaluation meetings and training sessions with the eHealth provider. During implementation, the project management moved into the nursing home for a week and ‘was available until they were up and running with the new system’. The project manager emphasized the importance of being available and involving the staff during the innovation process:

We’ve focused on following up on the staff and letting them know we can help. They need to understand the system, and when things do not work, it is possible to adjust it […]. There is room for improvement, it’s a system in change, and there are updates. We need to live with it, and we need to adjust it until it becomes our system. They can contact us.

The emphasis on being involved is also noticed among the staff:

I do get to influence […]. We have an excellent work culture and a nice group of leaders and unit managers. So, we are informed and have staff meetings in the units […]. We’re well off. There is a good work environment. We sort things out. Collaborating and communicating with the nursing home manager and unit managers is easy.

The project assistant agreed: ‘Everyone has something to say and can report needs. Everyone is involved’. The good work environment, work culture, collaboration, and communication were also vivid during the observation of the training session. The atmosphere during the training session was informal, and there was room for small talk, ‘stupid questions’, and comments, such as: ‘It’s unpleasant when dead people press the alarm because the superusers forgot to remove the user from the system’. The involving and collaborating process illustrates how the interaction is characterized by backstage behaviour (Goffman 1959). This backstage behaviour may also be facilitated by ‘mediators’, another discrepant role, facilitating interaction between two ‘teams’, for example, between health care professionals ‘on the floor’ and the management. In the following, we illustrate how the nursing home manager and the unit managers served as ‘mediators’ by having ‘one foot in each team’. The project manager stressed how the nursing home manager played an essential role during the innovation process:

They have a good manager. I do not think it’s been run this well ever. She’s on […] She is supportive. When the system crashed the other night, she came and was there for them […] She’s very involved. She joins the training. She logs into the system.

The nursing home manager elaborated on involvement:

I am primarily in administration. But I like to be curious about what’s going on. I thought it would be exciting to do this [training] and figure out how the system works […]. I am not often on the floor, but sometimes I am.

The nursing home manager was also focused on the unit managers having one foot on the floor and one foot in the management. Unit managers, assistant unit managers, and other staff with more prominent positions as superusers were a measure to break down barriers. The unit managers recognized this focus: ‘As a unit manager, you are both places as a buffer and a part of the morning routines […]. We work on the floor, really, and then higher up when [the nursing home manager] is not around’. An assistant unit manager elaborated on that: ‘I think it was excellent that us assistant unit managers were allowed to join. Because one of us works each weekend, so if something happens, we can try to help’. The project assistant also supported using unit managers as superusers: ‘I believe it’s positive that the unit managers are so close to the staff. Because they’re on the floor several days a week, I think that’s beneficial. They’ve been drivers. They’re close to the nursing home manager’.

Despite extensive involvement, superusers, and positivity during implementation, there was some resistance, mainly related to insecurity among staff: ‘Maybe there was some resistance right at the beginning when we implemented the patient warning system. It was new, and we didn’t really know what it was’. Another staff member elaborated on this: ‘It’s about feeling insecure and many theories about “uh oh” … We have smartphones with a chip. They can trace us and see where we are’. The project manager confirmed the resistance:

The staff initially thought it was pretty invasive, not for the patient but for themselves. They thought I sat in my office in another building, monitoring them. One of them got the impression and told everyone that I had a microphone down there and watched whether they did their job. I had to go up to them and tell them I was uninterested in that. I wanted to say, ‘Can’t you just behave when you’re in the patients’ rooms?’ What’s the problem here?

This episode is a good example of the dramaturgical difficulties that may occur when the staff cannot control the impression of themselves to others. Feeling insecure while handling technology may challenge the staff’s view and whether they actually possess the attributes their character appears to possess. However, the project assistant said this ‘turned around when the staff realised the benefits of digital supervision, what it was and how they could use it’. It turned out that there were no microphones at the nursing home, the image on the digital supervision was quite unclear, and the project manager did not monitor the staff continuously. As such, the backstage area remained a safe space where the staff could break out of character and buffer themselves from the deterministic demands surrounding them. Such resistance may also be a barrier if not acted upon. However, as the project management was present, they could improvise and act on the resistance and, as such, move the innovation process forward.

Case B: the mediocre theatre

Case B is a home nursing service in a rural municipality in the county of Western Norway, offering 24-hour services related to assistance in daily living and home health services. Most service users consist of frail older people in need of assistance to be able to live at home. The home nursing service has about 150 care recipients and 50 employees, including the home care service manager. Since 2015, the municipality has focused on implementing eHealth solutions in the healthcare sector to deliver sustainable healthcare services due to demographic challenges. One of these healthcare services involved implementing electronic door locks (e-locks) in care recipients’ homes to provide faster and safer help. The municipal manager of health, the department manager of health, and the project coordinator initiated the implementation planning. During the planning, they also involved the department manager of technical operations as there were areas where the health ‘department’ fell short. Stakeholders such as the eHealth solution provider, healthcare staff, and care recipients were not actively involved in planning the implementation process.

This innovation process is labelled as a mediocre theatre. Mediocre because, according to the staff, the home care service implemented the e-locks as in they were installed but only partially implemented and sustained. The staff used the e-locks half the time and always had the regular keys at hand as they were concerned about whether the e-locks would not work. The implementation did not reach the objective of providing more efficient service or providing patients with security. This innovation process was characterized by frontstage behaviour and impression management, which might be related to the lack of service specialists and mediators to merge frontstage with backstage (Goffman 1959).

Before implementing e-locks, staff would drive back and forth to the home nursing service office to pick up keys or use the old and rusty key boxes outside care recipients’ homes. Even though the benefits of installing e-locks were quite clear, according to the project management, the municipality faced several organizational barriers during the first two phases of the innovation process, such as a lack of resources, involvement, and collaboration across departments. The implementation planning lasted approximately one day and resulted in an action plan and a communication plan. About the communication plan, the project manager said:

We made a plan on who to engage and what to do with the resistant ones. We knew that we had to engage those we knew were a little negative and further ‘[information on] why we are implementing e-locks? And what should we communicate to whom? Because we had to communicate one thing to the staff and one thing to the janitors. And maybe something completely different to the care recipients.

Goffman would describe this as segregating the audiences. Hence, the individuals who witness the project managers in one of their roles would not be the individuals who witness them in another of their roles. Incapacity to maintain this control of the front stage leaves the performer not knowing what character to show from one performance to the next, making a successful performance difficult.

According to the project management, they expected more resistance during the implementation phase. Still, they did not ‘receive any feedback on any resistance to using the e-locks’ from staff. Further, the project manager said: ‘I do not think we have anyone openly resistant. But some worry, opt-out or avoid situations and say, ‘No, this is not something for me. I’m not going to learn this. Rather than being resistant to using new technology’.

The project management could check whether the staff used the e-locks through the e-lock system log, and they:

Discovered […] that the staff used the e-locks where they are installed. They did not use the keys, which is kind of an answer in itself’, they ‘found out that all the staff, absolutely all, used the e-locks when they were at work'.

As such, the project management did not need an evaluation, as the system log gave them the necessary answers. According to Goffman, evaluation is also a measure of controlling what’s going on backstage. Therefore, not going through with an evaluation is another measure of impression management and a defensive technique to ‘cover mistakes’ (Goffman 1959). A system log can provide numbers but does not say anything about adjustments, resistance, reasoning and negotiations that could come forward in an interactive evaluation. When the staff were asked whether they used the e-locks, they answered that they used them about 50% of the time. They reasoned this by ‘It is really easy just to find the right key and unlock’, and ‘It is faster with the key than that stuff [the e-lock]’. If the ‘truth’ about the limited use of the e-locks saw the light of day, it could disrupt the project management’s desired impression of a successful implementation with minimal resistance and sustained use of the e-locks.

When the staff was asked about being sufficiently informed and involved in the innovation process, they expressed that they were not and found the innovation process slightly forced upon them. Even though the project management was concerned with clarify[ing] if something is not right. Come forward and maybe talk and do something about it, one of the staff expressed: ‘I would have wished we knew about the plans a bit earlier. That we were a bit more involved in our everyday work’. Another one agreed, saying, ‘It is often forced upon us […]. We do not know about any plans’ and further: ‘if we had a little more information, then maybe we would have thought that [an e-lock] could fit there and there’. On the other side, they:

Got to provide feedback. But whether it is considered is another thing. We provide so much feedback [the project management] probably do not know what to say’, and ‘[the project management] are not always responsive. We have to try some more. That is often the answer.

The janitors, however, felt quite involved in the innovation process. The head janitor said, ‘There is a good dialogue in the municipality, and many have been involved in the project early. We received good information, and we were able to comment and influence’. As such, the degree of involvement of the different actors varied. This variation might result from several reasons. First, due to the audience segregation, and second, involving the staff was just a measure to support the idealized impression of a successful innovation process; and third, the lack of mediators and service specialists able to facilitate interaction between the different teams and, as such, merge backstage with frontstage.

The following are some issues related to audience segregation and frontstage behaviour. First, the e-locks needed to change their batteries occasionally, but there was no routine on who was responsible for it. The project management worried that the home care service had to do it, but they discovered that the janitors received a message from the e-lock system and that ‘the janitors just changed the batteries, and there was no discussion’. The project manager said: ‘I believe that it has something to do with the fact that they were involved, and then they took responsibility automatically’. However, the janitors expressed: ‘I want the home care service staff to [change the batteries] when they’re out there anyways. They could have a couple of batteries in their bag’. The home care staff, on the other hand, had no clue. One said, ‘I don’t know the routines for following up on the batteries. Is it technical operations?’. This lack of shared understanding illustrates how the actors perform on different scenes, challenging the knowledge sharing between them.

Second, installing the e-locks was also an issue. The janitors had heard a ‘rosy story’ from neighbouring municipalities with e-lock experience that installing the e-locks would be straightforward. However, the janitors meant that ‘some of the truths were held back’, as they experienced quite a few challenges when installing the e-locks. The project management knew about these challenges, but the home care service staff did not. They uttered that the implementation was ‘a slow process’, and one of the staff said: ‘I do not think it is hard to install. It is probably something else affecting it’. These quotes illustrate how audience segregation and frontstage behaviour challenge information flow between the actors.

Further, the department manager of technical operations demonstrates quite well the need to perform frontstage behaviour by idealizing a performance:

You should turn on your positive side when working with digitalization […]. One can, of course, ask questions about different things, but you shouldn’t nag too much because then it’s easy to be perceived as being pessimistic about the whole project.

According to the department manager, it seems beneficial, despite worries, to show ‘frontstage behaviour’ in interaction with others, as it is essential to him to define the situation and his identity as being optimistic. As such, the information he exchanges aligns with the impression he seeks to give others. Maybe this is why the project management and the healthcare staff were unaware of the issues regarding installing the e-locks or changing the batteries.

Case C: the failed theatre

The third case is a cross-sectoral collaboration between a hospital and a municipal home care service in Southern Denmark. The hospital treats injured patients who need emergency care, outpatient treatment, and examination services. The home care service offers 24-hour service, including assistance in daily living and home somatic- and psychiatric care. In 2018, the local hospital invited the municipality into a project on collaborating through video consultations when discharging complex and vulnerable patients from hospital to municipal care. The objective was to increase cross-sectoral collaboration through technology, provide more efficient discharge conferences, and provide patients with more coherent care. A project manager from the research unit at the hospital initiated the innovation planning process and invited unit managers and IT consultants from the hospital and the municipality to separate meetings concerning the planning of the training, implementation, and evaluation. The planning led to many training sessions where hospital- and municipal staff learned to use video consultations together.

This case is labelled a failed theatre, as according to the staff and the department managers, the video consultations were not implemented as planned or sustained despite many hours of training. Neither did the cross-sectoral collaboration reach any of the objectives. As a project manager led the innovation process from the research unit, the project manager had neither a foot in the hospital nor the municipality. Combined with audience segregation, separate meetings with hospital- and municipal unit managers led to a lack of information flow between the actors. Further, the innovation process lacked service specialists to set the scene, challenging the actors’ performance for the audience.

There were some initial organizational barriers during the innovation process. For instance, the hospital management only allowed the project manager to spend one hour on the initial planning meetings due to a lack of resources. Therefore, the project manager planned parts of the process by herself and handpicked questions and tasks that were realistic to go through within a short timeframe. One of the municipal managers reflected on the planning meeting during the interview: ‘It’s been practical and concrete. Relatively short meetings to get things started. It hasn’t been the big analyses’. And further:

The trainers had already defined the training content. When thinking about it retrospectively, maybe we should have included relevant staff in the planning […] It’s not something we have discussed in the meetings. We are not the right ones to say how the everyday work is for our staff.

Another municipal manager elaborated on the meetings: 'The first meeting concerned pointing out relevant units and employees. The follow-up meetings were status meetings to check whether the video consultations were carried out instead of physical meetings and concerned adjustments to secure future progress'. The planning meetings with the municipality and the hospital units were held separately, which probably challenged the interaction between the two ‘teams’. To make up for this audience segregation, according to a municipal eHealth consultant, they ‘planned the training to be a mix of employees from the hospital and the municipality so that they met physically and got the same training. To break down some barriers’. However, placing people in the same room does not necessarily make people interact as if they were backstage. The following quotes illustrate how the barriers were challenging to overcome. The manager of the home care service elaborated on the training:

The region invited us, and that was it. We met and received training in how [video consultations] are carried out and in what circumstances we can use them. In my team, we practised together with someone from the hospital unit. We agreed that we would continue the practice. We made some arrangements with specific dates and times and sat there… And no one showed up. Of course, something happened. Because it is a busy workday. I don’t think you prioritize it when it’s not something you are used to. That’s what happened. But it was… I have to say, the atmosphere was good.

When analysing this situation, we see that the hospital and municipal staff entered a frontstage region where they agreed on arrangements and collaborated to define a situation with a good atmosphere. However, when returning to everyday work, the staff enter backstage again where there is no audience they need to manage the impression of. The municipal staff blamed the hospital for not participating; one of the managers said: ‘We have often pointed out that we’ve been here before and will participate again, but it requires the hospital also to participate. […] It really requires a cultural change and a high prioritization’. This experience was also apparent during observation of the training sessions, where the municipal staff uttered:

It is hard to make the collaboration between municipalities and hospitals work, and the problem is not the video consultations. The problem is that I do not get invited to the discharge meetings. Just because it’s a technical possibility, it doesn’t mean I will be invited.

According to one of the municipal managers 'the meetings have always taken place at the hospital. [The hospital staff] don’t notice. I do not think [the hospital staff] experience the benefits or that it is timesaving the way we do'. This assertion was confirmed by several of the hospital staff both during observation and in interviews. A nurse in the cardiological unit explained: ‘It’s not because it is saving us time yet. In fact, it’s an extra task, you know. Maybe it’s timesaving in the long run or fewer hospital admissions. But the beds will be filled up with other patients anyway’. If the hospital nurses had been aware of the benefits experienced by the municipal staff, they might have answered differently. However, there was no fruitful exchange of information to influence the process since the interaction between hospital and municipal staff was either absent or characterized by frontstage behaviour. The municipal staff tried to use the trainers to create a communication channel: ‘We have sometimes called the trainer, and she has gone to the unit and said, “come on, you have a video conference now”. But she has not come through’. It seems like the innovation process lacked a ‘mediator’ to promote interaction between the two ‘teams’. The project manager and the trainers were in a unit outside the hospital and the municipality. It may be challenging to facilitate interaction between two sides if you are not present during everyday interaction, where it is possible to get insight into backstage knowledge.

Discussion

Previous research on interaction-related antecedents in public sector innovation processes has identified barriers as a lack of shared understanding, where actors struggle to reach a consensus on common goals and decisions due to their focus on negotiating individual interests. Other identified interaction-related barriers are insufficient support from end-users and staff and ineffective communication and knowledge sharing among collaborating actors (Cinar, Trott, and Simms 2019, 2021). Despite this knowledge, there is a limited understanding of these interaction-related barriers’ specific characteristics and dynamics. Based on microsociology and Goffman’s dramaturgical perspective (Goffman 1959), our study has provided a detailed and nuanced understanding of the dynamics and processes present during social interaction in public sector innovation processes. In line with previous findings (Hadjimanolis 2003; Nilsen et al. 2016), our study has shown that interactional barriers are complex and dynamic and may be regarded as opportunities if acted upon. As such, we agree with other researchers on expanding the conventional view on innovation barriers (S. F. Borins 2014; Torugsa and Arundel 2016). Accordingly, adopting Goffman’s dramaturgical perspective enhances our understanding of how actors’ interactions, negotiations, and positioning unfold in the innovation process. This lens reveals how actors’ performances and reasoning evolve through interactions, shaping the implementation and sustainment of eHealth solutions. The perspective also aids in comprehending the complex nature of innovation processes, shifting the focus from static factors to a dynamic perspective that acknowledges the evolving nature of interactions.

Although all three cases in this study were a part of the same EU project and used the same tools, including a co-creative planning framework and providing extended eHealth training based on an eHealth training programme, the outcomes varied. The outcomes differed between the cases from being successful to being a failure. For a case to be successful, the eHealth solution should be implemented and sustained according to the staff. Case A was the most successful, implementing and sustaining a patient-warning system with digital supervision. Case B was partially successful as the home care service only implemented e-locks, used approximately half the time. The rest of the time, the staff used the regular keys. Case C was the least successful, as the video consultation system was not implemented or sustained. When interpreting the findings in the three cases, it is important to remember that varying complexity plays an important role in the innovation processes. Complex projects in healthcare attempting to implement eHealth solutions interrelate and interact with the context in which they are expected to impact. The context does not consist of just the collaborating actors. The degree of success also depends on contextual factors such as the condition or illness of the patient, the technology, the value proposition, the involved organizations, workflows, hierarchy, the wider system, and regulatory, legal, and policy issues (Cucciniello and Nasi 2017; Eriksen, Dahler, and Øye 2023; Greenhalgh et al. 2020). The more complex each domain is, the more challenging the innovation process is (Greenhalgh et al. 2020). Case C was more complex than cases A and B, as the innovation process involved collaboration between two organizations. Further, video consultation technology is more complex than e-lock technology, resulting in additional barriers (Torugsa and Arundel 2016). One can also discuss whether the terms success and failure are beneficial in defining the outcomes of the innovation process. As the three cases show, the determination of success or failure is highly context-dependent. Some of the success in case A resulted from a project manager taking over the tasks of the ICT department, as they did not take the responsibility they should have, which might not constitute a success. Further, success and failure are not necessarily static but can evolve. An outcome initially perceived as a success may later be re-evaluated as a failure.

Conversely, the varying complexity and outcomes prompted interesting insights into the drivers and barriers of the innovation processes. The most prominent interactional barriers present in the three cases were frontstage performance, audience segregation and impression management, which led collaborating actors to ‘perform on different scenes’. However, the most prominent interactional drivers were ‘human’ and dependent on how and where certain actors were present and how and with whom they interacted. These actors, identified as mediators and service specialists, merged the scenes between collaborating actors and gained insight into backstage knowledge. The mediators and service specialists acted as key facilitators in addressing interactional barriers, enabling open communication and improvisational problem-solving. On the contrary, as seen in case B, impression management, audience segregation, and a lack of mediators hindered innovation. Frontstage behaviour, insufficient support and the absence of mediators led to communication issues and project failure. If the mediators and service specialists were able to act on backstage knowledge, they could transform a potential barrier into a driver and, as such, advance the innovation process. Therefore, recognizing the potential for interactional barriers to facilitate rather than hinder innovation is crucial for advancing the public sector innovation agenda. Further, the more complex the innovation process is, the more important it may be to recognize the role of mediators and service specialists.

Based on the findings in this study, collaboration may be equivalent to acting on the same scene. As seen in cases B and C, the actors did not act on the same scene and challenged the constructive exchange of knowledge, resources, competencies and ideas. In case A, however, mediators and service specialists managed to merge the different scenes, creating an information channel and facilitating information flow between collaborating partners performing on different scenes. Examining both the frontstage performance and the backstage dynamics can give one a more comprehensive understanding of the interactional barriers and drivers in public sector innovation research. For instance, a better understanding of ‘the self-centred tendency’ individuals have to negotiate according to their interests, ignoring common goals, visions and missions (Torfing, Sørensen, and Røiseland 2019; Tuckman 1965). Some of these tendencies might result from lacking communication channels and information flow, which the presence of mediators and service specialists could avoid. This knowledge can potentially enhance co-creative public sector innovation processes that require various actors to resolve a shared problem.

Limitations and further research

This research is not without limitations. Transferability to other fields may be challenging since the findings build on case studies. Yet, the rich descriptions of the cases may enable readers to determine transferability to other fields. The design of the case studies provided us with a static view of the innovation process, limiting the depth of understanding the long-term dynamics. The retrospective interviews compensated for this limitation to a certain degree and provided us with a longer-term perspective on the innovation process. Nevertheless, retrospective interviews may also cause memory-related biases. The interviewees may not accurately remember events or details, or they may recall events selectively, emphasizing certain aspects while downplaying or forgetting others. To compensate for this limitation, we have used data triangulation to enhance the reliability and validity of our findings. Future studies on innovation processes could perform longitudinal studies to provide insights into changes over time, the long-term sustainability of innovations, and the impacts of interaction antecedents.

In addition, the included cases in the study are quite diverse, and utilizing varying cases in research offers strengths and limitations. The choice of cases was pragmatic as the available cases in the EU project were limited. On the positive side, studying diverse cases enhances the generalizability and applicability of findings to different contexts, fostering a more comprehensive understanding of antecedents in innovation processes. However, the diversity in the three cases also poses challenges, including difficulties in drawing comparisons, increased complexity in analysis, and potential methodological inconsistencies. Despite these limitations, leveraging varying cases was a powerful strategy to capture the complexity and diversity of antecedents in innovation processes.

To contribute to a deeper understanding of the complexity and dynamics of innovation processes, future research could investigate the specific roles and strategies employed by mediators and service specialists in merging frontstage with backstage to facilitate knowledge sharing. Research could investigate the characteristics, skills, and behaviours that make these actors effective in bridging communication gaps and overcoming interactional barriers.

Conclusion

Through our analysis, we have found that collaborating actors interact, negotiate and position themselves on different scenes throughout the innovation process. This process is dynamic, improvisational, and dependent on who the actors interact with, and the more complex the innovation process, the more interactional barriers there are. Frontstage behaviour may be an interaction barrier, as the performance involves following social norms and projecting a desired impression. As such, the performance may not be ‘sincere’ and hinder knowledge sharing between collaborating actors, which could otherwise be fruitful for implementing and sustaining eHealth solutions. Further, through impression management, actors negotiate by segregating audiences and performing idealized versions of the “truth”, which also serve as an interaction barrier. However, actors’ performance and reasoning about the eHealth solutions may change when backstage and frontstage somehow are merged. Mediators and service specialists can merge the scenes or create a communication channel that facilitates knowledge sharing between actors not on the same scene, enhancing the implementation and sustainment phase. Mediators and service specialists, therefore, serve as interaction drivers. By merging frontstage with backstage, these discrepant roles can get insight into barriers and act upon them. As such, a barrier may be regarded as an opportunity, as the innovation is adjusted to and becomes more appropriate and beneficial to the context, which drives the innovation process forward. Acknowledging the possibility of interactional barriers to support rather than impede innovation processes is essential for advancing the public sector innovation agenda. Further, viewing interactional-related antecedents as dynamic processes in public sector innovation allows us to appreciate the intricacies of the innovation process, including how actors position themselves and improvise. Hence, it is imperative to consider interactional barriers in conjunction with other contextual factors, such as technology and workflows, to comprehend the success or failure of technology utilization in the public sector.

Ethics approval and consent to participate

Ethical approval was obtained from the Norwegian Centre for Research Data, ref. No. 198584. Informed consent forms were collected from all respondents. Anonymity was secured using fictive names and redrafting the empirical material if the quotes were recognizable.

Acknowledgments

We want to thank the participants who participated in our study and the project managers in the DISH project, Trine Ungermann Fredskild, Henriette Hansen, and Sabine Paasch Olsen, for all their help and support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Norwegian Ministry of Education and Research, Western Norway University of Applied Science, and the Erasmus+ Program of the European Union, Key Action 2 Cooperation for Innovation and the Exchange of Good Practices – Sector Skills Alliances.