Leadership in Evolving Learning Organizations [WLO: 4] [CLOs: 2, 5]

Prior to beginning work on this discussion forum,

Read Chapter 3 from Organizational Behavior and Theory in Healthcare: Leadership Perspectives and Management Applications.
Read the following articles:
How to Be a “Humbitious” Leader (Links to an external site.)
Bringing Value at Top Organizations, Learning Means Living (Links to an external site.)
A Learning Organization in The Service of Knowledge Management Among Nurses: A Case Study (Links to an external site.)
Exploring the Potential of a Multi-Level Approach to Improve Capability for Continuous Organizational Improvement and Learning in a Swedish Healthcare Region (Links to an external site.)

Assess how health care leadership is evolving. Describe the three takeaways found in the required articles for this discussion that you may employ in a learning organization. Support your response with a minimum of two scholarly sources published within the last five years.

Healthcare Admin healthcare

Careers

How to Be a
“Humbitious” Leader

Empirical evidence connects humility and
ambition with high performance.

Humility is making a comeback as one
of the most sought-after professional
virtues organizations look for in candi-
dates. The Wall Street Journal reported
that humility is becoming the “flavor
du jour” among executives in large
companies, as boards are increasingly
looking for humble leaders.

When Krispy Kreme Doughnuts was
looking for a CEO a few years ago, the
main traits it identified as important
for the leadership role were that of
humility and servant leadership.
Similarly, humility is what Google has
been looking for in its new hires.
“Without humility, you are unable to
learn,” Lazlo Bock, senior vice presi-
dent, people operations, Google, told
Harvard Business Review. A recent arti-
cle in the Journal of Business Ethics
agreed that, “the humble leader is pre-
cisely the person who is best qualified
to transform his firm into a profitable,
successful and respected organization.”

What does humble leadership actually
mean? The book Executive Ethics:
Ethical Dilemmas and Challenges for the
C-Suite identifies the five foundations
of humility related to leaders as authen-
ticity, teachability, transparency,
humaneness and interdependency.

Humble, authentic leaders confess to
their followers that they make mistakes

and ask for their patience in correcting
them. They demonstrate their teach-
ability by acknowledging openly
when they are wrong and asking for
forgiveness when mishaps happen.
They are transparent and admit when
they don’t know something, and they
constantly ask their team members
for their ideas. They show their
humaneness by accepting that they
can’t do everything and that they need
all their followers’ talents to achieve
their goals. And finally, they exhibit
interdependency by stressing that
they are there for a larger purpose
and not for themselves. Humility is
not, as some people believe, weak-
ness, low self-esteem, lack of assertive-
ness or absence of ambition. On the
contrary, humble leaders are ambitious,
strong, self-confident and fiercely deter-
mined. They are also highly effective.

The Case for Humility
The introduction of humility into lead-
ership studies can be credited to Jim
Collins and his management book
Good to Great (Harper Collins, 2001).
Collins and his team identified compa-
nies that made the transition from
good to great financial performance
over time and concluded that they were
all headed by “level 5 leaders” who are
humble and fiercely ambitious. Collins
and his team were surprised to discover
the type of leadership required for

turning a good company into a great
one. He notes: “Compared to high-
profile leaders with big personalities,
who make headlines and become celeb-
rities, the good-to-great leaders seem to
have come from Mars.”

These findings provided empirical evi-
dence to what many had suspected for
a long time: humility and ambition, or
“humbition,” are related to high per-
formance. However, what wasn’t clear
from Collins’ analyses is how humility
and positive outcomes are actually
connected, and recent research is start-
ing to clarify that connection.

One way leader humility can affect
performance is through employee
engagement and satisfaction. A study
of a large health services organization
asked employees to rate the humility
of their immediate supervisors. The
employees were also asked to assess
their own job engagement and satis-
faction. The results were published in
2013 in the journal Organization
Science. Participants who viewed their
leaders as more humble were more
likely to report being happy at work
and less likely to voluntarily leave the
organization.

“In contrast to ‘rousing’ employees
through charismatic, energetic and
idealistic leadership approaches […],
our study suggests a ‘quieter’ leader-
ship approach, with listening, being
transparent about limitations, and

Amer Kaissi, PhD

This column is made possible in part

by The Risk Authority Stanford.

Healthcare Executive
NOV/DEC 2017

appreciating follower strengths and con-
tributions as effective ways to engage
employees,” wrote the authors of the
study. In the current labor market,
where organizations are struggling to
attract and retain talent, humility can
be a valuable competitive advantage.

Another way leader humility works is
by creating a culture of shared unpre-
tentiousness that enables the team to
grow and reach its full potential. For
example, research published in 2016
in the Academy of Management Journal
found teams that perceived their lead-
ers as willing to learn, able to admit to
not knowing something and likely to
compliment others on their strengths
had higher collective humility, team
growth and performance. These find-
ings provide empirical evidence to

support the old adage, “leaders should
lead by example.” Similarly, humble lead-
ers in private companies were found to
empower their top and middle managers
to collaborate, share information, make
joint decisions and develop a shared
vision in an Administrative Science
Quarterly study, published in 2014.

The results from a study of healthcare
organizations published in my book
Intangibles: The Unexpected Traits of
High-Performing Healthcare Leaders
suggest that leaders who are approach-
able not only create an environment
where employees feel comfortable, but
also foster improved outcomes in the
organization. My team received sur-
vey responses from

7 employees,
supervisors, directors and executives
working in nine different hospital and

health systems. When asked about
the leadership traits that have had a
negative influence on their career,
52 percent of the respondents chose
arrogance as the top factor, making
it the most common negative leader-
ship trait chosen. Many respondents
indicated that nothing has been more
damaging to their career than having
an arrogant boss. Similarly, when
asked to describe the one leader that
has been the least successful in terms
of improving outcomes in the organi-
zation and getting things done,
44 percent of respondents described
this leader as “self-focused” and 42
percent described the leader as
“arrogant.”

According to these results, not only
do self-focused and arrogant leaders

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Careers
Reprinted with permission. All rights reserved.
Healthcare Executive
NOV/DEC 2017

frustrate their followers and disen-
gage them, they also may drive
their organizations into poor
performance. Here are some day-to-
day techniques and behaviors
healthcare leaders can adopt to
increase their humility:

How to speak: Use “we” instead of
“I”; talk about team accomplish-
ments; greet team members and gen-
uinely listen, understand and reply to
them; and use respectful language.

How to be approachable: Have a
true open door policy but protect
your time when necessary; talk to
employees at all levels; turn off elec-
tronic devices while listening; avoid
cell phone use in the hallways so you
are able to greet others as you pass by;
and—much like clinicians—do
rounds in your units regularly and
purposefully.

How to give credit to others: Give
credit frequently but only when it is
due; acknowledge employees doing
something good; say, “You went
above and beyond,” to employees
who exceed expectations; and provide
prompt, accurate and sincere feed-
back to those looking to improve.

How to handle mistakes and
failures: Be calm and controlled;
identify root causes, not scapegoats;
have tough conversations with low-
performers; admit mistakes, accept
responsibility and move on.

How to respond to success: Brag
about and celebrate team and organi-
zational accomplishments; share
credit; don’t show off with status
symbols; build on successes for future
improvements.

Effective leaders are admired for
their humility and are respected for
their ambition. They are humbitious.
There is an abundance of empirical
evidence that strongly suggests that
these types of leaders achieve signifi-
cantly more success in the long run
for themselves, their teams and their
organizations. s

Amer Kaissi, PhD, is an executive
coach, speaker and professor, the
Department of Health Care
Administration, Trinity University, San
Antonio. He is also the author of the
Health Administration Press book,
Intangibles: The Unexpected Traits of
High-Performing Healthcare Leaders
(amer.kaissi@trinity.edu).

IHL.StanfordToday.com

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Healthcare Executive
NOV/DEC 2017
57

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

58 NOVEMBER/DECEMBER n 2017

HEALTH CARE ORGANIZATIONS

BRINGING VALUE

AT TOP ORGANIZATIONS,
LEARNING MEANS LIVING
n Eugene Fibuch, MD, CPE, CHCQM, FACPE, FABQAURP, and Jennifer J. Robertson, MD, MSEd, FAAEM

In this article …
In a “learning organization,” knowledge is power. Acquiring information and processing it into useful business insight is
essential in every industry, including health care. Physician leaders have an important role to play.

THE CONCEPT OF ORGANIZATIONAL LEARNING
includes both acquisition and dissemination of knowledge that
an organization can use to shape its future. To efficiently man-
age the information, learning organizations use knowledge
management systems to facilitate sharing and integration.1,2

Using these systems, learning organizations have the ability
to think for themselves, communicate effectively internally,
and use the knowledge they acquire to create and innovate.

It is important to know the difference between “organiza-
tional learning” and a “learning organization.”3

Any institution may participate in ongoing organizational
learning, yet only a few can be called learning organizations,
especially in health care. That’s because there are environ-
mental, organizational and ecosystem constraints on every
health care organization that limit their planning, financing
and operational functions.4 Accordingly, the scope and prac-
tice of a health care organization as a learning organization
should be viewed in that framework.

Successful organizations are those that continually evolve,
using specific tools and strategies to adapt to the changing
marketplace. The best ones take a learning organization ap-
proach. While organizations can offer learning activities, they
aren’t learning organizations until they undergo key process
changes. That includes a transformation in which all primary
stakeholders are involved — senior management, the board
of directors, the medical staff and, of course, the workforce.4

Specific conditions within an organization are essential to
facilitate learning, including the capabilities for continuous im-
provement, a willingness to practice the newly acquired skills,
taking the necessary risks to learn, providing feedback to the
participants, and fostering a climate of rewarding all learning
participants.4 Often, that means major cultural change must
occur within every aspect of the organization and its related
processes.

In addition to the conditions noted above, six additional
critical elements5 help define a learning organization:

THE CONCEPT
The idea of “learning organizations” took root after
the publication of organizational expert Peter M.
Senge’s seminal book, The Fifth Discipline (Currency,
1990). It focuses on group problem-solving through
“systems thinking” — understanding how a system
works by examining the relationships among the unique
components.

With that understanding, an organization’s employees
can create, acquire and transfer knowledge that allows the
organization to adapt to unpredictable market conditions
more quickly than competitors.

American Association for Physician Leadership® n Physician Leadership Journal 59

Organizations that are able to acquire knowledge faster than
their competitors, and process it into useful insights for business,
have a distinct advantage in the marketplace. This isn’t a new
concept, but it has taken on contemporary importance in today’s
ever-changing business environment.

60 NOVEMBER/DECEMBER n 2017

n A process of continuous knowledge acquisition by the
workforce and the integration of this knowledge into
routine institutional processes.

n Effective knowledge generation and sharing among
participants.

n Critical systems thinking.

n A culture of learning.

n A group spirit of flexibility and experimentation.

n An organizational culture that values its workforce.

These additional critical elements characterize and define
the organization’s knowledge management system. An effec-
tive system creates the ideal framework for an organization’s
workforce to learn and compete.

FIVE ENABLING DRIVERS

In today’s competitive business environment, an organization’s
only sustainable advantage is its ability to acquire knowledge
at a faster rate than its competitors.2 Understanding this is
critical in a modern, ever-changing health care environment.

In addition to the concept of rapid knowledge develop-
ment, there are five enabling drivers that, if mastered, will pro-
pel any health care organization to higher levels of knowledge
acquisition. These drivers began appearing approximately 20
years ago but only now are starting to converge into an or-
ganizational learning model. These drivers include:

n Systems thinking: Seeing the big picture and how
work processes are linked.

n Personal mastery: Making individual commitment to
lifelong learning.

n Mental models: Managing preconceived ideas that
could hinder new insights and ideas.

n Shared visions: Building visions that will survive good
times and bad times.

n Team learning: Realizing organizations cannot learn
and improve if team members cannot learn and improve.

One could argue that these drivers can be organizationally
grouped under one common strategic initiative: the ability to
innovate faster than your competitors.

Employees must become skilled at acquiring, mastering,
and transferring and/or teaching new knowledge. Senior lead-
ers must be able to allow their organization to remain flex-
ible, take risks and use newly acquired information within the
framework of the organization’s strategic plan.

Despite a significant amount of information advising lead-
ers how to put a learning organization into operation, there
has been significant difficulty in doing so.6 Senior leaders
have had problems measuring organizational progress, using
important tools of a learning organization successfully, and
managing knowledge for innovation.6

To help direct physician leaders, three primary operational
pillars are key starting points for organizational learning and
adaptability.6 They are:

n Developing a supportive learning environment.

n Building strong learning processes into the culture and
work systems of the organization.

n Developing leadership behaviors that reinforce organi-
zational learning and knowledge acquisition.

THE ROLE OF PHYSICIAN LEADERS

To help develop a supportive learning environment, physician
leaders should consider directing attention to creating psy-
chological safety for their employees.6 The idea of removing
psychological risk from the workplace first was proposed in
the 1950s by Edward Deming in his famous “14 Points for
Total Quality Management.“ Workers must feel safe, rather
than fearful of their superiors, so that they can work effectively
with their leadership team, rather than withdrawing out of
fear of retribution.7

Physician leaders also should be open to differences of
opinion and opposing ideas. This attitude energizes individuals
and tends to spark creativity and innovation. Third, employees
should be encouraged to explore new ideas, even if these
new ideas entail some risk. Finally, physician leaders should
factor in some time during the day for problem-solving and
thoughtful reflection among their employees.

Another major task for physician leaders in helping to de-
velop a learning organization is to create the subsystems of the
learning processes and practices.6 These include the processes
of generation, collection, interpretation and dissemination of
information.

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American Association for Physician Leadership® n Physician Leadership Journal 61

Information in any organization resides not only in the
formal written arena of protocols and white papers, but also in
the minds of the workforce. For physician leaders, the ability to
tap into this workforce knowledge for organizational innova-
tion is important. Many successful companies are using their
employees to advance innovation and learning through team
interaction, knowledge sharing across silos, and shared infor-
mation data banks. Finally, senior leaders must reinforce the
learning environment, which entails human behavior. When
the environment is safe and leaders are supportive, employees
will be willing to entertain alternative ideas without fear of
losing their jobs.

CREATING THE STRUCTURE

Learning organizations neither can be developed nor sustained
without understanding the underlying structures that allow
organizations to constantly acquire and maintain new knowl-
edge.8 Think of these as the foundation, pillars and roof that
compose a physical building.

n Foundation: management science, computer science,
organizational development and cognitive psychology.

n Pillars: the organization, its people, knowledge and
acquired technology.

n Roof: the environment, the economy, society, politics
and evolving technology.6

For physician leaders, each of these components has im-
portant ramifications for guiding and directing not only the
organization, but also in helping facilitate the ongoing devel-
opment of the medical staff.

The list of substructures might sound fairly abstract, and it
might be unclear how to ensure an organization has a realistic,
easy-to-understand and actionable definition of a learning
organization that is also acceptable to all levels of the work-
force. Many suitable definitions have been proposed over the
years, but here’s one of the best: “A learning organization is
an organization skilled at creating, acquiring and transfer-
ring knowledge, and modifying its behavior to reflect new
knowledge and insights.”6

What should be recognized is that learning begins with
newly acquired ideas. New ideas sometimes are created in-
ternally, but they may also be acquired from the outside. It
is not simply the act of generating new ideas but rather the
act of generating and incorporating these new ideas into the
fabric of the organization.

How many team events generate lots of ideas that are
never actually implemented? Learning organizations find ways
to translate ideas into action. They know how to positively
change the behavior of the workforce. Physician leaders who
wish to ensure their organizations are learning organizations
should develop an understanding of organizational dynamics
and personal interplay among key constituencies.

FIVE ACTION PLANS

Physician leaders should focus on five specific action plans
when thinking about how to develop their organization into
a learning organization.6

n The first is related to problem-solving. Continuous-
improvement organizations use specific tools, such as
Deming’s Plan-Do-Check-Act Cycle, to ensure conclu-
sions being reached by work teams are scientifically
valid. In addition, using statistical methods ensures
bias-free decision-making. This analytical approach
creates workforce discipline and helps remove non-
fact-based decisions. Systematically embedding these
tools throughout an organization is critical to get every
functional aspect of an organization aligned.

n The second is experimentation. For health care organi-
zations, this often is difficult when they’re focused on
protocols, pathways and policies. Ongoing experimen-
tation requires risk-taking, employee time, educational
programs, resource allocation, and a defined process
that allows ongoing experimentation.

n The third is to learn from the past. Human nature tends
to extoll success while ignoring failure. But learning
from failure is powerful — and perhaps the ultimate
teacher. Most physicians hate failure and rarely admit
to it. Yet they have used trial and error to improve

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62 NOVEMBER/DECEMBER n 2017

their practices for centuries. Using information from
others is an important concept, sometimes known as
“benchmarking.”9 We can learn from colleagues, other
organizations, our own actions and from customers.
Organizations that do learn and can incorporate it into
cohesive processes to retain learning and knowledge
will be more competitive.

n The fourth is to learn how to transfer knowledge.
Learning shouldn’t be one person learning a new
technique. It must be a widespread effort so it can be
effective organizationally. For example, many medical
staffs employ “grand rounds” in which all members
participate and learn from a presented case study.
Many organizations also use site visits, training pro-
grams and cross-training to further the acquisition and
sharing of knowledge.

n The fifth is to develop yourself as a teacher, a designer
and coach. There is no easy process available for that.
Learning organizations are not built overnight, but
rather are cultivated over time. Same for individuals. Se-
nior leaders should ensure appropriate commitments,
management and processes are established to allow
learning to flourish — not only for physician leaders,
but also for medical staffs.

Consider starting with fostering an environment that’s
conducive to learning.6 Physician leaders should build in time
for reflection, analysis and strategic planning. This should in-
volve all members of the workforce, who should be trained
in brainstorming techniques and problem-solving. Problem-
solving should be done in the context of team activity across
the organization. Physician leaders should ensure that there
are adequate resources, both in time and money, to support
team activities of their organizations, and also should work to
eliminate any boundaries or silos in their organizations. Reduc-
ing boundaries allows an organization to develop powerful
and stimulating learning activities. Creating an environment
of openness also allows for effective communication, sharing
of ideas and risk-taking.

Eugene Fibuch, MD, CPE, CHCQM, FACPE,
FABQAURP, is professor emeritus at the
School of Medicine and co-director of the
physician leadership program at the Henry
W. Bloch School of Management at the
University of Missouri in Kansas City.

Jennifer J. Robertson, MD, MSEd, FAAEM,
is an assistant professor in the emergency
medicine department at Emory University in
Atlanta, Georgia.

REFERENCES

1. Alavi M, Leidner DE. Knowledge management systems: Issues, challenges,
and benefits. Communication of the Association for Information Systems.
1(7):1-37, 1999.

2. Senge PM. The Fifth Discipline: The Art and Practice of the Learning
Organization New Yor, NY: Currency and Doubleday Publishers. 1990.

3. Finger M, Brand SB., The Concept of the Learning Organization Applied to
the Transformation of the Public Sector. In Organizational Learning and the
Learning Organization, Easterby-Smith M, Araujo L, Burgoyne J, Ed. London:
Sage, 1999.

4. DeBurca S. The learning health care organization. International Journal for
Quality in Health Care. 12(6):457-8, December 2000.

5. Liebowitz J. Building Organizational Intelligence: A Knowledge Management
Primer. New York, London: CRC Press, 1999.

6. Garvin DV, Edmondson AC, Gino F. Is Yours a Learning Organization?
Harvard Businsess Review, March 2008.

7. Deming WE. Out of the Crisis. Cambridge, MA: . Massachusetts Institute of
Technology. Center for Advanced Engineering Study, 1986, p. 510.

8. Serrat O. Building a Learning Organization. Knowledge Solutions. Asian
Development Bank. May 2009.

9. Cox JW, Mann L, Samson D. Benchmarking as a mixed metaphor:
Disentangling assumptions of competition and collaboration. Journal of
Management Studies. 34(2):285-314, March 1997

Do you have a “learning organization”? How has it helped your

organization in these uncertain times for health care? What are

some of the best practices your organization has developed?

Tell us — and your fellow physician leaders — what’s working.

The Physician Leadership Journal welcomes unique perspectives

and opinions from around the world. Send your thoughts to

journal@physicianleaders.org to be considered for publication

in an upcoming issue.

YOUR
TURN

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Aims–amp–Scope-Editorial-Bo_2015_International-Journal-of-Information-Mana

International Journal of

Information Management
The International Journal of Information Management (IJIM) is an international, peer-reviewed journal which aims to bring its readers the very best analysis and
discussion in the developing fi eld of information management.
The journal:
• keeps the reader briefed with major papers, reports and reviews
• is topical: Viewpoint articles and other regular features including Research Notes, Case Studies and a Reviews section help keep the reader up to date with current

issues.
• focusses on high quality papers that address contemporary issues for all those involved in information management and which make a contribution to advancing

information management theory and practice.
Information is critical for the survival and growth of organisations and people. The challenge for Information management is now less about managing activities that
collect, store and disseminate information. Rather, there is greater focus on managing activities that make changes in patterns of behaviour of customers, people, and
organizations, and information that leads to changes in the way people use information to engage in knowledge focussed activities.
Information management covers a wide fi eld and we encourage submissions from diverse areas of practice and settings including business, health, education and
govern ment. Topics covered include: Aspects of information management in learning organisations, health care (patients as well health workers and managers),
business intelligence, security in organizations, social interactions and community development, knowledge management, information design and delivery, information for
health care, Information for knowledge creation, legal and regulatory issues, IS-enabled innovations in information, content and knowledge management, philosophical
and methodological approaches to information management research, new and emerging agendas for information research and refl ective accounts of professional practice.

EDITOR

Dr Philip Hills
Centre for Research into Human Communication
and Learning, The Old School House,
Little Fransham, Dereham
Norfolk NR19 2JP
Email: philipjhills@aol.com

REGIONAL EDITOR:
NORTH AMERICA
Dr Paul Solomon
Associate Professor
School of Library and Information Science
University of South Carolina
1501 Greene Street
Columbia, SC 29208
803-777-5512
Email: paulsolomon@sc.edu

REGIONAL EDITOR:
ASIA AND PACIFIC
Dr Thompson Teo
Department of Decision Sciences
NUS School of Business
Mochtar Riady Building
BIZ 1 #8-75

15 Kent Ridge Drive
Singapore, 119245
Email: bizteosh@nus.edu.sg

ASSISTANT EDITOR
Robert Wiggins
The Cura Consortium Ltd, 1,
Theatre Street,
Chichester. West Sussex. PO19 1SR
Email: rewiggins@gmail.com

REVIEWS EDITOR
Dr Stuart Fitz-Gerald
Principal Lecturer and
Course Director MSc BIT,
Kingston Business School,
Kingston Hill,
Kingston upon Thames,
Surrey, KT2 7LB, UK
Email: fi tzgerald@kingston.ac.uk

CASE STUDIES EDITOR
Professor Raymond A. Hackney
Chair in Business Systems
Brunel University
Business School, Uxbridge
Middlesex UB8 3PH, UK
Email: ray.hackney@brunel.ac.uk

RESEARCH NOTES EDITOR
Professor David Ellis
Department of Information Studies
Aberystwyth University
Aberystwyth
Ceredigion
SY23 3AS
Email: dpe@aber.ac.uk

INTERNATIONAL EDITORIAL BOARD

Professor Sherry Y. Chen
Graduate Institute of Network Learning Technology
National Central University, Taiwan, ROC
Email: sherry@cl.ncu.edu.tw

Dr Chun Wei Choo
Associate Professor
Faculty of Information Studies
University of Toronto
140 St. George St, Toronto, Ontario
Canada M5S 3G6
Email: choo@fi s.utoronto.ca

Professor Blaise Cronin
School of Library and Information Science
Indiana University, Bloomington,
IN 47405, USA
Email: bcronin@indiana.edu

Professor Paul Beynon-Davies
Cardiff Business School
Cardiff University
Aberconway Building, Colum Drive
Cardiff, CF10 3EU
Email: beynon-daviesp@cardiff.ac.uk

Dr Brian Detlor
DeGroote School of Business, McMaster University
DSB-419, 1280 Main St. W., Hamilton
Ontario, Canada, L8S 4M4
Email: detlorb@mcmaster.ca

Dr Kevin Grant
School of Business, Management & Economics,
University of Sussex, Brighton. Sussex
Email:k.grant@sussex.ac.uk

Professor Josef Herget
Head of Center for Knowledge and Information
Management Danube University Krems / Donau-
Universität Krems, Dr.-Karl-Dorrek-Str.30, A-3500
Krems, Austria, Tel: + 43-2732-893-2332 Fax:
+ 43-2732-893-4335 www.donau-uni.ac.at/wimjosef.
herget@donau-uni.ac.at

Professor Tommi Laukkanen
University of Eastern Finland
Business School
Joensuu, Finland
tommi.laukkanen@uef.fi

Professor Feng Li
Chaitr of Information Management
Cass Business School
City University
106, Bunhill Row
London EC1Y 8TZ
Email: FengLi.1@city.ac.uk

Professor Massimo Magni
Department of Management & Technology,
Bocconi University,
Milano 20136.
Italy
Email: massimo.magni@unibocconi.it

Dr Linda D. Peters
Associate Professor in Marketing
Nottingham University Business School
Jubilee Campus, Woolaton Road
Nottingham, NG8 1BB, UK
Email: Linda.Peters@nottingham.ac.uk

Professor Yannis Pollalis
Business Strategy and Policy
University of Piraeus
80, Karaoli & Dimitriou Street
GR-185 34 Piraeus, Greece
Email: yannis@unipi.gr

Dr Mark Stansfi eld
School of Computing
University of the West of Scotland
High Street,
Paisley, PA1 2BE
Scotland, UK
Email: Mark.Stansfi eld@uws.ac.uk

Colin Theakston
Durham Business School,
School of Economics,
Finance & Business,
Durham University,
Mill Hill Lane,
Durham DH1 3LB, UK
Email: colin.theakston@durham.ac.uk

Professor Adam Vrechopoulos
Department of Management Science and Technology,
Athens University of Economics and Business,
76 Patission Street, Athens 104 34,
GREECE
e-mail: avrehop@aueb.gr

Professor David Wainwright
Head of the Information Management Innovation
(IMI) Research Group
Professor in Information Systems
School of Computing, Engineering and Information
Sciences
Northumbria University
Pandon building
Camden Street
Newcastle upon Tyne
NE2 1XE UK
Email: david.wainwright@northumbria.ac.uk

Martin White
Managing Director,
Intranet Focus Ltd.
12 Allcard Close, Horsham
West Sussex, RH12 5AJ
Email: Martin.White@intranetfocus.com

Professor Susan P. Williams
Institute for Information Systems Research
University of Koblenz-Landau
Koblenz 56070
Germany
Email: susan.williams@uni-koblenz.de

How-are-citizens–public-service-choices-s_2015_International-Journal-of-Inf

International Journal of Information Management 35 (2015) 527–537

Contents lists available at ScienceDirect

International Journal of Information Management

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i n f o m g t

How are citizens’ public service choices supported in quasi-markets?

Agneta Ranerup a,∗, Lars Norén b,1

a Department of Applied Information Technology, University of Gothenburg SE-412 96 Göteborg, Sweden
b Department of Business Administration, University of Gothenburg, PO Box 610, SE-412 96 Göteborg, Sweden

a r t i c l e i n f o

Article history:
Received 30 March 2015
Received in revised form 7 May 2015
Accepted 22 May 2015
Available online 2 June 2015

Keywords:
Electronic government
Quasi-markets
Decision support
Sociomateriality
Citizen

a b s t r a c t

Many countries have introduced quasi-market reforms that enable citizens’ choice in education, health-
care, and other public services. The research question in this paper is the following: How can Web-based
decision support help citizens to make calculated public service choices in quasi-markets? In Section
3, the paper focuses on how decision support design helps citizens make such choices as they isolate,
examine, and rank alternatives. A case study, set in Sweden, explores 14 cases of decision support in
education, healthcare, elder care, and the public pension system. Decision support is most evident in the
area of education, but decision support is found in the other areas as well. In most cases, the support
consists of information on the right of choice and instructions on how to search among alternatives.
Many areas permit direct comparisons, but some areas only permit more indirect comparisons. All 14
cases explain how to make a choice, but only a few cases offer a ranking device. The decision support
for choice is inconsistent with the theoretical model of calculated choice in all aspects despite the trend
toward greater consistency with the model. Our results call for a critical discussion of technology design
that aids citizens as consumers or customers in their relationship with public services.

© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

In many countries, new institutional arrangements, in the form
of market reforms, have been introduced that affect the admin-
istration and deliverance of public services (Le Grand, 2007). For
more than two decades, different types of market reforms have
been important features in education systems in many OECD
countries (Grubb, 2002). Such reforms are also found in healthcare
(Chauvette, 2003) and in other public service areas.

These institutional arrangements, using supply/demand mech-
anisms, often strengthen citizens’ ability to make choices about the
public services that affect them. Some mechanisms allow citizens to
make their choice of services directly while others permit citizens
to make their choices more indirectly (e.g., through a mediat-
ing, contracting agency). Although the sellers, or service providers,
in these markets may not necessarily strive to maximize their
profits, they are very aware they exist in an environment where
other sellers/providers compete for the same citizens–buyers. The
citizen–buyers do not use private capital when they make their
public service choices. Instead, they have vouchers that allow them

∗ Corresponding author. Tel.: +46 31 7862766.
E-mail addresses: agneta.ranerup@ait.gu.se (A. Ranerup),

lars.noren@handels.gu.se (L. Norén).
1 Tel.: +46 31 7861540.

to “shop around” for public services. These arrangements are often
described as quasi-markets (Le Grand, 2007).

Clearly, the central figure in such arrangements is the citizen. Yet
there is little research on how to support citizens when they make
choices in quasi-markets (Greener, 2007; The Swedish Agency for
Public Management, 2007; Winblad & Blomqvist, 2013). In the
limited research available, the focus is the information needs of citi-
zens as they choose schools or doctors, and the design of Web-based
support for such choices (Allen & Burgess, 2011; Leckie & Goldstein,
2011; Ranganathan, Hibbard, Rodday, & de Brantes, 2009). It is
also important to note that the design of such technological, often
Web-based, decision support for citizens influences their relation-
ship with the state (Chadwick & May, 2003; Gauld, Goldfinch, &
Horsburgh, 2010; Lips, 2007). This relationship can be discussed in
terms of citizens, patients, service users as well as customers and
consumers.

The focus in this paper is the sociomaterial constellation con-
sisting of technology (“web-based decision support”) and people
(“citizens with a right to choose”) where the possibility of mak-
ing calculated choices in quasi-markets is present. The research
question is the following: how can Web-based decision support
help citizens to make calculated public service choices in quasi-
markets? In Section 3, we focus on the design of technological
decision support, especially as it can help citizens make calculated
choices (cf. Callon & Muniesa, 2005). Our study, which is set in the

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0268-4012/© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).

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http://creativecommons.org/licenses/by-nc-nd/4.0/

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528 A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537

context of Swedish public services, contributes to the research on
decision support in quasi-markets as well as the research on the
materiality of markets (cf. MacKenzie, 2009) with specific reference
to the sociomaterial design of Web-based support for choice.

2. Previous research on decision support for
citizens’ choice

Coulter (2010) discussed the introduction of, and the need for,
well-designed support for patient choice in a healthcare setting.
Green, McDowell, and Potts (2008), who studied the Choose &
Book system, found that doctors still retain considerable influ-
ence on patients’ choices. Ranerup, Norén, and Sparud-Lundin
(2012) and Damman (2010) conducted broad surveys of techni-
cal support for choice in healthcare in Sweden and in Holland,
respectively. Fasolo, Reutskaja, Dixon, and Boyce (2010), Moser,
Korstjens, van der Weijden, and Tange (2010), and Ranganathan
et al. (2009) emphasized the importance of design as an influence
on choice itself. They described the various kinds of infor-
mation that designs provide, such as quality information or
patient evaluations. Interestingly, Angst, Agarwal, Gao, Kuhntia,
McCullough (2014) discussed the voluntary provision of qual-
ity information by hospitals in a study of the costs of providing
such information. There is far less research on decision sup-
port in elder care; furthermore, the research that is available is
somewhat contradictory. Meinow, Parker, and Thorslund (2011)
described cognitive difficulties that the elderly have in making
choices. However, Goodwin (2011) argued that the elderly can
make such choices. Winblad and Blomqvist (2013) claimed that
both properly designed technologies and more information are
needed.

Regarding education, research in UK focuses on how parents
used quantitative information (“League Tables”) to choose schools
for their children (Allen & Burgess, 2011; Leckie & Goldstein, 2011).
More recent studies examine if and how quality information affects
parents’ choice of schools in Chile and the Netherlands (Gomez,
Chumarcero, & Paredes, 2012; Koning & van der Wiel, 2013), as
well as more generally how information should be designed and
provided (Allen & Burgess, 2013). A general theme in the research
on choice in education is that, despite difficulties, simple perfor-
mance tables are useful. More specifically, in a study of the visual
and textual designs of support for school choice, Wilkins (2012)
claimed these designs express cultural, historical, and pedagogical
values.

In one of the few studies on choice related to public pen-
sion investing, Ranerup (2007) concluded that support for choice
might exist if the intention is to provide information on rather
advanced knowledge levels. Sundén (2004) described technolog-
ical support for choice as a complement to written information.
Hagendorff, Hudson, and Keasy (2006) described the complexity
or “Byzantine” logic of designing electronic support for choice and
advice for pension annuities that would satisfy the various needs
of retirees.

In sum, most of the research on citizen choice, which is rather
“non-theoretical”, has been conducted in healthcare settings, prob-
ably because of the many different kinds of healthcare choices (e.g.,
doctor, hospital, treatment, primary care clinic, etc.). However, to
our knowledge, as yet, there is no research that examines in com-
prehensive fashion, decision support for choice in several different
public service areas. To fill this research gap, our intention with this
theory-based, comparative case study is to provide a comprehen-
sive study of available, Web-based support in four public service
areas.

3. Theory

Our study falls within the current sociomaterial tradition with
its focus on the joint activities of people and technology (Jones,
2014; Leonardi, 2012). This tradition is concerned with people’s use
of technology in general, viewing technology as a socio-technical
system that emphasizes the interdependence of social and techni-
cal subsystems (Leonardi, 2012). This tradition grew out of an older
tradition based on workplace studies conducted in the 1930s and
developed, for example, by key figures at the Tavistock Institute,
including Fred Emery, Ken Bamforth, Eric Trist, and others).

The sociomaterial tradition is more radical than this older tradi-
tion because of its focus on how people and technology act together.
In a discussion on the roles of people and technology, McMaster and
Wastell (2005, p. 179) concluded: “[T]echnology cannot act without
people, any more than people can act without technology. Agency
cannot be reduced to either pure humans or pure machines.”

Leonardi (2012, p. 34) took a broader perspective in his discus-
sion of sociomateriality:

[T]alking about sociomateriality is to recognize and always keep
present to mind that materiality acts as a constitutive element of
the social world, and vice versa. Thus, whereas materiality might
be a property of a technology, sociomateriality represents that
enactment of a particular set of activities that meld materiality
with institutions, norms, discourses, and all other phenomena
we typically define as ‘social’.

Of course, practical situations exist in which the social and
the material act together or, as described by Leonardi (2012),
are “constitutively entangled.” For example, several researchers
are now engaged in the on-going debate on the theoretical and
methodological problems in this tradition. This debate, among
other things, occurs in the investigation of “mute” technology and
in the investigation of agency and separation among the “hybrid”
actors of people and technology (see Cecez-Kecmanovik, Galliers,
Henfridsson, Newell, & Vidgen, 2014; Leonardi, 2013; Mutch, 2013;
Scott & Orlikowski, 2013). Some, although not all, studies in this tra-
dition combine theoretical and empirical research (Jones, 2014). In
our study, we contribute to a particular stream in this research with
our focus on markets and their constructed nature. This approach
allows us examine the sociomaterial design of Web-based support
that helps citizens make their calculated public service choices.

We call attention to other important studies that take this
approach. Callon (1998), for example, studied how actors use eco-
nomic theories to construct markets in which people as well as
technologies are involved in choice. MacKenzie (2009) used mostly
financial market case studies in his study that deals with how
economic agents are constructed, often in a very material sense.
In more recent publications, Jeacle and Carter (2011) and Scott
and Orlikowski (2012) studied how the spread of technology in
the travel sector allows people to evaluate and rank travel ser-
vices using technology that displays these evaluations on computer
screens. They also looked at how technology creates trust by dis-
playing other people’s evaluations. In all of these cases, people’s
joint activities with technology are the de facto focus, which makes
technology an important component of a hybrid actor.

Taking a somewhat different perspective, Pollock and Dı́Adderio
(2012) focused on technologies used in a material sense for rank-
ing options via computer screens. In their study of how lists
and graphic design aimed at ranking influence the actions of
human actors in the market, they created an additional layer
between the individual consumer and the market. In line with
these perspectives, we find that technology not only provides
the traditional (and neutral) decision support for choice, but also
mutually influences, or controls, citizens when they make their
choices.

A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537 529

Callon and Muniesa (2005) designed a fundamental model of
choice behavior that we use as the theoretical framework of our
paper. Their model assigns technology a role that enables people
to perform as calculating consumers/customers. Their theoretical
framework for the model includes the concept of calculation, which
refers to the general idea of how people make thoughtful and cal-
culated choices in any situation. In defense of their model, Callon
and Muniesa (2005) state that economists view reality as “pure”
calculation. Other social scientists, they argue, try to show that real
practices are more complex and leave little room for calculation
practices. In contrast to that perspective, Callon and Muniesa (2005)
looked at processes in which calculated choices were made in an
examination of the sources of economic calculation. As followers of
the sociomaterial tradition, they argue that material devices (e.g.,
weighing scales or supermarket shelves) as well as more abstract
tools (e.g., Web portals such as those described in this article) are
of critical importance in helping individuals act as calculating con-
sumers (see also Callon, 1998).

More specifically, Callon and Muniesa (2005) argue that design-
ers should follow certain basic principles when they construct
technological devices such that choice and ranking are supported
through the joint activities of technology and people. First, to enable
choice, options must be detached or isolated from their context and
grouped into a common framework such as on a computer screen.
In public services, this means, for example, that all schools or pri-
mary care clinics in a municipality are listed or shown on a screen.
In this format, consumers may easily obtain a general overview of
unknown or scattered options that otherwise would be unavailable.
Second, once the options have been isolated in this manner, con-
sumers require the means to examine and compare them. Advanced
devices, some more complex than others, as well as data about
the public services, support consumers in this step. For example,
detailed computer screen data for all options or selected options,
as well as various devices for use in comparisons of a few options,
may be available. Third, designers must create a method by which
consumers can use the comparisons to produce a new entity (e.g., a
sum, an ordered list, or a holistic evaluation). In this manner, rank-
ing/choice are enabled. The use of this method may produce a sorted
list or, at least, facilitate the selection of the best alternatives con-
sistent with people’s preferences that are revealed in the process.
In short, it is essential that technological devices, such as websites
be designed so that they support calculating consumers as they
study alternatives following the steps of isolation, examination,and
ranking/choice.

4. Material and methods

4.1. Research setting

In this paper, we describe several kinds of Swedish public ser-
vices in which citizen choice is permitted. The Swedish setting
is interesting for several reasons. Although Sweden’s governing
parties are on the centre-left of the political spectrum, since the
1990s, Sweden, as a country, has placed great emphasis on the
principles of New Public Management (NPM) that favor market-
oriented management of the public sector (Hood, 1995). Several
authors (e.g., Osborne & Gaebler, 1992; Le Grand, 2007) have
described NPM as a liberal project that reinvents government. How-
ever, NPM remains a controversial reform in Sweden.

Whatever the pros and cons of NPM in public services, it is clear
that Swedish citizens are offered choice in many areas, including
education, healthcare, daycare, welfare services for the disabled,
elder care, and public pension investment. It is also clear from pol-
icy documents that large public and private agencies are working
to increase greater citizen choice through the use of technology

(Ministry of Education and Science, 2012). One element of this
reform is the use of a voucher system (or something similar). Under
this system, citizens can choose any public service provider so long
as the public treasury finances the services (i.e., by taxation) (Le
Grand, 2007).

In this paper, we look at how Swedish public services are offered
in the following areas: education, healthcare, elder care and public
pension systems. The first three areas have been addressed in liter-
ature on choice reform (see, e.g., Le Grand, 2007). The fourth area,
the public pension system, is somewhat different from the others
because of its empirical character although it is still a public service.
Together, the four areas represent a broad spectrum (as well as a
significant portion) of public services in Sweden.

A number of countries, besides Sweden, have introduced citizen
choice in education and healthcare in recent decades. For example,
UK, Chile, Denmark, and New Zealand now allow choice in educa-
tion. And UK, Denmark, New Zealand, and Norway allow choice in
public healthcare. Sweden and Denmark also allow choice in elder
care and in the public pension system.

Our study examines 14 cases of Web-based decision support
for choice in four public service areas (see Tables 1–4). The major-
ity of these 14 cases are standard e-Government services of the
G2C or G2B type (Beynon-Davies, 2005) that are owned and oper-
ated by public sector agencies. However, we also look at cases in
which the services are owned and operated by private agencies or
by a mix of public–private agencies (a public–private partnership or
PPP) (Josefsson & Ranerup, 2003; Karpik, 2010). Our goal in exam-
ining this broad mixture is to describe the significant variations
among the choice providers and in their decision support designs.
Our intention is to achieve saturation on these two aspects.

4.2. Data collection and analysis

Our data collection and analysis consisted of four steps. First,
we conducted 14 semi-structured interviews. The interviewees
(project leaders, managers, and others) all had extensive knowl-
edge of the past, current, and future activities of their agencies,
plus an understanding of how the Web-based decision support for
choice works. We conducted our interviews between December
2012 and May 2014. All interviews (between 30 and 70 min each)
were audio-recorded and later transcribed. We asked the inter-
viewees to describe the general background of their decision
support systems as well as their basic features related to the com-
ponents of our theoretical model (“Isolating, Examining, Ranking
and choosing”). Second, we analyzed some of the providers’ pol-
icy documents. Third, we examined the design and content of the
decision support systems. In this step we examined the systems’
practical features in terms of Isolating, Examining, and Ranking:
Here, Isolating refers to the provision of technological devices that
describe the framework for choice of, for example, a primary health
care provider or a school, and the search for available units. Examin-
ing refers to the provision of technological devices that investigate
and compare available choices based on, for example, waiting times
and quality indicators. Ranking refers to the provision of technolog-
ical devices for sorting and choosing among selected alternatives.
Fourth, we compared and summarized the 14 cases. Our focus was
their theoretical and practical contributions to technological design
for choice in public services.

As MacKenzie (2009) states in a very relevant publication on
“material markets”, the preferred method for studying data collec-
tion that uses technology is to observe how the technology is used
“in action”. In order to study the public service areas addressed in
this paper, we made the alternative decision to use a multiple-case
study of 14 cases with interviews, technologies, and policy doc-
uments as our data. Thus, we rely on both the interviewees’ and
our own descriptions of the technology rather than on an ethno-

530 A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537

Table 1
Web-based decision support in education.

1. 13 municipalities in
cooperation: The Gothenburg
Region Association of Local
Authorities (GR)

2. The public–private
partnership: The Swedish
Association of Local
Authorities and Regions
(SALAR), Svenskt
Näringsliv, the Swedish
Association of Independent
Schools

3. A national public
authority: The Swedish
National Agency for
Education

4. A local government: the
local public administration
of education in the
municipality of
Gothenburg

Isolating alternatives Information about the rights of
choice

No information about the
rights of choice

Information about the
rights of choice

Search for units of upper
secondary schools in the GR
region (13 municipalities)
selecting municipality,
educational program,
ownership

Search for units of
secondary (and upper
secondary) schools in the
country selecting
municipality, distance,
location on map

Search for units of upper
secondary schools in the
country selecting
municipality, educational
program, ownership, and a
device where specific
preferred criteria can be
chosen as a basis for
selecting (grading,
competence of teachers,
number of pupils in class,
grading needed for
acceptance etc.)

Browsing in a list and texts
about units of upper
secondary schools owned
by the municipality of
Gothenburg

Examining alternatives Indirect comparisons of schools
and educational programs
based on link to schools with
same type of education as well
as schools own websites

Direct comparisons of
schools based on numerical
information and diagrams
in columns covering
grading, results in national
tests, competence for
further studies, student
investigations about
satisfaction applied to a
few selected schools

Direct comparison of
schools based on all types
of above numerical
information in columns
applied to a few selected
schools

Indirect comparisons of
schools and educational
programs based on online
marketing brochure and
link to schools own
websites

Ranking and choosing
alternatives

Manual ranking, IT-supported
choice

Manual ranking, no choice Manual ranking, no choice Manual ranking, link to
IT-supported choice (in
Case No. 1)

5. A local government: The
municipality of Gothenburg

6. An association: Svenskt
Näringsliv i.e., the Swedish
national association for
promoting free enterprise

7. A private company: The
Metro Corporation

Isolating alternatives Information about the rights of
choice

No information about the
rights of choice

Information about the
rights of choice

Search for units of upper
secondary schools in the
municipality of Gothenburg
selecting part of the
municipality, ownership, map

Search for units of upper
secondary schools in the
country selecting
educational programs,
municipality and name of
school

Search for units of upper
secondary schools in the
country selecting
educational programs and
municipality or region

Examining alternatives Indirect comparisons of schools
and educational programs
based on contact information
and schools own websites

Direct comparisons of
schools and educational
programs based on
numerical information in
columns about grading,
qualification to university
studies, results of national
tests, future income
opportunities,
unemployment etc. applied
to a few selected units

Indirect comparisons of the
same educational program
in one municipality based
on brief textual
information, contact
information and links to
schools own websites,
links to other schools with
same program.
Information about future
opportunities regarding,
e.g., salary levels (monthly
wages), chat during period
of choice

Ranking and choosing
alternatives

Manual ranking, link to
IT-supported choice (in Case
No. 1)

The device for comparisons
supports ranking through
colors indicating whether
selected alternatives
belong to the 25% best,
middle or worst units in
the country
No choice

Manual ranking, link to
IT-supported choice (in no.
1 or similar regional
support in other parts of
the country)

A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537 531

Table 2
Web-based decision support in healthcare.

8. An association for all public
regional authorities: SALAR
and its IT-department Cehis

9. An association: Svenskt
Näringsliv i.e., the Swedish
national association for
promoting free enterprise

10. A public regional authority:
The county council of Halland

Isolating alternatives Information about the rights of
choice

No information about the
rights of choice

Information about the rights of
choice

Search for units of primary care
clinics using a map or search
of, e.g., municipality or name of
clinic

Search for units of primary care
clinics indicating preferences
regarding perceived
importance of satisfaction,
waiting-times and actual
physical location

Search for units of primary care
clinic by names of
municipalities, needed access
(day, weekend, nights)

Examining alternatives Direct comparison of clinics
based on numerical
information and diagrams in
columns showing contact
information, measured
telephone access, first visit,
patient investigations about:
general reception, experienced
usefulness, information,
participation in care,
confidence, willingness to
recommend, overall perception
of a few selected centres

Direct comparison of clinics in
a sorted list based on all of
above aspects and occasional
personal judgments from
patients. Detailed information
about each one of the
suggested clinics in
percentages and available
diagrams

Direct comparison as in Case
No. 8 as well as additional
information about competence
(pediatrics, diabetes, etc.),
available e-services of a few
selected centres in format
yes-no

Ranking and choosing
alternatives

Manual ranking,
IT-supported choice

Ranking in list by indicating
preferred aspects as above

Manual ranking,
IT-supported choice

No choice

Table 3
Web-based decision support in elder care.

11. A national public authority: The National Board of
Health and Welfare

12. A local government: The municipality of Stockholm

Isolating alternatives Information about the rights of choice Information about the rights of choice
Search for units (local government, part of local
government in large city, private company) of provider
of help in home to elderly based on municipality, type
of owner (public, private), type of help (service,
personal care)

Search for units (part of local government, private
company) of provider of help in home to elderly in
Stockholm based on distance, owner (public, private,
cooperative) that can be sorted according to one
preferred criteria (randomly or client investigation of
participation, safety, satisfaction etc.) before selecting
instances to compare

Examining alternatives Direct comparison of units based on textual and
numerical information in columns covering type of
owner, detailed information regarding participation,
protective routines of a few selected units

Direct comparison of units based on textual
information, diagrams, and numerical information in
columns showing client investigations as well as
information about provided services (meals, shopping,
laundry, night service etc.) of a few selected units

Ranking and choosing
alternatives

Manual ranking Manual ranking but the phase of isolating supports
selecting a criteria by which to sort lists of units of
providers as above

No choice IT-supported choice

Table 4
Web-based decision support in public pension.

13. A national public authority: The
Swedish Pensions Agency

14. A public–private partnership:
Minpension that includes The Swedish
Pensions Agency, Banks, Fund companies

Isolating alternatives Information about the rights of choice Information about the rights of choice and
the pension system as a whole

Search for units of pension funds in the
public pension based on risk, fee, increase
in value, category, etc. These categories can
be used for ranking (i.e., sorting) according
to preferred criteria

No search for funds

Examining alternatives Direct comparisons of selected alternatives in
lists based on numerical information and
diagrams based on the selected criteria

Overview of choices made and their result
(total savings)
Personal forecasts based on future salary
and activity

Ranking and choosing alternatives Direct ranking before selection as above as
well as in diagrams showing increase in
value. An advanced DSS incorporating
personal preferences regarding risk, fees,
time, etc., supports comparing current and
future portfolios

No ranking

IT-supported choice No choice

532 A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537

graphic observation of its actual use. However, for our purposes,
we think our methodology is “good enough” because our intention
is to describe the potential agency embedded in the technologyı́s
material product as well as its textual content (Siles & Boczkowski,
2012).

5. Results

5.1. Education

In Swedish education, choice reform was introduced in the
primary and lower secondary schools in 1992 and in the upper
secondary schools in 1994. In each municipality, various tax-
funded agencies (public, semi-private, or private) supervise the
school choice system. The mandate for this reform was stated
in the national government proposition 1991/92:95: “Choice
and independent schools” (Ministry of Education and Science,
1991/1992Ministry of Education and Science, 1991/1992). In some
regions, a number of municipalities cooperate around choice in
upper secondary education.

Table 1 presents the Web-based decision support for upper sec-
ondary schools and education programs. Local authorities, national
public authorities, and public–private partnerships (PPPs) provide
the support. The PPPs are entities associated with Svensk Näringsliv
[Swedish Business Life], which promotes free enterprise and pri-
vate companies. As far as Isolating alternatives, five cases provide
information about the right of choice. Case No. 2 (a PPP) and Case
No. 6 (owned by Svenskt Näringsliv) do not provide this information.
Of the seven cases, six support the search among all schools (pub-
lic or private) and/or education programmes using various criteria.
Case No. 4 supports the search only among the municipality’s own
schools. This is a large municipality where school choice is highly
competitive. In addition, in Case No. 4, the description of choice has
a greater market orientation than in the other cases.

Other significant differences exist among the cases in the area of
education. Case No. 3 (a new national public support for comparing
schools operated by The Swedish National Agency for Education)
has a device with different personal preference criteria for use in
comparing schools (distance, size, qualification of teachers, grad-
ing, etc.) (see Fig. 1). The other cases feature indirect comparisons
using a list of separate schools. However, Case No. 3 still has
columns with selected schools including all provided criteria or
types of information. Case No. 2 allows comparisons of a few
schools, arranged in columns based on all types of information
(including diagrams and numerical data). Case No. 6 (financed by
Svenskt Näringsliv) is the only case that supports ranking of options.
In the other cases, the user must sort among the alternatives (“Man-
ual ranking”). Case No. 1 is the only case that permits direct choice
among all upper secondary schools in the 13 municipalities. Case
No. 4 and Case No. 5 (owned by the municipality of Gothenburg)
permit indirect choice among the regional schools through a link
to Case No. 1’s device. In Case No. 7, the Metro Corporation offers
Web-based decision support that is linked to Case No. 1 or to similar
regional support.

5.2. Healthcare

Sweden introduced choice reform in primary care in 2010
(Ministry of Health and Social Affairs, 2008/2009Ministry of Health
and Social Affairs, 2008/2009). With this reform, all citizens are
allowed to choose among the primary care centers in a county coun-
cil, although choice of doctors is not an option. The county councils
or private healthcare agencies operate these centers. In healthcare,
Case No. 8, operated by the national association (SALAR) and Case
No. 10, operated by an individual county council, provide infor-

mation about the right of choice. Case No. 9, operated by Svenskt
Näringsliv, is more concerned with allowing citizens to make com-
parisons (see Table 2). All three cases support comparisons based
on contact information and patient investigations. Case No. 9 is the
most advanced because of its ranking device that allows a user to
decide on the importance of basic features (e.g., distance, patient
satisfaction, ownership, waiting time before contact) (see Fig. 2).
The user may also add a personal evaluation that others may read.
However, Case No. 9 does not permit the user to make a choice
whereas Case No. 8 and Case No. 10 permit a choice selection.

5.3. Elder care

Choice in elder care (home help for the elderly) was introduced
in Sweden broadly in 2009 in connection with LOV (Law on the
Right to Choose) (Ministry of Health and Social Affairs, 2009). How-
ever, each municipality may choose whether to offer choice in elder
care. Approximately 60% of the municipalities have introduced
the choice option (Swedish Association of Local Authorities and
Regions, 2013).

Public agencies own both elder care cases (see Table 3).
Regarding Isolating alternatives, both Case No. 11 and Case No.
12 provide information about the right of choice. Both cases per-
mit searches among provided services according to simple criteria
(e.g., type of care, municipality). Case No. 12, owned by the Stock-
holm municipality, has the capacity for sorting among the often
rather long list of private and public providers in particular areas
of the municipality. Selected criteria are used in the sorting step.
Regarding Examining alternatives, both Case No. 11 and Case No. 12
permit comparisons according to a list of features (e.g., organization
type or available services). However, Case No. 12 also permits more
direct user searches. Regarding Ranking and choosing alternatives,
specific ranking is not possible in either case. Case No. 12 permits
choice in the Stockholm municipality, but Case No. 11 does not.

5.4. The public pension system

In 2000, pension reform in Sweden offered a choice compo-
nent for the public pension system. People were offered a choice
of investing in approximately 800 premium pension funds. These
funds charge an obligatory fee on all earnings. Employees con-
tribute 16% of their earnings to general public pension fund, and
2.5% of their earnings to the premium pension system fund (SOU,
2005).

Table 4 presents two cases: Case No. 13, owned by a national
public agency, The Swedish Pension Authority, and Case No. 14, a
PPP (Minpension.se). Regarding Isolating alternatives, both cases
include information about choice. However, Case No. 13 supports
searches for alternatives using many criteria. These criteria include
a Decision Support System (DSS) to make advanced comparisons for
Ranking and choosing premium pension funds. In contrast, Case No.
14, which offers a more indirect form of support for choice, shows
the results of choices made in the premium pension plan as well
as how the choices fit into the individual’s entire pension portfolio,
including the individual’s private retirement savings (see Fig. 3).
Case No. 14 does not offer the Ranking and choosing alternative.
Despite its indirect support, Case No. 14 clearly intends the decision
support to be used for choice.

5.5. Isolating alternatives

In this section, we summarize the sociomaterial process of
making choices that the joint activities of technology and people
support. Eleven of the 14 cases have information about the right of
choice of, for example, a school, a primary care centre, elder care
in the home, or a pension fund. This information isolates the avail-

A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537 533

Fig. 1. Case No. 3 with its device to select types of information that are important to the individual for closer examination (to the right).

Fig. 2. Case No. 9 with its ranking of the primary care clinics.

able options in a very simple but important way. Case Nos. 2, 6,
and 9 that are, or were, at least partly owned by Svenskt Näringsliv
do not provide such information. Therefore, a broader context for
choice and the related individual rights of citizens is often sup-
ported. Generally speaking, Swedish society firmly supports this
concept. However, the Swedish Association of Independent Schools
states:

Unfortunately there is still [in some regions and municipalities]
a lack of knowledge about the rights of school choice. As a result,
often the school that is closest to home is “chosen”. Thus, it is
important to address this lack of knowledge so that everybody
knows about their rights (Hamilton, 2015).

It is of equal importance (as observed in all cases except Case
No. 4 related to the marketing of the municipal upper secondary
schools) that support for searching alternatives is available.

5.6. Examining alternatives

Case Nos. 3, 6, and 11 provide numerical and textual data that
can be used for examining alternatives. Case Nos. 2, 8, 12, and
13 provide diagrams or graphic information. Furthermore, many
cases enable comparisons based on neutral information with the
exception of links to a provider’s website. However, the website
for Case No. 4 markets the municipality’s upper secondary schools.
Some cases in education, healthcare, and elder care present evalu-
ations, such as student, patient, or user views. Other information is
available about various entities and their capacities (e.g., location,
access, services, etc.). According to Jeacle and Carter (2011), it is
somewhat unusual to find personal and spontaneous evaluations
from users in decision support design. In our study, only Case No.
9 permits such evaluations (in healthcare only). Such user evalu-
ations use the material capacity of information technology, unlike

534 A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537

Fig. 3. Case No. 14 shows all the savings in the pension portfolio including public pensions, occupational pensions, private pensions, and a pension forecasts.

historical technologies, (e.g., hotel evaluations by guests) to make
judgements visible (Orlikowski & Scott, 2014).

Many of the 14 cases provide direct support for making compar-
isons (see Tables 1–4). Case Nos. 1, 4, 5, and 7 permit comparisons
more indirectly; a user has to check each alternative and then com-
pare it with others. Some cases offer more advanced devices for
comparing alternatives. Often this support appears as information
about a few selected entities, arranged in columns. In Case No. 3
(see Fig. 1) and Case No. 12, the designs allow selection of preferred
information that can be used for making comparisons. Case No. 9
allows the selection of preferred information that can be used to
create a sorted list of comparisons (see Fig. 2). Additionally, Case
No. 13 has a device consisting of different steps that can be used to
indicate various preferences (e.g., preferences about risk level, fees,
and search time results). It also permits examination of a citizen’s
current pension portfolio and comparison of it with a potential new
portfolio of pension funds.

Case No. 14 has less sophisticated devices for comparing and
examining alternatives (see Table 4). However, its design allows
evaluation of pension fund choices in the context of other choices,
from both short- and long-term perspectives (see Fig. 3). Of course,
pension funding is, by its very nature, a long-term activity. How-
ever, so are many of the other choices described in this study, for
example, education. Interestingly, the designs in Case Nos. 6 and 7
project future salary levels. This alternative takes a more long-term
perspective as well as a broader perspective on calculated choice
than a temporary choice made at one moment in time. An interest-
ing issue is whether this long-term perspective on choice is relevant
in other areas. For example, in healthcare is the long-term perspec-
tive useful for a patient with a chronic illness who is being treated
at a primary healthcare clinic? Would such a perspective allow the
patient to evaluate data on treatment results for a specific illness
at a specific clinic?

5.7. Ranking and choosing alternatives

Comparatively few of our 14 cases offer devices for ranking
alternatives on their Web-based screens in terms of specified or
preferred criteria that would make choice a simpler decision. Callon
and Muniesa (2005, p. 1231) describe the theoretical basis of rank-
ing as follows:

A new entity must be produced (a sum, an ordered list, an
evaluation, a binary choice, etc.) that corresponds precisely to
the manipulations effected in the calculative space and, con-
sequently, links (summarizes) the entities taken into account.
This resulting entity is not new, in the sense of springing from
nowhere; it is prefigured by the considerations described above.

Our cases show alternative ways to make rankings using socio-
material constellations related to choice in quasi-markets (see
Tables 1–4). Case No. 12 (elder care) and Case No. 13 (public pen-
sion funds) show (indirectly) ordered lists that have been ranked by
preferred types of information. The ranking step thus precedes the
selection of alternatives for comparison. Case No. 9 (healthcare)
summarizes (more directly) several criteria or types of informa-
tion as a joint list. Case No. 13 shows diagrams that compare the
increase in the value of selected alternatives. Alternatively, Case
No. 6 (education) even more directly offers a form of holistic eval-
uation that ranks the 25% top, middle, or bottom alternatives using
graphics and colors. Case No. 13 permits a full comparison of a new
portfolio using graphics and information in a multifaceted DSS that
constructs a carefully selected portfolio of alternatives for compari-
son with the citizen’s current portfolio. Thus, here we see how lists
and graphics (Pollock & Dı́Adderio, 2012) can be used in various
ways for rankings in quasi-markets.

There are several possible reasons why relatively few of our
14 cases have a design that supports ranking. One reason is that
ranking may be perceived as controversial because it points to the
“best” and the “worst” alternatives in a very obvious manner (!).
Another reason is that ranking must be based on available data
rather than on unavailable data that may be still more relevant.
Ranking is also a controversial issue because the available data
may be unclear about new service providers (The Swedish Agency
for Public Management, 2007). However, this issue, which relates
to the contradictory role of public authorities in providing clear
messages for choice, is under discussion. An interviewee stated:

[The] authority must offer a support for choice. [. . .] It is a
conscious strategy from our side that we do this quite clearly.
[However] we still can not provide anything that seems like
advice. (Project leader, Pension Authority, May 27, 2013)

Some research claims that ranking also influences the activities
of those who are ranked by causing them to try to improve their
position by manipulating or concealing information. The use of the

A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537 535

ranking technologies can also affect which options (e.g., service
providers) are shown when there are multiple options available
(Pollock & Dı́Adderio, 2012). The issue of technologies for rank-
ing and their interaction with people is, thus, an issue for further
research. Nevertheless, a severe problem may result from the rela-
tively minimal use of devices that support ranking. An abundance
of information, which cannot be used in ranking, may influence
choice negatively. More confusion, rather than simplification, may
be the result. Last, but not least, our theoretical model represents
the activity of making choices. Surprisingly, only eight of our cases
support actual choice via Web-based support (see Tables 1–4).

5.8. Comparing the 14 cases

What conclusions can we draw about the sociomaterial constel-
lations in our 14 cases related to calculated choice in the areas of
education, healthcare, elder care, and public pension funds? Edu-
cation has the largest repertoire of Web-based support for choice as
well as agencies that provide support. Choice reform has existed in
education in Sweden since the beginning of the 1990s. By contrast,
choice reform was introduced for primary healthcare and elder care
in 2010 in Sweden. The diversity of support in the various public
service areas, especially in education, indicates a “battle of judge-
ments” (Karpik, 2010). In education, citizens can choose among the
education alternatives. However, they must choose among one or
several systems of Web-based support for choice (!) before they
can locate the available options and make comparisons. In educa-
tion, quite recently (2013–2014), a PPP (Case No. 2) and a national
public authority (Case No. 3) revealed a positive move toward sup-
port for more citizen choice. This new support movement can be
contrasted with support for school leaders, also used by parents
for choice (Ranerup, 2006), and Case No. 6 (which ended in 2013).
However, as Section 5.7 discusses, this long tradition of choice does
not mean that education has devices that support calculation with
sophisticated ranking mechanisms.

We conclude that, increasingly, in education as well as in
healthcare and public pension funds, private agencies (e.g., Svenskt
Näringsliv and the Metro Corporation) provide support (Case Nos.
2, 6, 7, 9, and 14). In fact, in Case Nos. 2 and 14, these agencies
work in cooperation with public agencies. In other words, they take
an active part in what we usually see as the technological con-
struction of the relationship between the state and the individual.
This relationship is featured in the research field of e-Government
that often, we argue, is implicitly assumed to be an area for public
agencies only (Beynon-Davies, 2005).

We also conclude there are a number of areas where there are
differences between the cases. With Isolating, differences exist as far
as the availability of information about rights and in the search
devices for alternatives. With Examining, differences exist as far as
the kind and availability of information and the types of devices for
making comparisons. With Ranking, differences exist in the outlay
of available alternatives, and in the support for choice. These dif-
ferences may be of use for designers interested in understanding
how calculated choice may be supported.

Another conclusion is, despite the details about available sup-
port in the 14 cases, enabling calculated choice, the support is
somewhat lacking, especially when it comes to devices that offer
ranking and choosing. The main exception is Case No. 13 where the
choice of pension funds is supported. Pension fund reform introduc-
ing choice, which began in 2000, involved a leading national public
pension authority as well as a number of banks and investment
firms. Thus, organizations quite accustomed to making choices
were involved with the reform from its beginning. Interestingly,
instead of a “battle of judgements”, such as we find in education
where there are many instances of available support, in public pen-

sion a number of companies offer pension fund investment advice
“for a small fee”.

Ranking is an activity that very obviously shows the author-
ity of materiality. In ranking, technology is a powerful actor that
influences choice (Pollock & Dı́Adderio, 2012). Although ranking,
in perhaps its most important use as a producer of a sorted list
(Case No. 9), is not common in our 14 cases, many devices, in inter-
action with their users, enable calculation through a clear use of
technologyı́s discretionary power. The simplest example is tech-
nology’s capacity to enable a selection of a few instances for further
comparisons in columns based on various types of data. While this
capacity appears in many of our cases, there are examples more
directly related to ranking (Section 5.7). The design in each case
influences the joint activities of technology and people. The opera-
tor or owner of the technology is yet another “actor” who appears
between the consumer and a market (Pollock & Dı́Adderio, 2012)
that consists of many service providers. This is important because
various public agencies operate the support systems in many of
our cases. These agencies have, generally speaking, higher status
than commercial actors, or are themselves commercial actors with
access to public data.

A final conclusion of our study is that that the sociomaterial
constellation in the 14 cases very clearly shows variations in the
division of labor between people and technology. When we look at
Isolating alternatives, people have a larger role because technol-
ogy only reveals a general aspect such as the right of choice and a
number of instances of the requested services (Section 5.5). When
we look at Examining alternatives, sometimes people have to do
most of the work compared to situations in which technological
devices, to some degree, exist to support examinations and com-
parisons. However, people must make a significant part of these
examinations and comparisons because each alternative has many
different kinds of information even when it is structured in columns
(Section 5.6). In contrast, in the various ranking displays (Section
5.7), materiality plays a larger role.

5.9. Contributions

Our study’s contribution to previous research on decision sup-
port for choice in quasi-markets (see Section 2) is its theoretically
informed discussion of how more sophisticated Web-based sup-
port designs for choice are developing in several public service
areas. Sweden is a good context for such as study because of its long
tradition of school choice and its experience with choice reform in
many public service areas. In contrast to some previous studies,
our intention is not to show how these designs influence choice
in practice (cf. Gomez et al., 2012; Koning & van der Wiel, 2013)
or to discuss how citizens can use these online channels (Van de
Wijngaert, Pieterson, & Teerling, 2011). Our technological focus
contributes to research into sociomateriality in a general sense, and
to research on the material construction of markets in a particular
sense (Callon & Muniesa, 2005; MacKenzie, 2009).

In addition, unlike many other studies that apply theories about
sociomateriality (Cecez-Kecmanovik et al., 2014), our conclusions
derive from empirical data (Jones, 2014). Our study is also of practi-
cal relevance for the politicians, project leaders, and designers who
today are responsible for the improvement of public services as
a whole (Panagiotopoulos, Al-Debei, Fitzgerald, & Ellliman, 2012).
We provide a view of potential technological outlay of 14 instances
of decision support and make a comparative, structured analysis of
their functions (Section 5 and 5.5–5.8). This is of special value, we
argue, because previous research deals with public service areas
individually.

Therefore, three design principles can be extracted from our
cases.

536 A. Ranerup, L. Norén / International Journal of Information Management 35 (2015) 527–537

a The provision of information about the right of choice is impor-
tant. In fact, this right appears in many public service areas where
public and private entities, such as those in our study, provide
decision support. The exception is Svensk Näringsliv. Interest-
ingly, as Gingrich (2014) concludes, providing information also
has significant influence on people’s values and participation in
elections.

b The awareness of the full repertoire of potential types of infor-
mation is important. Our study of cases in several areas indicates
that an extensive amount of information can be provided about
available options and opportunities via Web-based decision sup-
port. This information may be presented, for example, in numeric,
textual, or graphic form [“format”]. This repertoire may use neu-
tral information (vs. marketing information), information about
present circumstances (vs. future opportunities), and user evalu-
ations from official investigations (vs. more personal evaluations
of opportunities [“aim”]). In this manner, information designers’
choice of information can be based on a more complete and com-
plex understanding than that described in previous studies (Allen
& Burgess, 2011; Leckie & Goldstein, 2011; Ranganathan et al.,
2009).

c The awareness of the full repertoire of available ways of sorting
and ranking is important. Because of risk of information over-
load in choice situations, providing comparison devices for use
in selecting alternatives is necessary. However, making compar-
isons of long columns of data on relatively few alternatives may
still be unsatisfactory. In contrast to studies of single cases in
single areas (Pollock & Dı́Adderio, 2012; Pollock and Dı́Adderio,
2012), our study discusses a number of ways to reduce this com-
plexity. For example, user preferences on service options and
opportunities for certain aspects or types of information can be
highlighted before users examine a few selected alternatives. Or,
sorted lists can be prepared for users based on these preferences.
Our study also shows that ranking can be achieved by presenting
graphic information and examples as well as by sorted lists.

Last, but not least, our results are theoretically relevant to the
technological construction of the relationship between the state
and its citizens (Gauld et al., 2010; Lips, 2007), for example, in the
context of NPM reforms. Our results contribute with a new per-
spective on these reforms in their focus on the role of citizens as
consumers or customers (Mosse & Whitley, 2009). Thus, our results
depict the design of quasi-markets and their technologies that, in
part, aim to support citizens in their more traditional democratic
role as well as in other roles such as consumers.

5.10. Limitations and further studies

A limitation in our research methodology, as noted above,
is that we have not studied the actual use of decision support
designs (MacKenzie, 2009). However, as Gad and Jensen (2010)
argue, research goals allow differences in applying theoretical and
methodological concepts in the study of sociomateriality. We have
tried to present a theory-based, comprehensive view of several
areas of public services by describing the content of information
provided and the design or general outlay of the functionality as a
representation of the sociomateriality of (quasi-) markets in Web-
based decision support.

A study, such as ours, which applies Callon and Muniesa’s (2005)
framework, is not neutral. Therefore, it may create critical discus-
sion of the world that we would like to design (Roscoe & Chillas,
2013). One very relevant issue in this context is the strengthening
of the citizen’s role as a consumer or customer (Clarke, Newman,
Smith, Vidler, & Westmarland, 2007; Mosse & Whitley, 2009).
The technological decision support for choice very obviously has
this dimension and aim. Other technologies dedicated to citizens’

collective discussion and action might well complement the tech-
nologies we describe. On the other hand, all but a few of the 14
cases we studied had information about the rights of citizens as a
part of the Isolating alternatives.

We suggest that researchers more closely examine the perfor-
mative implications when technologies and people are involved
(Cecez-Kecmanovik et al., 2014). The most urgent question con-
cerns how the value of the services and their ranking are
constructed in actual use.

6. Conclusion

In this paper we examined how Web-based decision support
and citizens jointly contribute to calculated public service choices
in quasi-markets, using Sweden as our setting. The area of edu-
cation has the greatest amount of support, perhaps reflecting the
“battle of judgements” Karpik (2010) refers to. However, decision
support also appears in many other public service areas. Regarding
Isolating alternatives, the majority of our 14 cases include informa-
tion about the right of choice as well simple devices for searching
among and listing alternatives. Regarding Examining alternatives,
the majority of our 14 cases permit direct comparisons based on
various kinds of information although a few support more indi-
rect comparisons. Regarding Ranking and choosing alternatives,
all 14 cases explain how to make a choice although relatively few
have ranking devices. Nevertheless, our cases provide a reasonable
summary of the available sociomaterial designs of ranking devices.
Ranking is an activity that very obviously shows the authority of
materiality and how it mutually influences, or controls, citizens
when they make choices.

Therefore, the studied Web-based support for choice in quasi-
markets is not consistent with the theoretical model of calculated
choice in all its aspects. Nevertheless, there is a clear trend in this
direction. On the other hand, our cases do, in interaction with their
users, enable calculation through a clear use of discretionary power.

Our results call for a critical discussion of “the world we like to
design”. An important issue in this discussion issue is the increas-
ingly evident role of citizens as consumers or customers in their
relationship with public services.

Acknowledgement

The Swedish Research Council is greatly acknowledged for fund-
ing our research.

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dx.doi.org/10.1111/joms.12114

dx.doi.org/10.1177/1350508413485497

http://www.skl.se/vi_arbetar_med/valfrihet/valfrihetuppdrag/ersattningssystem-hemtjanst-2013

How are citizens’ public service choices supported in quasi-markets?
1 Introduction
2 Previous research on decision support for citizens’ choice
3 Theory
4 Material and methods
4.1 Research setting
4.2 Data collection and analysis

5 Results
5.1 Education
5.2 Healthcare
5.3 Elder care
5.4 The public pension system
5.5 Isolating alternatives
5.6 Examining alternatives
5.7 Ranking and choosing alternatives
5.8 Comparing the 14 cases
5.9 Contributions
5.10 Limitations and further studies

6 Conclusion
Acknowledgement
References

Socializing-in-emergencies-A-review-of-the-use_2015_International-Journal-of

International Journal of Information Management 35 (2015) 609–619

Contents lists available at ScienceDirect

International Journal of Information Management

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i n f o m g t

Review

Socializing in emergencies—A review of the use of social media in
emergency situations

Tomer Simon a,b,∗, Avishay Goldberg b,c, Bruria Adini a,b

a Emergency Medicine Department, Recanati School of Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
b PREPARED Center for Emergency Response Research, Ben Gurion University of the Negev, Beer Sheba, Israel
c Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel

a r t i c l e i n f o

Article history:
Received 26 June 2015
Accepted 9 July 2015
Available online 31 July 2015

a b s t r a c t

Social media tools are integrated in most parts of our daily lives, as citizens, netizens, researchers or
emergency responders. Lessons learnt from disasters and emergencies that occurred globally in the last
few years have shown that social media tools may serve as an integral and significant component of
crisis response. Communication is one of the fundamental tools of emergency management. It becomes
crucial when there are dozens of agencies and organizations responding to a disaster. Regardless of the
type of emergency, whether a terrorist attack, a hurricane or an earthquake, communication lines may
be overloaded and cellular networks overwhelmed as too many people attempt to use them to access
information. Social scientists have presented that post-disaster active public participation was largely
altruistic, including activities such as search and rescue, first aid treatment, victim evacuation, and on-
line help. Social media provides opportunities for engaging citizens in the emergency management by
both disseminating information to the public and accessing information from them. During emergency
events, individuals are exposed to large quantities of information without being aware of their validity
or risk of misinformation, but users are usually swift to correct them, thus making the social media
“self-regulating”.

© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1.1. Disaster characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1.2. Social order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1.3. Disaster management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1.4. Communication challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1.5. Loss of communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
1.6. Public participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
1.7. The need for information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611

2. Social media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
2.1. Short introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
2.2. Social media for emergency management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
2.3. Social media and preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
2.4. Technology adoption and usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
2.5. Remote islands of innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
2.6. Recruiting the public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613

∗ Corresponding author at: Emergency Medicine Department, Recanati School of Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the
Negev, P.O. Box 653, Beer Sheba, 84105, Israel. Fax: +972 8 6472136.

E-mail address: tomersi@asonot.org.il (T. Simon).

http://dx.doi.org/10.1016/j.ijinfomgt.2015.07.001
0268-4012/© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).

dx.doi.org/10.1016/j.ijinfomgt.2015.07.001

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http://www.elsevier.com/locate/ijinfomgt

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mailto:tomersi@asonot.org.il

dx.doi.org/10.1016/j.ijinfomgt.2015.07.001

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610 T. Simon et al. / International Journal of Information Management 35 (2015) 609–619

2.7. Crowdsourcing in disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
2.8. Information categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
2.9. Location based information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
2.10. Information dissemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
2.11. Disinformation and inaccuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
2.12. Emergency responders and social media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
2.12.1. Budget and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
2.13. Challenges to data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
2.14. Global social sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617

1. Introduction

Social media (SM) tools, especially Facebook and Twitter, are
taking an ever growing part in disaster response (Cohen, 2013;
Sarcevic et al., 2012). SM during disasters and emergencies was
initially utilized by the general public to communicate, and is
now being adopted by emergency responders, governments and
non-governmental organizations as an integral tool for disaster
management (DM).

This paper reviews how SM tools are used in disasters by the
public, emergency organizations and academic institutions. This
paper reviews the literature concerning utilization of social media
in emergencies between 2007 and 2014. Some of the reviewed arti-
cles reference earlier materials and these are noted in the review
concerning specific topics.

1.1. Disaster characteristics

In the last few decades, numerous regions worldwide have been
stricken by severe natural disasters, such as earthquakes, floods and
hurricanes, causing extensive damages to human lives and infras-
tructures.

Disasters have been defined as a state in which the social fab-
ric is disrupted and becomes dysfunctional to a greater or lesser
extent causing “maximum community disruption and dislocation”
(Britton, 1988; Fritz, 1961).

Natural disasters have spatial characteristics such as extent and
boundaries. This configuration is disrupted during the onset of a
sudden disaster which adversely affects the natural and human
resources, as well as the social relationships in the region (Jigyasu,
2005; Palen & Liu, 2007). At present there seems to be a consensus
among researchers that a disaster cannot be explained by a number
of recognizable factors, and efforts are being made to understand
why and when people perceive a certain period or common expe-
rience as a disaster (Boin, 2005).

In response to disasters, numerous agencies and organizations
often work together and direct their efforts towards a common goal
(Reddy et al., 2009; Kopena et al., 2008). Frequently, the public-
private interface is strengthened to support crisis management, and
governments may simplify processes to access resources and goods
without due process (Quarantelli, 2006).

1.2. Social order

According to Alexander (2005) an average day in the world
“would see two to three disasters in their emergency phases,
15–20 in their recovery periods, and about a dozen conflict-based
emergencies in progress”. These include events such as wars, earth-
quakes, and extreme weather conditions. Coupled with the loss
of communications, it becomes a period of uncertainty that may
cause collective stress resulting from deprivation of a large portion
of the society from expected routine conditions. These conditions,

deprived from many, are socially defined as normal human needs
(Barton, 2005). However, the general public often takes an active
role in disasters and their involvement is becoming more and more
visible, through the use of Information and Communication Tech-
nologies (ICT) (Palen & Liu, 2007).

1.3. Disaster management

An organized response to disaster management (DM) is cru-
cial to mitigating loss of lives and damage to infrastructure. Dynes
(1970) described both theoretical and practical aspects of an orga-
nized response, including staffing, strategy, tasks, and relationships
between various responding organizations and the social environ-
ment itself.

Information sharing and coordination are a critical factor in
DM, especially among responding organizations (Yates & Paquette,
2011; Bharosa, Lee, & Janssen, 2010). In his research, Bharosa
et al. (2010) found that responders prefer to receive information
and are reluctant to share it with others. Also, even when for-
mal information flows through the command structure, ad hoc and
personal-basis channels are created to support multi-level infor-
mation sharing (Bharosa et al., 2010). The US National Incident
Management System (NIMS) is based on a hierarchical command
structure to “divide responsibility of labor and support inter-
jurisdictional coordination” (Palen & Liu, 2007). According to this
model, there is a single official, the Incident Commander (IC), to
whom all responding organizations report, and he has the author-
ity and overall responsibility to maintain a unified command during
the entire event.

An integral part of DM is situational awareness (SA), described
by Vieweg, Hughes, Starbird, and Palen (2010) as features
contributing to the understanding of the emergency situation,
especially in respect to the operational needs of command and con-
trol. SA reports can originate from local residents, reporters, first
responders or from authorized information sources (Qu, Huang, &
Zhang, 2010).

1.4. Communication challenges

Communication is one of the fundamental tools of emergency
management. It becomes crucial when there are dozens of agencies
and organizations responding to a disaster. DM requires that these
organizations’ rapid response, along with their own set of roles and
responsibilities, be coordinated within and between sectors (Reddy
et al., 2009).

Each organization operates its own radio frequencies, making
it difficult to create a unified and synchronized response. The pri-
mary challenge is technological, ranging from rapid deployment of
a communications system for first responders, to interoperability
between various organizations. Communication systems must be
able to withstand a disaster and enable devices to function effec-
tively even when communication networks have collapsed (Manoj

T. Simon et al. / International Journal of Information Management 35 (2015) 609–619 611

& Baker, 2007). These findings were further reinforced by Reddy
et al. (2009) who found that current technologies are ineffective and
inadequate to support the flow of information within and between
coordinating teams during a disaster.

1.5. Loss of communication

Most disasters cause severe damage to communication infra-
structure (Low et al., 2010). Phone switches and cell phone towers
might collapse, fully or partially, thus disrupting the much needed
communication (Palen & Liu, 2007). Regardless of the type of emer-
gency, whether a terrorist attack, a hurricane or an earthquake,
communication lines may be overloaded and cellular networks
overwhelmed as too many people attempt to use them to access
information. Severe natural disasters may cause the entire com-
munications grid to blackout, as infrastructure is severely damaged
(Stiegler, Tilley, & Parveen, 2011). In some cases the disaster may
strike a geographic region that lacks communication infrastructure;
but even in places where partial communication infrastructure
remains intact, deployment of new systems may be found to be
complex (Manoj & Baker, 2007). As the conventional means of com-
munication become irrelevant during and immediately following a
disaster, alternate means such as social networks become an impor-
tant conduit for information gathering and sharing (Hughes, Palen,
Sutton, Liu, & Vieweg, 2008; Bird, Ling, & Haynes, 2012; Huang,
Chan, & Hyder, 2010).

1.6. Public participation

People have experienced disasters since the dawn of humanity,
and as such their high involvement in the response phase is not
new. The public’s part in disasters has been studied by many soci-
ologists since the 1950s, including emergent behavior as a means
to substitute and form important societal functions after a disas-
ter strikes. Individuals and groups agree that action must be taken
in response to an event (Drabek & McEntire, 2002). This usually
materializes as volunteerism, both emergent and organized, with
different manifestations depending on the type of disaster, stage
of the response, region and society. Some volunteer from per-
sonal reasons and some for altruistic causes (Wolensky, 1979).
Studies have presented that while victims of physical disasters
such as earthquakes engage in active self-help, victims from other
situations of mass deprivation (i.e. starvation, economic crash or
oppression) seem to generate fatalism, lack of active self-help, self-
blame, or an irrational search for a guilty party (Barton, 2005).

Most social scientists have presented that post-disaster active
public participation was largely altruistic, including activities such
as search and rescue, first aid treatment, victim evacuation, and
on-line help (Kendra & Wachtendorf, 2003; Palen & Liu, 2007). The
general public serves as the true “First responders”, with a visible,
active, and extensive high involvement. Today, through the use of
new ICTs, their role offers additional ways to participate and com-
municate (Palen & Liu, 2007; Lu & Yang, 2010). Researchers have
compared the physical convergence of people to a geographical site
after a disaster to the convergence to online SM tools, and found
similarities in the population’s behavior. At present, there are no
limitations to the locations or number of people that can participate
in the on-line convergence (Hughes et al., 2008).

1.7. The need for information

People are natural information seekers, relying primarily on
their own social networks (Palen & Liu, 2007). Following a disaster,
the public initially seeks the most common and familiar chan-
nels; phone calls, emails, or text messages. If unsuccessful, they
turn to alternative and/or official sources of information (Stiegler

et al., 2011). Mileti & Darlington, 1997 presented that individuals in
emergency situations use whatever means available to find infor-
mation. People seek information for themselves, to learn about
the emergency event, locate their family and friends, and reduce
uncertainty regarding what has happened; they will seek any avail-
able venue of information including newspapers, television, and
the Internet (Boyle et al., 2004; Stiegler et al., 2011; Hughes et al.,
2008). Skinner (2013) describes how she as a researcher collects
and aggregates information from different sources during emer-
gencies, and publishes it in order to inform those who are affected
by the event. In events that endanger the public’s health there is
high importance to the ability to act, especially when expected to
take ameliorative actions, or actions to identify the risk (Maxwell,
2003). Messages should be disseminated quickly and be simple
enough so that people with high anxiety would be able to com-
prehend and comply appropriately (Wray et al., 2008).

With the advancement of internet technologies and tools, users
in crises surfed online to seek information specific to their neigh-
borhoods and activate weak ties in their social networks (Abbasi,
Hossain, Hamra, & Owen, 2010). These novel capabilities have cre-
ated a new form of “civilian journalism” that enables participation
during emergency events (Laituri & Kodrich, 2008). The internet is
becoming a more reliable tool as traditional media channels suffer
disruptions and damage caused by the crisis (Procopio & Procopio,
2007).

People have identified forums as a communication and infor-
mation sharing platform through which they can seek, share, and
synthesize information (Qu, 2009). The next step in the evolution
was the massive use of social network sites, such as Facebook and
Twitter.

2. Social media

2.1. Short introduction

Social media (SM) consists of tools that enable open and online
exchange of information through conversation, interaction and
exchange of user generated content (Huang et al., 2010; Abbasi
et al., 2010; Kavanaugh et al., 2011). Unlike traditional ICTs, SM
manages the content of the conversation or interaction as an infor-
mation artifact in the online environment (post or tweet) (Yates &
Paquette, 2011).

SM allows people to establish connections and links with other
individuals who are similar to them, or whom they find interesting.
Users can post news or links, discuss them, and share their opinions
during real times. The SM can be utilized to mobilize and organize
populations in order to achieve various objectives, and update them
with the most up-to-date information, which might not be available
through alternate official channels (Lerman & Ghosh, 2010).

During natural disasters SM provides access to relevant and
timely information from both official and non-official sources, and
facilitates a feeling of connectedness (Taylor, Wells, Howell, &
Raphael, 2012). This connectivity to loved ones and the commu-
nity provides reassurance, support and assistance to potentially
distressed individuals and populations (Taylor et al., 2012).

Facebook is the largest SM network, with 1.35 billion monthly
active users (Facebook Newsroom, 2014). The users of Facebook
have the ability to connect and share thoughts and information
with friends, join common interest groups and state their prefer-
ences (signify ‘like’). People mark ‘like’ in posts, pages and groups
they want to follow and publish their agreement, or support, of the
content published (Bird et al., 2012).

Twitter is a service through which users can post short messages
of up to 140 characters, called tweets, from web- and mobile-
based clients. Twitter has 284 million monthly active users (Twitter,

612 T. Simon et al. / International Journal of Information Management 35 (2015) 609–619

2014). Users establish a network by “following” other Twitterers,
and having others “follow” them (Vieweg et al., 2010). Users often
mark their posts with topic labels, named “hashtags”, which are
used as operational proxies to identify messages (Weng, Flammini,
Vespignani, & Menczer, 2012), and help others understand the con-
text of the message (Starbird & Palen, 2010). Information can be
redistributed by users in the form of re-tweets, which are a conven-
tion in Twitter to pass on already published information. Usually
re-tweets are a response to tweets that users find more interesting
or important (Vieweg et al., 2010).

Twitter provides an Application Programming Interface (API)
that can be used to perform searches according to keywords and
hashtags (Abbasi et al., 2010), but it is limited to accessing only a
restricted number of entities (Lerman & Ghosh, 2010) These key-
words have to be extracted from the public’s Twitter stream, as
conducted by Vieweg et al. (2010) in their research. The results can
be traced back to the Twitterer and from there, the entire stream
of tweets, replies and re-tweets can be accessed. There are many
available tools on the internet that enable visualization of data from
Twitter. Social networks’ information exchange supports the per-
sistence requirement stated by Palen & Liu, 2007 regarding forms of
communications that emerge during or after an onset of a disaster.
Persistency refers to communications that are visible, recordable,
and/or transferable to other people over time.

Another advantage of the SM compared to the traditional
media is the simplicity of collecting and disseminating information.
Utilization of traditional media websites and channels necessi-
tates an active search for information, while the SM accesses
the information newsfeeds at live and real times (Bird et al.,
2012). Coupled with an internet connection that has become
available to all, individuals are connected almost regularly and
continuously (Jansen, Zhang, Sobel, & Chowdury, 2009), which
enables them to share, coordinate and distribute information
regarding events in real time (Gupta, Lamba, Kumaraguru, & Joshi,
2013). SM provides unprecedented access to information that
is published online by various users (Hale, Gaffney, & Graham,
2012). During emergencies, the amount of available informa-
tion in SM exceeds the capacity of the public to consume it,
and thus a competition over the attention of the individual and
the public is created (Weng, Flammini, Vespignani, & Menczer,
2012).

2.2. Social media for emergency management

The utilization of SM for communicating during emergencies
was initiated by the public before its utilization by emergency
authorities. It is possible that the way emergencies are managed
and the uni-directional communication coerced the public to find
alternate ways to search and publish relevant and updated infor-
mation concerning the event (Sutton, Palen, & Shklovski, 2008).
According to Latonero & Shklovski, 2010, two main branches of
research deal with the uses of social media during an emergency;
the first focuses on ways in which emergency organizations use it
to coordinate activities during their response actions, and the sec-
ond deals with the ways the public and victims share information
during emergencies. This review article is based on 57 research
articles that delineate various aspects of the use of SM during
emergencies. Table 1 classifies these articles according to the emer-
gency/disaster type they address (natural disaster, terror attack,
communicable disease, public order and non-specific events), the
research methodology utilized (quantitative or qualitative), the SM
they cover (Twitter, Facebook, Flickr, or other), the research type
(active, passive, simulated, or exercise), and the year of the event.
The research type relates to the method the data was collected by,
where passive indicates using any computational way to collect SM
data (i.e. Twitter API). Active means that the researchers made an

Table 1
Classification of articles according to topics analyzed in each manuscript.

# Of articles Percentage Comments

Type of disaster covered
Natural disaster 26 46%
Terror attack 3 5%
Communicable disease 3 5%
Public order 2 4%
Non-specific 23 40%

Research methodology
Quantitative 31 54%
Qualitative 26 46%

Social media analyzed Some articles
cover several
types of SM

Twitter 35 61%
Facebook 11 19%
Flickr 2 3%
Other 17 30%

Research type
Active 34 60%
Passive 19 33%
Simulated 2 3.5%
Exercise 2 3.5%

Years of occurrence
2007–2008 5 9%
2009–2010 19 33%
2011–2012 9 15%
2013–2014 3 5%

‘active’ effort to collect the data/information (i.e. interviews); sim-
ulated generally refers to computer models who do not deploy real
information to run; exercise refers to research that used an exercise
to test a theory and collect the information.

Fig. 1 presents the total number of tweets in four major emer-
gency events that occurred between 2010 and 2013, and a trend line
showing the rise in SM adoption during such events. Following the
Haiti earthquake, 3.28 million tweets were posted (Sarcevic et al.,
2012); 20 million tweets were posted during hurricane “Sandy”
in 2012 (Olanoff, 2012); 27.8 million tweets were posted following
the Boston Marathon bombing in 2013 (Rovell, 2013); and, 5.72 mil-
lion tweets were posted during typhoon “Haiyan” in 2013 (Levine,
2013).

2.3. Social media and preparedness

SM provides opportunities for engaging citizens in the emer-
gency management by both disseminating information to the
public and accessing information from them. These tools have
been used to improve preparedness by linking the public with
day-to-day, real-time information, as was well presented during
the 2009H1N1 pandemic. A few minutes after the Alexandria,
Virginia health department tweeted regarding availability and loca-
tion of vaccines, people rushed to the vaccination sites (Merchant,
Elmer, & Lurie, 2011). This has presented that integration of
social tools into preparedness activities could facilitate an effec-
tive emergency response for professional responders as well as
the citizens, using familiar tools during a crisis (Merchant et al.,
2011). Despite the low cost, wide reach and proven advantages
before, during and following crises, SM tools have been shown to
be underused by health professionals (Vance, Howe, & Dellavalle,
2009).

2.4. Technology adoption and usage

Most individuals tend to use technologies that they are famil-
iar with (such as mobile phones, email and known news websites)

T. Simon et al. / International Journal of Information Management 35 (2015) 609–619 613

Fig. 1. Total number of tweets posted during emergencies between 2010 and 2013.

prior to an emergency to access information, but some adopt new
ICTs during an event. The goal is not the utilization of the technol-
ogy itself but rather how communities fulfill unmet needs through
adaptation and innovative uses of ICT (Shklovski, Palen, & Sutton,
2008). ICT offers a means for those living under extreme circum-
stances to reconnect with other residents, solicit and aggregate
information that affects them all. It has been implied that people
have “found community” (though a virtual one) through the use of
ICT, in which they actively seek others with similar needs and con-
cerns regarding their geographical communities (Shklovski et al.,
2008).

There are significant differences in the adoption of Facebook
and Twitter in terms of usage, news consumption, demographics
and the country. A Princeton led survey found that 70% of Face-
book users receive their news from friends and family and 13% from
news organizations. On Twitter, 36% of the users receive news from
friends and family, while 27% from news organizations. The survey
also found that despite the rise of news consumption through SM,
it does not come at the expense of direct access to news sites. 71%
of Facebook users and 76% of Twitter users still get news directly
from news sites or apps (Mitchell, Rosenstiel, & Christian, 2012).

2.5. Remote islands of innovation

Media coverage of an affected area is not equal in all disasters;
while central locations are widely covered; remote sites with inad-
equate access tend to receive little or no coverage at all (Fernando,
2010). The need for local and reliable information can moti-
vate residents with technical skills to create simple solutions for
their community, facilitate exchange of information and promote
humanitarian relief efforts in their area. These actions can accel-
erate empowerment of the community, provide support during
and between variable emergency events, serve as a communication
platform during a specific emergency (Procopio & Procopio, 2007),
and shut down not long after the emergency has subsided. The out-
come depends on the maturity and experience of the community
(Shklovski et al., 2008). If the public will not find or receive infor-
mation from official sources, they will turn to unofficial sources
in order to access it in real time (Hagar, 2013). Community solu-
tions appeared almost immediately following the floods that were
experienced in Australia during 2011. The local residents accessed
community Facebook pages in order to assist their families and
allow others to share photos. Though formal administrations inte-
grated official information into their web pages, the most important
source of information was accessed from local residents (Bird et al.,
2012).

2.6. Recruiting the public

Once sources of information have been recognized, technologi-
cally competent residents in the disaster area are able to utilize a
range of SM to redistribute information to community members
who might not have the same access. These community mecha-
nisms, information hubs and repositories of local information are
available resulting from the common concern and joint actions of
local area residents. Twitter users have frequently filled the func-
tion of information hubs following disasters (Hughes et al., 2008).
The unidirectional communication and information distribution of
emergency authorities might have ‘compelled’ the public to find
alternative ways to search for and disseminate updated and rele-
vant information regarding the event (Sutton, Palen, & Shklovski,
2008). People have reported feeling compelled to collect and dis-
seminate information as a way of alleviating concerns of those
around them (Shklovski et al., 2008; Bird et al., 2012). Using an
online survey Bird et al., (2012) discovered that most people iden-
tified relevant community pages through friends’ invitations, or a
Facebook search. She also presented that two-thirds of the respon-
dents accessed Facebook groups to find information regarding their
own community. Taylor et al. (2012) claimed that the activity of
people utilizing SM mirrors their actual needs, whether searching
and seeking information about what was happening, or actively
asking for information and providing assistance to others.

2.7. Crowdsourcing in disasters

The term “crowdsourcing” was first coined in 2006 refer-
ring to organizations outsourcing tasks to the connected crowd,
irrelevant of their location or identity (Howe, 2006). It is also
defined as an “online, distributed problem-solving and production
model” (Brabham, 2008), allowing “capable crowds to participate in
various tasks, from simply ‘validating’ a piece of information or pho-
tograph to complicated editing and management” (Gao, Barbier, &
Goolsby, 2011).

Following the 2011 Haiti earthquake, an unprecedented activity
was observed in which many communities world-wide under-
stood that they did not need to be in Haiti physically, in order
to provide assistance. Through common workgroups established
in 2009, as CrisisCamps and CrisisCommons, civilians, NGOs, gov-
ernments and private companies combined their efforts to collect
massive amounts of data to create maps. These maps were dissem-
inated directly to the Haitian government, emergency responders
and the US Army that were on site (Zook, Graham, Shelton, &
Gorman, 2010). Crowdsourcing was incorporated to the DM field

614 T. Simon et al. / International Journal of Information Management 35 (2015) 609–619

following the 2010 Haiti earthquake when Ushahidi’s crowd-map1

became a shared social disaster response tool for responders lever-
aging information from the “crowd” (Starbird, 2011; Abbasi et al.,
2010). Crowdsourcing platforms enable the creation of different
types of maps rapidly, thus facilitating the shift of existing limited
resources to other tasks (Zook et al., 2010), as well as collection
and analysis of information concerning damages in the area of
the event (Yang et al., 2014). These platforms include two types
of users – those located at the scene of the event (on-site) that
perform rescue and management operations and need updated
information, and remote users (off-site) that are able to perform
different tasks in order to assist the on-site users, such as the infor-
mation analysis and provision of updated information. This form
of work may provide real-time or per-request information to the
field emergency management personnel (Yang et al., 2014), and
enable the creation of a virtual teams, or virtual operation support
team (VOST), which can assist the response efforts (Denis, Hughes,
& Palen, 2012).

2.8. Information categories

The public can assist during emergencies in classifying and sor-
ting the large amounts of information flowing through SM, enabling
simplification of its analysis and processing (White, Plotnick,
Kushma, Hiltz, & Turoff, 2009). Information disseminating on SM
can include updates regarding the writers’ status, links to news
sites, and emotional messages to those affected by the event, as
well as humoristic messages (Skinner, 2013). Chew & Eysenbach,
2010 presented in their research that the public publishes 14 dif-
ferent types of information through SM – news, information or
updates about the event; personal experiences; personal opinion
and interest; jokes; marketing and advertising; spam and irrelevant
information to the event; humor and sarcasm; joy; risk reduction;
concern, fear, anxiety and/or sadness of the writers towards oth-
ers; despair and anger; misinformation; and questions about the
event/subject. Each piece of information on SM can be assigned
to one or more categories as it includes both direct information
derived from the text, as well as information derived from its anal-
ysis, such as the mood and attitude of the writer (Jansen et al.,
2009). In contrast, another group of researchers (Imran, Elbassuoni,
Castillo, Diaz, & Meier, 2013) stated that it is sufficient to divide the
information during emergencies to two main categories – personal
(relevant to family and friends of the writer) versus informative
information (relevant to the public).

2.9. Location based information

Following a disaster, there is a significant demand and need
for maps and spatial information, as presented after the Haiti
earthquake in 2010. In order to implement an effective response,
the emergency responders need to receive information as to the
location of the afflicted population and how best to reach them
promptly (Zook et al., 2010; Abbasi et al., 2010)

MacEachren et al. (2011) found that “social media is becoming
increasingly geographic” and the potential use of this information
in emergencies had been recognized by both academic institutions
and the emergency organizations themselves (MacEachren et al.,
2011; Palen & Liu, 2007).

Tweets and Facebook posts can provide two types of loca-
tion based information. The first is Geo-location data which is
clearly identifiable information that includes street addresses and

1 Ushaidi’s platform is based on Web 2.0 technologies which handle data inte-
gration from a variety of social media sources using crowdsourcing techniques to
(Denis et al., 2012) create SA reports and cooperation (Gao et al., 2011).

intersections, city and county names, highways and place-names,
whether precise or more general. This type of information not
only aids those who access it, but also accommodates automatic
retrieval of relevant information regarding a specific emergency
event (MacEachren et al., 2011). The second type is Location-
referencing which refers to information that uses one place as a
replacement for another, or mention of location via a landmark.
These do not contain easily extractable geo-location information,
but rather data concerning the location of both individuals and the
emergency (Vieweg et al., 2010). In events where the two types
are not available, it is possible to extract the location of the user’s
residence from his personal profile, and assume that he publishes
information from the same area. This assumption carries the risk
of placing events in the wrong location, as the user might publish
information while located in a different region/country completely
(Earle, Bowden, & Guy, 2011; Hale et al., 2012). It was also found
that analyzing tweets for geographic location according to language
analysis is difficult, with low accuracy rates, and necessitates fur-
ther research (Hale et al., 2012). The stage of emergency has an
important effect on geo-location information, as during the initial
warning/alert stage people do not as yet know the entities or loca-
tions that will be affected; these are crucial during the impact and
recovery stages as there is a need for information regarding the
locations of hazards, evacuation routes, availability of resources and
efforts that are invested to manage the situation and provide relief
to the population (Vieweg et al., 2010). There are numerous tools
and platforms available that aim at locating, capturing and display-
ing geo-information based on SM (MacEachren et al., 2011). Social
mapping platforms utilize crowdsourcing capabilities to map entire
areas for roads, buildings and damage (Zook et al., 2010; Starbird,
2011). The resulting maps can be used to allow responding organi-
zations to promote collaboration between them, share information
and enhance coordination during implementation of their missions
(Gao et al., 2011). Chatfield & Brajawidagda, 2012 presented that
47% of users included their location in tweets, a fact that enabled
placing them on maps, while in the research of Vieweg et al. (2010)
it was shown that the numbers are 40%. It seems that less and less
users are adding their location to tweets, as can be seen in the
research of Starbird, Muzny, & Palen (2012) where the numbers
dropped to 0.23% out of all tweets. Hale et al. (2012) showed that
approximately 16% of the users do not include information about
their location in their personal profile. Local populations may rec-
ognize and refer to places and regions under different names, and in
fact replace the official name with a known alternative. To resolve
this issue researchers have developed an information system that
analyzes information from Twitter in order to create a database of
such names (Chan, Vasardani, & Winter, 2014). This information
may assist emergency responders in identifying the places that the
public uses without the need to mention the exact official address.

2.10. Information dissemination

In the traditional disaster management model, information
flowed from emergency organizations to the public (Low et al.,
2010). After analyzing millions of tweets Shklovski et al. (2008)
extracted and coded situational features on Twitter communica-
tion elaborating the standard information categories of emergency
management (warning, preparatory activity, fire line/hazard loca-
tion, flood level, weather, visibility, road conditions, advice,
evacuation information, volunteer information, animal manage-
ment, and damage/injury reports). The incorporation of SM tools
has changed the traditional information dissemination pathways
during emergencies. Today there are many more information
providers and a higher involvement of the public using official and
unofficial sources (Zook et al., 2010).

T. Simon et al. / International Journal of Information Management 35 (2015) 609–619 615

The mechanism for spreading information during different
disasters is similar, namely, users watch their friends’ activities or
their reported behavior, and through messaging actions, they make
this information visible to their own fans or followers (Lerman &
Ghosh, 2010). In a survey conducted by Bird et al. (2012), 97% of
the respondents claimed to have communicated and forwarded
directly the information they accessed from Facebook pages to their
family and friends. In some instances, reports issued through SM
tools appeared much earlier than through the news channels (Qu,
Huang, Zhang, & Zhang, 2011; Lerman & Ghosh, 2010). SM tools
present an excellent mechanism for information dissemination. In
Twitter, re-tweeting can cause an exponential proliferation and
dissemination of the information (Tamura & Fukuda, 2011).

A government organization that wants to use social tools during
a crisis to communicate with the public should first define its poli-
cies, receive the support of the managers, define what information
should be shared and through which channels (Kavanaugh et al.,
2011).

During the 2011 floods in Queensland and Victoria, Australia,
Facebook became the primary tool to disseminate information
to the public. In the 24 h following the flash floods, the number
of ‘likes’ to the Queensland Police Service (QPS) Facebook page
increased exponentially from 17,000 to 100,000, and two days later
it had more than 160,000 ‘likes’. Traditional media channels, such
as radio and TV, relied on the information posted on Facebook, and
reported it within minutes after it was published on the QPS page
(Bird et al., 2012). In a different study, Taylor et al. (2012) found
that although SM are popular, people are still likely to turn to the
television for emergency information. Nevertheless, the research
also shows that SM serve as a conduit, directing people “to official
sources of information and amplifying these messages to a broader
audience” (Taylor et al., 2012).

2.11. Disinformation and inaccuracy

The identity of users and accuracy of the information they post
on SM sites cannot be guaranteed (Merchant et al., 2011). During
emergency events, individuals are exposed to large quantities of
information without being aware of their validity or risk of misin-
formation (Lu & Yang, 2010).

Zook et al. (2010) wrote that for recovery operations follow-
ing a disaster, only “Good enough” geographic information can be
sufficient, and that crowdsourced information is as useful as infor-
mation produced by an expert. Zook et al. (2010) added that “with
enough people working together, any errors by one individual can
easily be corrected by another” (Zook et al., 2010).

Even though rumors and inaccurate information can be dis-
seminated during the peak of a disaster, users are usually swift to
correct them, thus making the SM “self-regulating”. More so, offi-
cial authorities publish corrections to disinformation and rumors
using their own SM sites (Bird et al., 2012). In their work, Mendoza,
Poblete, & Castillo, 2010 followed the propagation ‘confirmed
truths’ and ‘false rumors’ on Twitter after an earthquake in Chile.
They found that approximately 95.5% of tweets validated the ‘con-
firm truths’, and only 29.8% validated the ‘false rumors’; while
more than 60% denied or questioned them (Mendoza et al., 2010).
According to Taylor et al. (2012) research found that only a very
small percentage (6%) of the population will rely solely on SM for
information, resulting from their suspicion of the validity of infor-
mation. It was also stated that in order to maintain integrity and
trust, the administrators of the SM pages must identify and ban as
early as possible ‘trolls’2 and other disturbances. It should though

2 A ‘troll’ is internet slang for those who provoke other users and disrupt discus-
sion (Taylor et al., 2012).

be taken under consideration that maintaining trust and rebutting
misinformation, requires a high level of active management that
can be challenging to community-based SM channels (Taylor et al.,
2012).

In their research, Latonero & Shklovski, 2011 presented that val-
idating information accessed from the public poses a big challenge
to the emergency organizations that need to decide whether or not
to commit resources, based on the information supplied. Accord-
ing to their findings, the emergency management professionals that
review the SM must use intuition, experience and traditional means
of communication rather than innovative technological solutions
(Latonero & Shklovski, 2011). As the information flow increases,
emergency authorities have less control over it, and might be pres-
sured to validate and authenticate the information generated by
the public (Zook et al., 2010)

2.12. Emergency responders and social media

Only limited scientific literature focus on emergency respon-
ders and their use of social media. Nonetheless, many researchers
have noted the potential use of this media by emergency respon-
ders, and stated that if used, their ability to reach larger crowds
faster will increase significantly (Denis et al., 2012). The London
Police started using social media as an additional communication
channel with the public during the riots of 2008 (Crump, 2011), and
again in the riots of 2011 (Denef, Bayerl, & Kaptein, 2013). Since the
2010 earthquake in Haiti, emergency responders around the world
have adopted social media as an important additional communica-
tion channel with the public (Bird et al., 2012; Sarcevic et al., 2012).
Hurricane “Sandy” in 2012 was a turning point where the majority
of emergency authorities and first responders from the East Coast in
the United States adopted social media as the main communication
channel with the public (2013). In Kenya, all of the first respon-
der organizations use social media as the major communication
channel with the public during emergencies, as manifested in the
Westgate Mall terror attack in 2013 (Simon, Goldberg, Aharonson-
Daniel, Leykin, & Adini, 2014).

Rapid assessment of critical information, such as the affected
area, distribution of damage, locations of the population and poten-
tial areas where search and rescue missions are likely to be
required, are of high priority in DM (Durham, Johari, & Bausch,
2008). Emergency authorities must verify the information they
publish, so there is an eventual delay until it is delivered to the
public (Bird et al., 2012), but it will be needed and requested on a
near real-time basis (Zook et al., 2010).

The decision making process for official emergency response
that is provided by the various organizations are part of
the government’s responsibility; political considerations may
make large-scale adoption of technologies complex (Latonero &
Shklovski, 2011).

Emergency authorities are often structured in hierarchical,
rank-based organizations which operate according to specific
“silos” with particular expertise, as described by Yates & Paquette,
2011. During the Haiti earthquake in 2010, the US Government
and Armed Forces relied almost completely on organizational SM
tools (Microsoft SharePoint) to coordinate knowledge and actions
between cooperating response agencies (Yates & Paquette, 2011).
The traditional risk and crisis communication was one-way from
the emergency organizations to the public through the news media
(TV and radio), acting as intermediaries. Although these chan-
nels remain the primary means of communication, integrating SM
provides the potential for “interactive, participatory, synchronic,
two-way communication” (Latonero & Shklovski, 2011; Palen & Liu,
2007).

A government organization that wants to use social tools during
a crisis to communicate with the public should first define poli-

616 T. Simon et al. / International Journal of Information Management 35 (2015) 609–619

cies, receive support of the management, define what information
should be shared and through which channels (Kavanaugh et al.,
2011).

It has been recommended that every organization utilizing tech-
nological solutions and integrating SM for emergency response,
should incorporate professionals with Information Technology (IT)
expertise, as Public Information Officers (PIO) and technology
‘evangelists’ (Latonero & Shklovski, 2011), SM moderators (Bird
et al., 2012; Qu et al., 2011), or a Communications and Informa-
tion Technology expert to configure SM tools (Yates & Paquette,
2011). Nevertheless, emergency managers also do not want to be
distracted by too much information that might be irrelevant or
not-critical (Bharosa et al., 2010).

Understanding the “overall picture” during a disaster may be
difficult as the ever-growing information flow is being updated
constantly, while large portions of it are redundant (Qu et al.,
2011). Kavanaugh et al. (2011) stated that emergency managers can
“detect meaningful patterns and trends in the stream of messages
and information flow”, and emergency events “can be identified
as spikes in activity, while meaning can be deciphered through
changes in content” (Kavanaugh et al., 2011).

2.12.1. Budget and training
Using SM entails two types of costs that should be considered.

The first is the cost of training employees that will operate and pub-
lish information through SM tools, although it has been shown that
most government employees have a profile on at least one SM tool.
This might reduce costs and shorten training programmes. The sec-
ond is more covert, referring to the return-on-investment (ROI) of
using SM tools (Kavanaugh et al., 2011). Latonero & Shklovski, 2011
presented in their case study that emergency organizations lever-
aging SM do not train their PIOs, relying solely on their self-learning
skills, and depending on “their ability to utilize social media effec-
tively”. Furthermore, Denef et al. (2013) stated that as SM are novel
communication channels for the emergency responders and there
are almost no available guides or procedures, they are required
to practice their use. There are guiding principles that emergency
organizations provide to their employees regarding the need to
separate their personal profile from their organizational presence
(Beneito-Montagut, Anson, Shaw, & Brewster, 2013).

To effectively use SM tools in disaster situations, they should be
utilized by the involved parties during routine times and incorpo-
rated in daily activities. In the last three years, disaster simulation
games were encouraged in order to test the ability to collect infor-
mation from SM tools during different stages of a disaster. During
these exercises, people posted messages through SM tools and took
part in crowdsourcing tasks (Abbasi et al., 2010). Another exer-
cise leveraged social media tools in response to an earthquake.
The exercise was performed by actual first responders who used
social media, on top of in addition to conventional communica-
tion technologies, to improve their search and rescue operations
(Simon, Adini, El-Hadid, & Aharonson-Daniel, 2013). In the last few
years, the organizers of the Great California Shakeout Drill have
used social media to enhance communications prior to and dur-
ing the drill, as well as to extract feedback from participants. The
use of social media enables the organizers to reduce the number of
resources required (Wood & Glik, 2013).

2.13. Challenges to data analysis

On August 22nd, 2012 Facebook revealed some statistics
regarding its daily information flow. Facebook ingests daily more
than 500 terabytes of data, 2.5 billion pieces of content, 2.7 bil-
lion ‘likes’ and 300 million photo uploads (Constine, 2012). Twitter
has more than 400 million tweets daily, and above 140 million
active users, most of which use Twitter via mobile devices (Farber,

2012). SM sites constantly produce vast amounts of information,
both relevant and irrelevant. Using filtering and pattern recognition
on the data streams, emergency managers can access important
and meaningful information in real-time, and be able to provide
an immediate response, and understand events as they unfold
(Abbasi et al., 2010; Kavanaugh et al., 2011; Sheth, Purohit, Jadhav,
Kapanipathi, & Chen, 2011). Over time, the detected patterns can
provide responders with perceptions and trends of communities.
Conducting surveys via phone or mail requires substantial efforts
prior to and during data collection, as well as substantial funding.
Analyzing the results often takes months to complete. Information
flow through social tools is a much more effective and economical
method to gather data in real time. In 2009 the American Red Cross
conducted a survey which presented that 75% of the population
reported that they will use SM during a crisis situation; approxi-
mately 50% would let others know that they were safe through SM;
86% would use Facebook; and 28% would use Twitter (Kavanaugh
et al., 2011).

Studying Twitter communication during emergency events is
challenging as access to tweets is short-lived, requiring quick deci-
sions regarding what information to collect while the event is still
in progress, but before its scope and data produced are fully under-
stood (Vieweg et al., 2010).

SM sites continuously create large amounts of information
with different degrees of relevancy. For example, during hurri-
cane “Sandy”, approximately 20 million tweets were published on
Twitter, and about 10 photos related to the storm were uploaded
to instagram every second. Numerous entities, both official and
non-official, publish information simultaneously, including civil-
ians, government or private organizations, journalists, news sites
and others that create an information overload during emergen-
cies, making it difficult to find, organize, understand and act upon
it (Hagar, 2013; Verma et al., 2011; Kavanaugh et al., 2011).

Approximately 300 million users publish hundreds of millions
of tweets daily (Hale et al., 2012). Manual analysis on such amounts
of information is not possible, especially in times of stress during
emergency management, and thus automated systems that enable
real-time monitoring of the flow of information are required (Pohl,
Bouchachia, & Hellwagner, 2012). At the same time, there is a need
to prevent cognitive overload of the commanders and decision
makers by flooding them with such unlimited information (Blum,
Eichhorn, Smith, Sterle-Contala, & Cooperstock, 2013). The writing
style of tweets, due to the length constraints and the use of natural
language, complicates the automatic analysis capabilities, such as
different names people assign to events and locations (Chan et al.,
2014).

2.14. Global social sensors

SM that connect millions of users worldwide and enables rapid
communications can be leveraged as an effective mechanism to
transfer information without delay (Chatfield & Brajawidagda,
2012). Furthermore, the internet and SM tools enable health profes-
sionals to transform the ways in which disease outbreaks and other
disasters are tracked and responded to (Schmidt, 2012; Cookson
et al., 2008). It was even shown that using Twitter, H1N1 out-
breaks and activity can be identified in real-time, 1-2 weeks prior to
detection based on the Centers for Disease Control and Prevention’s
(CDC) surveillance system (Signorini, Segre, & Polgreen, 2011).

The US Geological Survey (USGS) has reported that 75% of earth-
quake detections through tracking tweets containing the word
“earthquake” were made within 2 min of the origin time. This rep-
resents a much faster identification than seismographic detections
in many regions in the world, and has a low rate of false triggers
(Earle et al., 2011).

T. Simon et al. / International Journal of Information Management 35 (2015) 609–619 617

The first indication of a number of emergencies throughout
the world was published on Twitter, which enabled the publica-
tion of information to large crowds in real time. The World’s first
posts on two terrorist incidents in 2013 were published initially via
Twitter: the Boston Marathon bombing (Cassa, Chunara, Mandl, &
Brownstein, 2013), and the Westgate mall terror attack in Nairobi,
Kenya (Simon et al., 2014).

On August 8th, 2014 the World Health Organization (WHO)
declared the Ebola epidemic outbreak in West Africa as an inter-
national emergency (WHO, 2014). From reading traditional media
websites, it is clear that social media takes an active and impor-
tant role, whether in the dissemination of news and information by
government agencies (Murphy, 2014), and in the spread of rumors
and misinformation that might even put the lives of their read-
ers at risk (Blair, 2014). Crowdsourcing platforms are also active
in tracking the Ebola outbreak on social media, and assist in locat-
ing suspected Ebola cases (Morgan, 2014). The research papers that
have been published to date, focus mainly on the risks of rumors
and misinformation spreading on Twitter (Oyeyemi, Gabarron, &
Wynn, 2014).

3. Conclusions

SM tools are integrated in most parts of our daily lives, as
citizens, netizens, researchers or emergency responders. Lessons
learnt from disasters and emergencies that occurred globally in the
last few years have shown that SM tools may serve as an integral
and significant component of crisis response.

Emergency managers who were formerly used to one-
directional dissemination of information to the population are now
exposed to vast amounts of information, originating from the pub-
lic. This crowd-information precedes any other formal available
information and exposes emergency managers to a large influx of
information.

The innovative usages of SM tools during disasters were initiated
by resourceful individuals and then incorporated by the public for
their own objectives. During and mostly after a disaster, new ways
of utilizing SM tools to collect, share, and disseminate information,
were witnessed. Emergency authorities, NGOs and governments
were “coerced” by the public’s demands and needs to use the SM.
Researchers from different academic professions, such as sociol-
ogy, psychology, computer sciences, health sciences, emergency
management and communication strive to develop new tools to
analyze trends in the extensive data flows and transform them into
knowledge.

Four main types of SM users during disasters have been iden-
tified including: (1) Innovative – users who improve and adjust
SM for their special circumstances; (2) Reactive – users who try
to respond and assist the afflicted population using SM tools for
the first time; (3) Responsive – emergency responders that use SM
tools regularly, but step-up and leverage them during disasters;
(4) Proactive – users or emergency organizations that use SM tools
to promote preparedness in routine and are able to leverage them
during emergencies.

Twitter is currently the most widely researched SM tool, proba-
bly due to the ease of extracting information, while Facebook does
not provide an effective option to search or collect information from
its pages. These differences might cause a “selection bias” in the
research, thus not representing the population’s true SM behavior
during emergencies.

Further studies of the potential utilization of the social media
by first responders and governmental agencies prior to and during
disasters, are highly recommended.

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Socializing in emergencies-A review of the use of social media in emergency situations
1 Introduction
1.1 Disaster characteristics
1.2 Social order
1.3 Disaster management
1.4 Communication challenges
1.5 Loss of communication
1.6 Public participation
1.7 The need for information

2 Social media
2.1 Short introduction
2.2 Social media for emergency management
2.3 Social media and preparedness
2.4 Technology adoption and usage
2.5 Remote islands of innovation
2.6 Recruiting the public
2.7 Crowdsourcing in disasters
2.8 Information categories
2.9 Location based information
2.10 Information dissemination
2.11 Disinformation and inaccuracy
2.12 Emergency responders and social media
2.12.1 Budget and training

2.13 Challenges to data analysis
2.14 Global social sensors

3 Conclusions
References

A-learning-organization-in-the-service-of-know_2015_International-Journal-of

International Journal of Information Management 35 (2015) 636–642

Contents lists available at ScienceDirect

International Journal of Information Management

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i n f o m g t

Case study

A learning organization in the service of knowledge management
among nurses: A case study

Marie-Pierre Gagnon a,b,∗, Julie Payne-Gagnon b, Jean-Paul Fortin c, Guy Paré d, José Côté e,f,
François Courcy g

a Faculty of Nursing Science, Université Laval, 1050 avenue de la Médecine, Quebec City, Canada
b CHU de Québec Research Center, 10 rue de l’Espinay, Quebec City G1L 3L5, Canada
c CSSS de la Vieille-Capitale, 880 Père-Marquette, Quebec City G1S 2A4, Canada
d Department of Information Technology Management, HEC Montréal, 3000 chemin de la Côte-Sainte-Catherine, Montreal H3T 2A7, Canada
e Faculty of Nursing Science, Université de Montréal, 2375 chemin de la Côte-Ste-Catherine, Montreal H3T 1A8, Canada
f CHUM Research Center, 850 rue St-Denis, Montreal H2X 0A9, Canada
g Department of Psychology, Université de Sherbrooke, 2500 boulevard de l’Université, Sherbrooke J1K 2R1, Canada

a r t i c l e i n f o

Article history:
Received 29 April 2015
Accepted 9 May 2015
Available online 23 May 2015

Keywords:
Learning organization
Knowledge management
Nursing
Continuous learning

a b s t r a c t

It becomes critical for health care organizations to develop strategies that aim to design new work prac-
tices and to manage knowledge. The introduction of learning organizations is seen as a promising choice
for better knowledge management and continuing professional development in health care. This study
analyzes the effects of a learning organization on nurses’ continuing professional development, knowl-
edge management, and retention in a health and social services centre in Quebec, Canada. The learning
organization seemed to affect daily nursing work in a positive manner, despite its variable impact on
other professionals and other sites outside the hospital centre. These changes were particularly pro-
nounced with respect to knowledge transfer, support for nursing practices, and quality of health care,
objectives that the learning organization had sought to meet since its inception. However, it seemed to
have a limited effect on nurse retention.

© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Today’s society emerged as a result of a transformation from an
industrial era to a knowledge era, leaving room for the creation,
collection, and use of knowledge (Johannessen & Olsen, 2010). As
highly knowledge intensive institutions requiring continuous edu-
cation in order to improve their potential (Tsai, 2014), health care
institutions have seen their knowledge capital increase in impor-
tance with the transformation of society (Estrada, 2009; Tsai, 2014).
Health care professionals are also in need of knowledge since their
practice requires lifelong learning in order to improve their com-
petencies and provide effective and quality care for their patients
(Tsai, 2014).

∗ Corresponding author at: Faculty of Nursing Science, Université Laval,
1050 avenue de la Médecine, Quebec City, Canada. Tel.: +1 4185254444×53169;
fax: +1 4185254194.

E-mail addresses: marie-pierre.gagnon@fsi.ulaval.ca (M.-P. Gagnon),
julie.payne-gagnon@crchudequebec.ulaval.ca (J. Payne-Gagnon),
jean-paul.fortin@fmed.ulaval.ca (J.-P. Fortin), guy.pare@hec.ca (G. Paré),
jose.cote@umontreal.ca (J. Côté), francois.courcy@usherbrooke.ca (F. Courcy).

On the other hand, health care institutions are also facing impor-
tant challenges in the area of knowledge management. Managing
knowledge in health care organizations is complex since they are
multi-level and multi-site networks with central management,
but also strong local organizations (French et al., 2009). Also, the
sheer amount and fragmentation of information, rapid expansion of
knowledge, and context dependency make it impossible for a per-
son to access all the available knowledge in this domain (Estrada,
2009; French et al., 2009). Additionally, the health care sector is
experiencing a widespread nursing shortage in many developed
and developing countries around the globe (Buchan & Aiken, 2008;
Littlejohn, Campbell, & Collins-McNeil, 2012), and faces an ageing
population (World Health Organization, 2010). An important loss
of knowledge capital is attributed to the retirement of experienced
and knowledgeable nurses across the institutions (Clauson, Wejr,
Frost, McRae, & Straight, 2011). This situation is alarming due to
the possible consequences that they may have on health care pro-
fessionals practice as well as access, security, and quality of health
care (Clauson et al., 2011; Estrada, 2009).

In this context, it is critical for health care organizations to look
for innovative solutions, as well as to develop strategies that aim to
design new work practices and to manage knowledge. Among the

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0268-4012/© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).

dx.doi.org/10.1016/j.ijinfomgt.2015.05.001

http://www.sciencedirect.com/science/journal/02684012

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mailto:marie-pierre.gagnon@fsi.ulaval.ca

mailto:julie.payne-gagnon@crchudequebec.ulaval.ca

mailto:jean-paul.fortin@fmed.ulaval.ca

mailto:guy.pare@hec.ca

mailto:jose.cote@umontreal.ca

mailto:francois.courcy@usherbrooke.ca

dx.doi.org/10.1016/j.ijinfomgt.2015.05.001

http://creativecommons.org/licenses/by-nc-nd/4.0/

M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642 637

possible solutions, learning organizations are seen as an interesting
and promising choice for better knowledge management (Davies,
Wong, & Laschinger, 2011; Zheng, Yang, & McLean, 2010).

1.1. Learning organization

The term ‘learning organization’ was popularized in Peter
Senge’s “The Fifth Discipline: The Art and Practice of the Learn-
ing Organization” (Senge, 1990). A learning organization is defined
as an organization that exhibits adaptability, learns from mistakes,
explores situations for development, and optimizes the contribu-
tion of its personnel (Wilkinson, Rushmer, & Davies, 2004). Senge
outlined five personal disciplines that are key features of a learning
organization: system thinking, personal mastery, mental models,
shared vision, and team learning (Senge, 1990). These disciplines
allow for the creation of infrastructure that promotes continuous
learning, adaptation, and growth in organizations (Estrada, 2009).
Consequently, one of the main goals of the learning organization is
to construct an organizational culture of learning (Tsai, 2014).

The development of a learning culture in an organization
involves the continuous education of its members. This process
takes place by converting individual memory, which is the accu-
mulated knowledge of an individual, into organizational memory,
which takes the form of goals, handbooks, or standard procedures
(Chen, Lee, Zhang, & Zhang, 2003). When successfully converted, it
is critical to make organizational knowledge accessible to promote
organizational learning (Chen et al., 2003). This knowledge needs
to be transmissible, easily distributable, and comprehensive so that
all members consider it valid and useful (Abel, 2008; Chen et al.,
2003). Completely integrated knowledge represents a coherent,
accessible, and maintained organizational memory, a vital aspect
in a healthy organizational learning process (Abel, 2008).

It is believed that introducing a learning culture in health care
organizations could improve the quality of professional practice,
satisfaction, lifelong learning, and patient care, while also lowering
costs (Bell, Robinson, & See, 2013). However, despite the impressive
documentation on learning organizations, studies on this topic in
health care settings remain scarce in the current literature (Bell
et al., 2013).

In order to better understand the impacts of introducing a learn-
ing organization in these settings, this study aims to explore its
effects on nurse professional, educational, and organizational fac-
tors related to continuing professional development, knowledge
management, and retention in a Health and Social Services Center
(French acronym: CSSS) of the province of Quebec, Canada. A CSSS
is an integrated health care organization that usually comprises
various types of facilities and health care services: local commu-
nity services centers, residential and long-term care centers, and,
where applicable, general and specialized hospital centers on a
given territory (Quebec Ministry of Health, 2013). This CSSS rep-
resents the only case where a formal learning organization culture
was introduced in the Quebec health care context.

2. Context of study

In 2003, a major medico-nursing crisis was caused by a fail-
ure to rescue event. Confronted with this situation, the Nursing
Directorate put in place a clinical committee on continuous qual-
ity improvement composed exclusively of nurses. Their mandate
was to understand and to identify the problems experienced by
their colleagues. Members of the committee quickly realized that
their CSSS was ill equipped for the promotion of the education and
expertise of their nurses, which threatened the quality and security
of care.

The chosen solution to these issues was the implementation
of a new organizational culture, the learning organization, which
had three main goals: better quality and security in health care,
support for nurse practice, and knowledge transfer. The imple-
mentation, which began in 2005, was done in two initial phases.
The first was the restructure of the continuous support to nurses
in their practice through a mentoring program. The second phase,
that aimed to accommodate, support, and retain employees, was
realized through the development of learning strategies focused
on the idea of knowledge that was there “just in time, just enough,
and just for me”.

A variety of strategies assisted by information and communica-
tion technology (ICT) were created to support the learning process
in the organization. Among them, the most used was the video.
The first projects involving knowledge transfer were the creation
of four DVD videos about topics judged more problematic and
that required in-depth study: newborn assessment, Plum A+ infu-
sion system, CADD pump, and the maternity unit. Later, animated
memos were added to the DVDs. As explained by the manager, an
animated memo is a few minutes video filmed in action by a sim-
ple over-the-shoulder camera. These videos are generally used to
illustrate health care practice (such as delirium management) and
were introduced to replace old paper memos scattered on notice-
boards of the facilities. Doing so made the animated memos more
accessible to employees. Other important learning strategies and
programs supported the value of continuous learning and collec-
tivity promoted by the learning organization: checklists, guidelines,
aide-memoires, procedure sheets, lunch conferences, as well as
mentoring, integration, speciality, and orientation programs.

3. Methods

3.1. Study design and participants

To investigate the learning culture implemented in this par-
ticular CSSS, we conducted an exploratory case study. The study
received the approval of the CHU de Québec ethical committee prior
to the recruitment of participants. We used a purposive sampling
approach, targeting key informants who had been involved in the
learning organization, due to the exploratory nature of the study.
Recruitment began from a list of ten individuals who had partic-
ipated in the learning organization’s projects whose names were
provided by the Nursing Directorate of the targeted CSSS. All of
the individuals on the list were contacted by phone. Before the
interviews, participants had to give their informed and voluntary
consent by reading thoroughly and signing a consent form.

3.2. Data collection and analysis

We conducted face-to-face semi-structured interviews based
on a conceptual map that was developed in the first phase of
the project (Gagnon et al., 2013). The interview guide included
three sections: the effects of the learning strategies and activities
developed by the learning organization on nursing practices, the
factors that influenced the adoption of projects developed within
the learning organization, and the influence of the learning orga-
nization on nurse retention. The interviews lasted approximately
one hour and were audio recorded with the participants’ consent.

Interviews were transcribed verbatim producing a total of 103
pages of transcripts. We then analyzed their content with the help
of the qualitative data analysis computer software NVivo (QSR
International). In order to do so, we adopted a deductive–inductive
thematic analysis, using the conceptual map as the starting point
for the codification, and completing it with emerging themes. Two
people independently analyzed the interviews and then compared

638 M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642

their codification in order to reach consensus. Interview quotes
presented in section 4 were translated into English from French.

4. Results

4.1. Participants’ characteristics

From the ten people contacted by phone, eight agreed to par-
ticipate in the study. Two declined to participate due to heavy
workload. Two more individuals, who were met at the study site,
agreed to participate, bringing the total number of participants to
ten. Eight face-to-face interviews were completed (seven individ-
ual interviews and one with two participants), and one individual
interview was done by videoconference (the participant was absent
during our visit to the CSSS). All participants but one was a nurse;
the other participant was an information technology technician
who had an important role in the creation of various learning strate-
gies assisted by ICT for the learning organization. All participants
were female. This was accidental, but not surprising considering
that the great majority of nurses in the province of Quebec are
female (Marleau, 2013). Most nurses had more than 20 years of
experience, but their tenure in their current position was more
varied, ranging between 1.5 and 20 years. Finally, half of the par-
ticipants were fairly new to the learning organization, working in
this CSSS for less than three years. See Table 1 for more details.

4.2. Changes in nursing practice

The learning organization brought important changes to nursing
practice. Specifically, it brought a new culture to the nurses based
on continuous learning at work. According to six participants, the
mentoring program for nurses of zero to five years of experience
was a good incentive to new nurses to begin and continue working
in this CSSS and a great way to promote continuous learning. Firstly,
the program integrated new nurses to their environment through
training on the basic procedures in place in the CSSS given by a
nurse-educator. Secondly, novice nurses were paired with experi-
ence colleagues in their specific field of practice in order to support

Table 1
Participants’ characteristics.

Participants’ characteristics All participants
(n = 10)a

Role
Nurse 3
Nurse-educator 2
Assistant chief-nurse 1
Chief-nurse 2
Manager 1
Technician 1

Gender
Female 10

Years of experience (nursing)
10–14 years 1
15–19 years 1
20–24 years 2
25–29 years 4

Years in current position
Less than 5 years 2
5–9 years 2
10–15 years 3
16–20 years 1

Years working with a learning organization
3 years and less 4
4–6 years 3
More than 6 years 1

a Two participants did not answer the three questions related to years of experi-
ence, reducing the total number of participants for these questions to eight.

knowledge transfer and their work. Thirdly, the nurse-educator
also conducted routine assessments of the novice nurse practice
to ensure the progression of her integration and knowledge acqui-
sition.

New nurses as well as older nurses also benefited from the
learning strategies created through the learning organization, par-
ticularly in the case of videos. The video format used for many
projects of the learning organization was considered worthwhile
by four participants since it allowed nurses to show the experien-
tial knowledge in their daily practice and to describe it visually and
audibly, something that could hardly be done before these video
projects were carried out. The four DVD videos were distributed in
the form of binder so that every installation and unit could have
access to these videos. Also, some novice nurses received DVD
copies if it was related to their speciality.

Six participants claimed that these strategies made it possible
to learn anytime and anywhere since the videos were accessible
to them at any time of the day or night on a variety of topics.
Seven participants thought that the information acquisition was
fast and believed that having the information quickly accessible
decreased the time spent for searching it. Additionally, five par-
ticipants noted that the information was customizable and eight
participants pointed out that these videos represented a great infor-
mation reminder for nurses. See Table 2 for a summary of the
changes brought to nursing practice by the videos prepared within
the learning organization.

Participants also mentioned other changes that took place in
relation to their new work environment. All nurses noticed that
the practice of care improved with the introduction of the learning
organization. Specifically, participants observed improvements in
the level of nurse autonomy; three participants noticed time sav-
ings and two participants noticed a decline in the level of stress at
work. Four participants believed that the learning organization sup-
ported the standardization of practices, and four noticed that nurses
reflected more on their practice. In terms of work satisfaction,
five participants noticed an improvement in general satisfaction
at work. Two participants also mentioned that a collective pride
among nurses seemed to take hold. Eight participants noted that
there was a feeling of recognition often associated with the learning
organization’s projects. For example, some nurses noted that more
colleagues referred to them after their participation in certain video
projects. It is also interesting to note that all of the learning organi-
zation’s projects were created by a group of chosen experts on the
topic, strengthening collaboration and communication between
nurses, and even with other professionals participating in these
projects.

Five participants believed that the exposure to the learning
organization’s programs and projects would help the process of
appropriation of information by their colleagues and, ultimately,
develop an intellectual curiosity that could bring them to “learn to
learn” by themselves. For four of them, this curiosity could even
encourage some to engage more actively to the learning organiza-
tion culture through proposing new projects or themes and even
participating directly in the creation of learning strategies. Table 3
summarizes the positive effects of the learning organization on
nurses’ work environment.

In this CSSS, the distance between the facilities is important,
and the use of ICTs was judged critical to achieve the goals of the
learning organization across the points of services. According to
three participants, the committee chose ICTs that were already
available, but that could complete similar tasks at a more reason-
able price than more expensive alternatives. The manager gave
one particular example of this re-appropriation with respect to
the videoconference. Instead of installing expensive videoconfer-
ence systems, the organization opted to use equipment that could
allow practical communication among nurses from different points

M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642 639

Table 2
Summary and selected quotes related to the changes brought by the videos to nursing practice.

Changes n Selected quotes

Information reminder 8 After a while, we forget our notions and when we come back with a video that reminds us of the outlines, we
can get back to the basics more easily . . . We are more aware that we have forgotten information and need to
read up on it again. [. . .] Or we remember teaching that was done in the morning. The nurse can say that we
will look at the video again, together. That’s its purpose. (Nurse)

Fast information acquisition 7 Suppose that you don’t know a procedure or a technique. Before, I would take my big notebook of techniques,
I would browse through it until I got to. . . Oh, there it is! I would need to read the technique, memorize it, see
it with someone or have someone show me. It’s the same thing now. There are cases when nurses do not
remember certain procedures or techniques. They need to seek that information somewhere. What the
learning organization does is to make the information available right then and there. (Nurse-educator)

Accessible knowledge 6 There are often relatively few nurses on the floor, one or two per shift. If on a Saturday evening at 10:00 PM a
young nurse needs an application of the displacement pump, and she doesn’t know how to do it, well, it’s for
these reasons that we created the learning videos. (Nurse-educator)

Customizable information 5 There are some people who still like paper. But if you want, I can give you another format. You can listen to it
on the iPad, you can watch it at home, and you can see it directly on the computer if you know how it works.
[. . .] It’s a new way to present things. It’s interesting for them. (Nurse-educator)

Demonstration of experiential
knowledge

4 The nurse will do something automatically sometimes. After that, you ask her to describe the technique that
she used. . . She will write it out, but the little thing she did to save time is not written. That’s experiential
knowledge. We were not transmitting such knowledge. We were wondering how it was done. We would start
videos and nurses noticed: “Hey I do that; I didn’t think that I was doing that. . .” We began writing things
down and describing them, and we noticed that there were a lot of unspoken actions. (Chief-nurse)

of services while being economical and mobile. The chosen equip-
ment for these tasks was the iPad and iPhone. These devices did not
produce the same video quality as dedicated videoconference sys-
tems, but they still fulfilled the functions entrusted to them. iPads
and iPhones were also used for remote support of novice nurses.
The novice nurse had the possibility to call the nurse-educator for
a direct consultation when encountering an issue with a patient.

Additionally, these devices allowed access to the videos created
by the learning organization, since all of them were integrated into
the system by the technical team before giving them to the nurses.
For six participants, this access was particularly interesting when it
came to the transportability of information, especially in home care.
For three participants, these devices were seen as easy to handle

Table 3
Summary and selected quotes related to the positive effects of the learning organization on nurses’ work environment.

Effects n Selected quotes

Improved care 10 [The learning organization] has a ripple effect, we optimize our knowledge, we train the young nurses, we
transfer our knowledge and we reinforce our team. [. . .] All these projects share the concern to optimize our
care and to offer a better service to our clientele. (Nurse)

Feeling of recognition 8 Since I was part of one of these projects, I helped a nurse who had to work with [the equipment the project
was on]. I was also the expert that assisted a nurse for a new project [for another equipment]. New nurses, and
even the older ones. . . those who are doing their bachelors, they refer to us a lot more since the project. It was
enjoyable. I liked it. (Nurse)

Appropriation of information 5 It is to recognize expert nurses in their fields, the leaders. They’re the key persons to seek out. They’re the one
that have credibility and those we want to see in the videos. People will identify to them. The novice that sees
[the expert] in the video says: “She is in the TV, she must be quite the expert!” You recognize the person and
her personality. It makes the videos enjoyable to watch. You cannot do otherwise than to understand why you
need to change your practice. It has an impact. And you want to follow them in these projects. (Nurse)

Increase in work satisfaction 5 Nurses are more satisfied since they have now their say in the projects, can suggest ideas and management is
more attentive to what they say. (Technician)

Engagement in the organization 4 I believe that it’s a significant project, it’s a team project. It created a synergy and pride. Because when the
product is out, and we receive praises, it falls down on all the team. And it stimulates others to do projects,
too. (Nurse)

Reflection on practice 4 I find that nurses will be more alert, they will raise questions on the procedures. “Is it the last version? It is
really like that? Is it well like that?” I am more solicited at this level as an educator. (Nurse-educator)

Standardization of practices 4 What the learning organization allows me to do is to ensure a basis. For example, if I take work or work results
that the learning organization has done for the maternity unit, it allows me to give a concrete training to
young nurses or beginner nurses who will be novices in the maternity specialty. To give them the same
functioning basis. (Chief-nurse)

Gains in time 3 We won’t send them [outside the region] for training on leadership. We won’t bring somebody over from
outside the region for one or two full days like before. We will take someone from here, that we know she has
strengths, and we will organize something short, such as a little clinic. We will film it. We will make a video,
and make a tool with it. We will make something so that the nurse will be able to plan and make her daily
team meetings more efficient. (Nurse-educator)

Collective pride 2 The learning organization was a process. People like it. They like the organization. It is a source of pride,
collective pride. We diminished our medication errors. [. . .] Employees are committed to improve, committed
to learn to learn, committed themselves. You don’t need management. It created more autonomy, more pride.
We want that people be able to solve problems by themselves, all the time. (Manager)

Diminution of stress 2 It is especially the retention, the increased confidence for novices, to bring them to be expert rather quickly.
That’s what we ask from them. It’s really, really stressing for them. I think that an environment where they
feel good, where they feel supported by older nurses and where they can enjoy multiple tools to update or
improve their competencies is important. (Nurse)

640 M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642

and not requiring technical support, even though four participants
believed that this support was available to the nurses.

According to all participants, the use of ICTs was gaining
popularity among nurses. Indeed, they noticed that the nurses
increasingly used ICTs as much for communicating than acquir-
ing information in the workplace. One nurse even hoped for the
complete computerization of the strategies used by the learning
organization. Summary of the changes brought to nurses by the
ICTs implemented within the context of the learning organization
can be seen in Table 4.

As explained in Section 2, the learning organization’s commit-
tee pursued three main objectives in the CSSS: better quality and
security in health care, support for nurse practice, and knowledge
transfer. The comments that were collected suggest that these goals
were met. Indeed, all participants emphasized that the learning
organization brought about an important improvement in these
three fields.

4.3. Variable impact

Despite the positive effects of the implementation of a learn-
ing organization on nursing practice, its impact was uneven across
the CSSS. According to five participants, the involvement of other
health professionals (apart from nurses) was very low. Being a
nurses’ initiative, the creation of a learning culture was presented
to the other professionals later in the change process and they
were not always involved in learning strategies projects, which
made it more difficult for these workers to take ownership of the
project. Moreover, introducing the learning organization required
an important process of culture change. This was not carried out
symmetrically among the facilities of the CSSS. For instance, nurses
from one local health center reported that they would not take part
in conferences at the hospital center that is a 45-min drive away. A
nurse at another facility reported that people were not conscious
of being part of a learning organization; it was just another project
for them.

This situation was caused in part by the role that the hospi-
tal center played in the learning organization. According to the
comments gathered during four interviews, the majority of the
learning organization’s projects were conceived, created, and car-
ried out at the hospital center. This situation provided little room
for the learning organization to be integrated into the other facili-
ties, which hampered its incorporation in their environment. At the
hospital center, the learning organization was omnipresent on all
floors, especially in the form of posters presenting past and ongo-
ing projects. This presence was less noticeable in the other two
facilities visited.

It should further be noted that accessibility problems caused by
the fact that the organization could not equip all its facilities with
new equipment and decent network access, due to a limited budget,
were also an important factor explaining the dissymmetry between
the hospital center and some of the other facilities. According to
six participants, these deficiencies resulted in major accessibility
issues when it came to using the learning strategies assisted by
ICT in facilities that were not up-to-date on the technological level.
Also, two participants noted that there was some resistance over
the use of ICTs for communicating and for learning among certain
nurses, particularly the older ones. See Table 5 for a summary of the
barriers to the adoption of the learning organization in the CSSS.

Lastly, participants perceived that the effect of the learning orga-
nization on nurse retention was limited. Even if seven participants
highlighted that the implementation of this culture could help the
retention of nurses in the CSSS, most believed that other factors
were more important. Origins (ten mentions), work environment
(eight mentions), and family situation (six mentions) were iden-
tified as the most important incentives in the choice of nurses to
work in the CSSS. Nevertheless, all the participants believed that the
learning organization was important to support nursing practice
and knowledge transfer.

5. Discussion

Our study identified many impacts that a learning organization
has when it comes to supporting nurses. It also outlined the learning
organization’s adoption factors in a CSSS in the province of Que-
bec, Canada. Few studies have analyzed the effects of a learning
organization in health care settings (Bell et al., 2013). This research
sought to help fill this gap by contributing to the understanding
of the effects of introducing a learning organization in a Canadian
health care institution. This project also aimed to explain how the
learning culture influenced nursing practices, the service organi-
zation, and knowledge management, as well as how the evolution
of the organizational culture resulted from the introduction of the
learning organization.

Overall, the interviewed participants seemed to believe that
the learning organization addressed the lingering issues of de-
professionalization of the nursing profession and challenges related
to the transfer of knowledge in this CSSS located in a remote region.
One of the learning organization’s preferred learning strategies
assisted by ICT for knowledge transfer is video, in the form of
DVDs or animated memos. These homemade videos allowed easier
transmission, not only of the explicit knowledge associated with
nursing practice, but also of the experiential knowledge embedded
in nursing practice that would otherwise be hard to formalize. The

Table 4
Summary and selected quotes related to the changes brought by the ICTs to nursing practice.

Changes n Selected quotes

Transportability of the information 6 There are no more nurses who go for nothing to patients’ homes, I don’t have patients who are not treated,
there are no more refusals. With [an iPhone or iPad], a nurse can go to a home, see the video section she needs
and program a pump. (Manager)

Available support for ICTs 4 I am not really into computers! So, we’re really lucky to have since two, three years, an intern specialist that
programmed for us and show us how to work with these technologies. We also have many IT technicians.
When we have an issue, or we do not know how to use it, they give us little training or information that allow
us to work with them. We are very well supported at the technical level. (Nurse-educator)

Ease of handling 3 I learned [to use iPads] on the fly. I had also the technician who was there. She was very skillful, patient and
kind. There were also trials and errors. I brought it at home and I played with it, then I worked with it. At first, I
was embarrassed to bring it at home. It is a work instrument; I won’t have fun with it at home, go on the
Internet and things like that! The technician told me that it was made for that, and after playing with it, I
would master it and do a lot of things with it. . . She was right.

Technologies at reasonable costs 3 A problem we had, and a key to our success, was that we were small and we didn’t have the means. IT did not
want to help us, so we went with resources from the community. These resources were: cameras, television,
DVDs, iPads, iPhones. We went with the things on the market. We didn’t go with e-learning companies since it
was so huge, heavy and practically counter-productive compared to our upcoming needs. (Manager)

M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642 641

Table 5
Summary and selected quotes related to the unfavorable factors to the adoption of the learning organization.

Factors n Selected quotes

Inappropriate network access 6 At the hospital center, we are lucky; we have a broadband that is pretty strong. The problem is when you look
into residential and long-term care centers or some local community services centers, where there are only
one or two places in the facility where nurses can go and watch videos. The level of accessibility of the
information is not equal everywhere. (Nurse-educator)

Low involvement of other professionals 5 There’re not a lot of multidisciplinary teams [for the projects]. It really needs to be an issue that touches
everyone. [. . .] There’s maybe an influence [of the learning organization on other professionals], but I don’t see
it. They don’t see which videos we do. They hear about it, but they don’t see any of it. (Nurse-educator)

Centralization around the hospital 4 There are a lot of people [outside the hospital center] who are not aware or don’t know the amplitude of [the
learning organization]. They know it is something interesting, they hear about it, they know the outlines, but
they’re not that involved in it. (Chief-nurse)

Resistance of nurses 2 Some nurses on the work floor, such as the older nurses, are stuck in a routine and say “[the learning
organization] is not for me. I don’t have time for these things. I will go take my break and don’t bother me with
it”. [. . .] Saying that they don’t have the time is a lack of interest in disguise. It’s the classic and fatal excuse: I
don’t have the time. I don’t believe so. If you want to be up to date, you always have the time for something.
(Nurse-educator)

latter statement is consistent with solutions proposed by Nonaka,
Toyama, & Konno (2000) and followed by the learning organiza-
tion committee, which consist of using observation and imitation
to overcome the communication barrier surrounding this particular
type of knowledge. By using videos to transfer knowledge, nurses
created collective knowledge that preserved both explicit and tacit
knowledge of their profession.

Moreover, peers and mentors transmitted to both young and
more experienced nurses the ideas behind the learning organiza-
tion and the value of “learning how to learn”. This type of transfer,
adopted by the learning organization committee, follows the ideas
of Marchand and Lauzon (2007) who assert that, ultimately, nurses
should learn to learn and internalize the tools available in the orga-
nization to improve their practice. This is also consistent with other
authors who state that continuous learning in action, as seen with
the learning organization, is more likely to influence behavior than
other more traditional, passive and non-interactive learning meth-
ods (Borbolla et al., 2013; Van Hoof & Meehan, 2011). Moreover, the
literature supports the idea that continuing learning environments
not only enhance the quality of work for health professionals, but
also improve outcomes for clients (Pool, Poell, & ten Cate, 2013),
which is in line with the objectives of the studied organization.

Other changes were brought about by the learning organiza-
tion as regards nursing practice, such as improved communication
among nurses, as well as their collaboration, thanks to the devel-
opment of projects and the availability of ICT. Participation in
learning organization initiatives also resulted in feelings of recog-
nition, pride, and autonomy, as well as time savings, reductions in
stress at work, standardization of practices, continuous support to
nurses, and reflection. Moreover, the learning strategies assisted
by the ICTs used within the context of the learning organization
allowed rapid access to flexible information. These effects were also
identified in the literature on ICT use in nursing education (Button,
Harrington, & Belan, 2014).

Nevertheless, there are still elements that could be improved
by the learning organization. At the time of this study, the imple-
mentation of the learning organization was still incomplete among
nurses, and even more so among other health professionals. The
lack of other professionals in the learning organization is an inter-
esting point to underscore, since we could easily imagine that a
participatory process that promotes collaboration like the process
promoted by the learning organization (Harrison-Broninski and
Korhonen, 2012; Song, Jeung, & Cho, 2011) would facilitate mul-
tidisciplinarity. However, some of these professionals have already
participated in the projects, and the learning organization commit-
tee expected that this participation would grow over time.

Finally, the learning organization had a limited effect on reten-
tion of nurses in this CSSS. While the value of the learning

organization is generally acknowledged, factors such as origins,
work environment, and family situation seemed more important
as incentives to work in the CSSS.

5.1. Limitations

Even though this exploratory case study is not by its very nature
generalizable, it could serve as a basis for comparison when study-
ing other cases as well as provide evidence that could be used by
others to judge the applicability of a learning organization approach
for their situation. For example, this study could be included in a
larger research on the influence of learning organizations on health
care professionals’ practice. Moreover, we wanted to improve and
deepen understanding of the effects of the learning organization
using the rich and meaningful experiences and descriptions of par-
ticipants, which would have been impossible with other research
designs (Collingridge & Gantt, 2008). Nonetheless, this study meets
the requirements of valid qualitative research, according to vari-
ous quality criteria including triangulation, respondent validation,
exposition of methods, reflexivity, attention to negative cases, fair
dealing, rich description, and relevance (Mays & Pope, 2000).

6. Conclusion

The organizational culture change process—through a learning
organization promoting knowledge transfer in the work envi-
ronment and collective learning—instituted in a CSSS of Quebec
brought about important and much needed changes in nursing
practices and work environment. Research on new and innovative
solutions to improve knowledge management and support con-
tinuing professional development of health care professionals is
still limited. This case study can help clarify the impacts of a learn-
ing organization on health care professionals’ practices. According
to the participants in this case study, the learning organization
seemed to affect daily nursing work in a positive manner, despite
its variable impact on other professionals and other sites outside
the hospital center. These changes were particularly pronounced
with respect to knowledge transfer, support for nursing practices,
and quality of health care objectives, which the learning organi-
zation had sought to meet since its inception. As a final remark, it
would be interesting to study in the future the longer-term effects
of the integration of a learning organization on nurses’ professional
development, as well as on those of other health care professionals
who are part of this new culture.

Conflict of interest

The authors are not aware of any conflict of interests.

642 M.-P. Gagnon et al. / International Journal of Information Management 35 (2015) 636–642

Acknowledgments

Funding for this research project was provided by Canadian
Institutes of Health Research (CIHR) (No 200911PHE-217005-PHE-
CFBA-11114). The funding source had no involvement in the study
design; in the collection, analysis and interpretation of data; in
the writing of the report; and in the decision to submit the arti-
cle for publication. The authors thank Erik Breton who helped with
the data collection and analysis and the review of this paper. They
would also like to give a special thanks to the participants of this
case study.

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Marie-Pierre Gagnon is Associate Professor at the Faculty of Nursing of Université
Laval and researcher at the CHU de Québec Research Center. She also holds the
Canadian Research Chair in Technology and Practice in Health. Her research interests
include telehealth, organization of health services, professional practices and health
information systems.

Julie Payne-Gagnon is a research professional at the Public Health and Practice-
Changing Research Axis of CHU de Québec Research Center. An anthropologist by
training, she currently works on the subject of implementation and use of informa-
tion technologies in health care.

Jean-Paul Fortin is a retired Professor at the Department of Social and Preventive
Medicine of Université Laval and researcher at the Centre de recherche sur les soins
et services de première ligne of Vieille-Capitale Health and Social Services Centre. He
developed an extensive expertise on ICTs in health and on the evaluation of health
services research.

Guy Paré is Professor at the Department of Information Technology Management
and holder of the Chair in Information Technology in the Health Care Sector of HEC
Montréal. His research interests include change-related issues to the implementa-
tion of new technologies, the effective management of these changes and the use of
information technologies in support to emergent organizational forms.

José Côté is holder of the Research Chair in Innovative Nursing Practices and full pro-
fessor at the Faculty of Nursing Science of Université de Montréal. She is a regular
researcher at the CHUM Research Centre and the recipient of a senior researcher-
clinician grant from the Fonds de recherche du Québec en santé (FRQS). Her research
focuses on the development, implementation and evaluation of cyberhealth inter-
ventions in the treatment of client groups living with a chronic health condition.

François Courcy is Professor at the Department of Psychology of Université de
Sherbrooke. He is interested in the prediction of work-related counterproductive
behaviors, the promotion of psychological health at work, the assessment and diag-
nostic of organizations, as well as staff training and work performance.

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http://www.who.int/whr/2010/en/

A learning organization in the service of knowledge management among nurses: A case study
1 Introduction
1.1 Learning organization

2 Context of study
3 Methods
3.1 Study design and participants
3.2 Data collection and analysis

4 Results
4.1 Participants’ characteristics
4.2 Changes in nursing practice
4.3 Variable impact

5 Discussion
5.1 Limitations

6 Conclusion
Conflict of interest
Acknowledgments
References