XXVI. International RESER Conference:

The Cinderella story – A Skilled Worker´s New Chance in the Digitalization of Services

Eveliina Saari1, Sari Käpykangas2, Mervi Hasu3

1,2,3 Finnish Institute of Occupational Health, Finland

Abstract

The aim of the paper is to analyse how backstage service employees may rise from invisibility to active agency when their work changes and even disappears during the digitalization of services. Our case study is of an intervention process aimed at envisioning future digital ser-vices and new work. The analysis is based on employee interviews on the future work hori-zons, and two workshops organized to support co-creation of the future service and work. Our main finding is that invisible backstage service workers may face a similar developmental pat-tern to that of “Cinderella” when finding their way in the digital era. Employees need to have a new kind of active agency in order to shift into new roles in which human expertise is crucial. Managers should be alert to involve employees designing their new job descriptions when technology replaces human work.

1. Introduction

“ In the fairytale of Cinderella, a girl is exploited as a servant by her family but enabled by a fairy godmother to attend a royal ball. She meets and captivates Prince Charming but has to flee at midnight, leaving the prince to identify her by the glass slipper that she leaves behind.”

Digitalization embraces almost every aspect of contemporary work and ranges from local care services to highly specialized cloud services. Thus also the contents and arrangements of work change in concert with the digital development. New types of business start-ups, entre-preneurship and flexible forms of work have moved towards each other. The insecurities in societal and economic developments have given rise to new forms of employment with need for increased flexibility by both employers and employees. The characterisation and theoreti-sation of the new work and new employment forms are still much under way. (e.g. Frey and Osborne 2013; Brynjolfsson & McAfee 2014).

The current process of transition into the digital era is radically changing the service context in our societies. For clients, services become ubiquitous, constantly available, smart, and glob-ally reachable. This new service context is not only changing client experience; it also has a profound influence on how frontstage and backstage work is organized (Ostrom and al. 2015). The introduction of new technology can have significant effects on the work lives and careers of employees, not only by replacing manual service work, but also by offering them new developmental horizons (Stam, Stanton and Guzman 2004). We would like to ask: How are service workers actually involved in designing (their) new job descriptions in the digital

era? And what kind of opportunities do they have to develop their skills for future service work? Should the organizations support the empowerment of their employees such as in the fairytale of Cinderella a godmother intervenes into routinized everyday life before the royal ball?

This study highlights the workplace and job level consequences and opportunities of digitali-zation in health care organization and contributes to the employee-driven and human-centered perspective in the digitalizing care service context.

2. Agency of employees in transition

In the complex and digitalized service environment, the frontline employee’s role, which represents dyadic client-employee interactions, is in transition. As IT-enabled innovations turn the clients operators of their own services, it reinforces the diminished role for employees (Rust and Huang 2014). For individual worker, building new work role and crafting a new job in the rapidly changing labor market is not an easy task. In this paper we use agency as theo-retical concept to explore the emergent motivational state of employees as ‘scouting’ for new competence, responsibility and role/relations. Agency can be seen as human potential to es-tablish and pursue different projects in life (Archer, 2000). It includes forming interests to-wards the society, as well as having resources and capabilities to pursue goals in interaction with other people (Archer, 2003). The relational view of agency emphasises interconnected nature of peoples’ lives; people need each others’ support and resources when navigating in the social world, and the relations between them influence their choices and possibilities (e.g., Donati & Archer, 2015). Changes in agency can be traced in (transformational) speech, dis-cussions and interactive (work) situations, as employees discursively and habitually perform previously unused voice or action (e.g. Halford and Leonard 2005).

However, as service employees’ face-to-face servant role may seemingly fade away when the technological interface pushes them into back offices, these employees may be given the op-portunity and space to form new agency and adopt new roles and relations. The employees may become innovators of new services based on their deep experience with clients; en-ablers, helping and training clients use the technology; differentiators, giving the genuinely empathetic and personal face on the surface of the service, or co-ordinators, handling the in-tegration and building bridges between different offerings (Bowen 2016).

Employee-driven perspectives on innovation have been widely discussed recently (e.g. Høyrup et al. 2012). However, research and intervention efforts have scarcely focused on how, in practice, frontline employees may change into service innovators or designers of their own work (Hasu, Saari and Mattelmäki 2011; Saari, Lehtonen and Toivonen 2015). Work-place-level intervention methods and tools to enhance employee innovation, and especially the process and outcome assessment of interventions have been reported scarcely (Nielsen 2013; also Watanabe, Fukuda and Nishimura 2015). Case studies so far indicate that em-powering and allowing employees to apply their customer know-how and ideas to service in-novation increases preconditions for development, improves services, and positively influ-ences their well-being (Hasu and al. 2014; Honkaniemi, Lehtonen and Hasu 2015).

Only a few studies have captured workers’ positions, experiences and subjectivities anchored in place, space and time (Halford and Leonard 2005) in the implementation process of a new technology. One sensitive, ethnographic analysis of a nurse and doctor implementing the use of the neuromagnetometer (MEG) in the clinical activities of a hospital laboratory unfolds as the story of an employee being both an insider and an outsider, struggling with the unfinished software, and working as an invisible actor for the developers (Hasu 2005, Star 1991). In the

ethnographic interviews Doctor Sara indicated she was a step ahead of the technology devel-opers in concretizing the emerging measurement service for the patients. However, several and continuous problems in using the program and not being taken seriously, finally made her resign from the task (Hasu 2000). This shows how unofficial and fragile the agency of the em-ployees might be during the technological implementation process. Social service profession-als’ resistance to mobile reporting has been seen as contradicting their primary motivation, which is to help their clients. If the new technology takes too much time from interaction with the clients and if it is experienced disturbing the way of being able to operate autonomously, the employees tend to resist it (Stam, Stamton and Guzman 2004). Unfortunately, IT-systems and mobile applications designed to employees appear to be more cumbersome inside or-ganizations, than they appear to the clients.

Mobile technology has been considered a device to control and make employees objects of managers’ surveillance in e.g. in home care work (Vuokko 2008). This contains a risk of loos-ing the autonomy of individual work situations and may have serious risk for employees’ moti-vation, particularly if the reporting to the managers with unfinished technology starts to domi-nate the mundane service work. These studies raise up important hints on why implementation of a new technology is such a subtle process. However, we think we should also analyse how backstage workers could be more involved in designing their new work, when part of their work is being digitalized.

3. Medical documentation service as a case

Our case context is the largest specialized medical care organization in Finland; more specifi-cally, one of its sub-units responsible for various internal support services for hospitals operat-ing under the organization. The particular service unit in question provides word processing services for the entire hospital district (five hospitals) and employs 300 typists who type ap-proximately two million medical texts per year, dictated by almost 3000 medical doctors and other clinical personnel. Word processing of medical texts are integral part of medical records and documentation in specialized care.

The current phase of development is the implementation of a new medical documentation service for doctors who perform medical dictation as part of their patient work. Recently, after the manual dictation process, which used several hundreds of specialized typists located in hospital clinics (decentralized process), was replaced by a more digitalized and integrated (centralized ‘typing factory’) process including also opportunity to work from home, the num-ber of typists considerably decreased. Currently, the digitalization of medical documentation is intensifying in the organization, through the adoption of speech recognition technology, which aims to make doctors the users of the system and will eventually reduce typist work, and, consequently, the number of typists to a minimum.

In the health care sector, speech recognition can be technically implemented in front-end or back-end of the medical documentation process. Front-end speech recognition is where the provider (doctor) dictates into a speech-recognition engine, the recognized words are dis-played as they are spoken, and the dictator (doctor) is responsible for editing and signing off on the document. Back-end or deferred speech recognition is where the provider (doctor) dic-tates into a digital dictation system, the voice is routed through a speech-recognition machine and the recognized draft document is routed along with the original voice file to the editor (typ-ist/doctor), where the draft is edited and report finalized. Deferred speech recognition is widely used in the industry currently (https://en.wikipedia.org/wiki/Speech_recognition).

At the time of our study, neither typists nor medical personnel were familiar with speech rec-ognition technology. From 18 interviewed doctors in our case study, only one had used speech recognition during a test project in 2014. Attitudes towards the system among doctors were heterogeneous, partly negative but partly also positive. Image of front-end speech rec-ognition dominated. Doctors did not know about different ways to apply the automated sys-tem. Positive future expectations included increased time saving, improved patient care and documentation quality. From the point of medical work and documentation, most important future opportunities that doctors anticipated were wireless/ mobile work, multi-location work/ work without standard office, fast operations, full digitalization (without paper documents), just-in-time work, patient-centeredness and simplicity. However, what seems to be unclear for all stakeholders was the question of how to differentiate and categorize different user groups, and how many types of process variations should be offered.

4. Methods and analysis

First, we analysed how transformative agency is emerging, by interviewing the typists. In the interviews, the typists were asked to predict the future horizons for manual transcription work from the employee’s perspective, when automatic voice recognition was about to replace rou-tine manual work. We identified the alternative horizons of the typists through content analysis of nine individual or group interviews. These interviews took place before the intervention (workshops), and their purpose was to explore how the typists saw their current work and its future. The special focus of the analysis was on what motivates the interviewees in their work, and how they foresee their future work. Interviews were also used for informing the design of intervention workshops, in which employees, managers and other involved stakeholders to-gether participated to construct a vision for the future service and work.

Then, we analysed workshop discussions, in which the typists were asked to create an inspir-ing story of their future work, when their current service had become majorly digitized. We analysed the discussions in two voice-recorded and partly video-recorded workshops. The workshops tasks were to 1) construct a shared vision of the future, and 2) create an inspiring story of one’s future work and expertise when the service had been digitized. We analysed the two workshops as an ethnographic narrative, which resembled, in a metaphorical sense, the developmental pattern of the Cinderella story. The narrative interprets the significant inter-vening roles and the consequences of the employees’ actions and speech turns. We present excerpts from the public speeches after the group works as a samples of output from the in-tervention.

5. Findings

The results of the analysis indicate the hidden potential of the backstage workers. They are motivated to design alternative futures for their work, if they are allowed to be involved in de-signing them. We identified four different developmental horizons from the interviews. The workshop discussions and their consequences indicated that if the typists were given subtle support, they could rise from a humble workers’ role into designers of their own jobs. In the following three sections we present the empirical findings in detail.

5.1 Change horizons of the employees

The analysis (in table 1) outlines four different developmental horizons interpreted from the employees’ conceptions. These are: 1) quality control editor, 2) ICT bridge-builder, 3) clinically oriented worker, and 4) efficient homeworker. These developmental scenarios are not mutu-ally exclusive, and may even be realized simultaneously, depending on how the digitalization of the service proceeds.

Quality control editor and ICT-bridge builder appear quite clear and obvious job horizons, if the speech recognition technology replaces mechanical typing work. Becoming a clinically oriented worker and finding a new role in care value chain would probably need exploration of the clinical work processes at hospitals and expertise in health care. The efficient homeworker represents the current organizing of the typists’ work, in which digitalization has enabled doing work at home. This may realize also in the future, if the typists change into editors. It should be noted that we do not take a stand on how many jobs may disappear after the speech rec-ognition technology is implemented. These job horizons are potential zones of proximal de-velopment, which either are grasped or not.

Table 1: Motivation and developmental horizons of the typists

Typist type Motivation Change horizon

Quality control editor

Ambitious in terms of quality and rapidity of the service Appreciates independent work without interruptions

Eagerness to learn and take part of speech recognition projects,

expects editing work to be a positive and more accountable

alternative to typing

ICT-bridge builder

Has good ICT skills and per-ceives grievances in useful-

ness, likes independent work, but is happy to guide others

as well

May become a lead user or trainer of the speech recognition

system to peers and MD´s

Clinically ori-ented worker

Is interested in contents of the dictations, wants to learn more on medical details, ex-periences herself as a part of

the care process

May potentially discover new work between MDs and the pa-tients, interested to specialize

into medical glossary, humaniza-tion of the current typing factory

Efficient home-worker

Thinks that mobile working is combined well with hobbies or family life. Virtual connec-tions to peers is not a prob-

lem

Ergonomics and security could be improved and social support

at work

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5.2 Towards a shared vision

The aim of the first workshop in January 2016 was to construct a shared vision for the future experiment in the case organization. For inspiration we provided the group a beginning of a sentence to continue on, such as: In 2025, when you dictate your patient information as a Medical Doctor ….We also provided four scenarios of the future typist’s work constructed from the interviews to be further worked on.

In the first workshop, the group was heterogeneous. There were 6 typists, 3 supervi-sors and 3 persons from other involved organizations (called godmothers or godfa-thers), who supported the discussions, and 2 researchers either facilitating or observ-ing. It is worth noticing that it is not very common that basic level workers such as typists are invited to organization or innovation development projects and participants in workshops. a The group was obviously too big to include all the participants into discussion. The discussion started by wondering whose point of view they should focus on. Two young male typists; called John and Hans (pseudonyms) began to lead the discussion, while all the other typists mainly listened without intervening. The supervisors were silent in the first half of the discussion, however they became active when there was a pressure to conclude the results.

The topic chosen was how the work of the medical doctor (MD) changes, when the speech-recognition system becomes a mundane tool. The group figured: He has more time to patients. The typists raised up a practical procedure into consideration: Does the MD put the patient data by himself into the different systems in the future?

Hans: So as it has been referred that dictaphones have been in use, and secretaries used to type the speeches. So previously, it was a straightforward process, in which the MD dictated and someone typed it to the paper. Nowadays, there are so many ICT-systems and they integrate into different ways, that the MDs should remember by heart what codes he should use, in order to shift the data into right places in right time, so if the MD could…

Godmother: How has it changed?

Hans:..just concentrate into care work and then explain it, without a need to bother how the system processes the information.

John: We face the problem, which you said and which is the fact, that it is the MD, who is finally him- or herself responsible of it. That cannot be outsourced ever for any reason, but that makes it a small kind of bottleneck into the process in any case.

In the workshop discussion, the future work of typists was hardly dealt at all. The ob-server tried to remind it: Researcher: What is going to happen to the employee, to the typist?

John: That was thrown away.

This comment referred either to the inspiration card that was supposed to stimulate thinking of future typist’s work or that the work would disappear as a job. A supervisor raised up the patient perspective very strongly: “after 10 years, everything works from the patient point of view. The patient enters his information to the systems or he is measured from his body and the data then shifts automatically to the systems.” This was an ambitious and a futuristic vision. The discussion moved into the patient ex-

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perience. A typist raised up again a point from his experience into the discussion. The patient does not usually understand MD’s language, as he described:

Hans: When the personal data of the patients is entered to the database, is it avail-able for the patients as well? Or do we need a feedback system in which you may ask additional information? I have said many times that every time my acquaintance visits a doctor and then arrives. I ask what did the doctor say? The reply is: I don’t know.

Godmother: Or he does not remember.

Hans: They speak so different language.

John: Exactly.

Hans: Can the patient consult virtually or by mail that my patient data says this, can I get some additional information about it?

Interestingly, the typist recognizes another bottleneck, in which new advice giving work could be needed.

A godmother and a godfather were promoting the discussion all along by questioning or supporting comments, such as:

Godfather: In this phase, do we really want to get rid of the typist’s work? Whose task is this streamlining? Do we focus it to the MD work or to the assistant work?

---

Godmother: When you said that the doctors speak such language, that the patient do not understand what has happened. It is a challenge. What does the digitalization then bring, in order to make it clear?

---

Godmother: Help each other, please help now.

When the facilitators pushed participants to compress the perspective into one single vision, the group figured out the concept of effectiveness. They formed the vision at first: “Digitalization as a tool to more effective care.” A typist added: “and better rela-tionship between doctor and the patient.” The concept of digitalization disturbed many as a formulation, so finally, after an intervening speech of a godfather, the vi-sion turned into: “Open patient data improves care relationship and the effectiveness of the care.” Hans who wrote the vision was chosen to make a pitch-speech of it. The typist was obviously nervous, but somehow assertive when it was his turn to make the speech in public.

Hans’s oral presentation: The Medical Doctor does not use his time into dictating the previous cases, but just dictates the fresh research findings, the care plan and the admission note for example to x-ray. And the speech-recognition produces the text into the computer screen as fast as he dictates it. He corrects a few words, which the machine had misheard. The text then shifts into our unit, where a careful office worker takes care that the information is put into the right places. Probably the MD has left a sentence, which is open to interpretation with double meaning. And he de-

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notes it, that this is open to interpretation, that could you please complement. It is not delayed though, although it is denoted and will be checked out.

The pitch speech was a convincing, customer-oriented description, unfolding how the patient gets better treatment and better care relationship, when he is himself respon-sible of entering his own patient data into the system. What was surprising in the speech, was that the new role of a typist as a kind of quality inspector emerged into the speech, without formulating it in the previous discussion. The supervisors were keen to listen to the speech, and did not want to add a word.

5.3 A story of the future typist in action

In the second workshop, organized in March 2016, the aim was to accelerate the fu-ture service experiments that were chosen after the first workshop. The main task was to envision and construct a story which concretizes the experiment and actual-izes the future vision, and in which the workers and service users act in their future roles. We provided two tools: 1) a profile form to fill in personality description of a typical worker and a typical user, and 2) a story template, in which employees were asked to write the beginning, the solution (middle) and the grand finale of the story. Typists were organized this time to their own group in order to be able to deepen their understanding of their future work. The group consisted of four male typists and one female typist, a researcher, a godmother and a godfather.

In the beginning of the conversation employees mentioned that typists did not have any educational requirements to their job at the present. The problem of the story was chosen to be a situation in which the speech recognition system misinterprets the amount of the drug in the prescription. The group started to discuss whether the editor could correct the mistake without bothering the doctor. This would demand both to extend employees’ liability and to increase their knowledge onmedicine, as the following excerpt shows:

Typist 1: How should I write? Speech recognition misinterprets the speech of MD and the patient have been prescribed a wrong medicine. Somehow like that.

Godmother: The system simply makes a mistake. But then, this is the problem, but how it is solved?

Typist 1: Let us assume that the editor [typist] discovers the mistake. The patient does not know the proper dosage.

John: It is the editor´s task to notice it.

Godmother: Our task was to think about your role in the situation.

John: Editor´s task is to notice the mistake.

Godmother: The editor discovers the mistake, and what does he do then?

Typist 2: We should extend our responsibility.

John: So, should we extend the editor´s responsibility just like that? What it takes?

Typist 2: Currently in some units the typists are allowed to correct a bit.

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Typist 1: Oh, is there an official authorization?

Typist 2: Small mistakes may be corrected in some places.

Typist 1: I would like to correct or add too, when I am very sure about it, but I can’t, I am not allowed to.

Typist 2: There are different practices.

Godmother: In our case, we should think about the trammels and the good experi-ences.

Typist 2: If our knowledge increases, then the responsibility can grow.

The conversation indicated that in some contexts the typists were allowed to correct minor factual mistakes, but usually the doctor had to check every ambiguity by him/herself. Obviously, this slows down the information flow to the patient. A god-mother made questions all the time to promote the discussion, but also provided space for the solutions of the workers. In the discussion, peer support was recog-nized as important in order to gain good quality texts.

Along the workshop a young female typist Sandra silently wrote down new areas of expertise into the worker profile description form. She volunteered, when we asked the public presenters of the stories. John and Sandra together stepped forward to present the story to other groups. The culmination of the story was that the editor was shown to be authorized to correct a mistake, which requires medical expertise.

John’s oral presentation: I do not need to bother the doctor Pekka. He can continue playing golf. We have a trained editor who can immediately say that this is up the spout (there’s a clear mistake). He can check out the original dictation and find out that the speech recognition system has recognized it wrong and it should be some-thing else. He can correct it himself, without bothering any other person. Probably he can consult his colleagues in the case (wawing his hands back and forth) and ask for help. And the case is very quickly taken care of without having to bother the doctor. If there is a bigger problem then, in that context, he consults a doctor. Such relatively trivial cases, but not trivial for the patients, but trivial in terms of using time for the trouble, can be solved in this same utopia in a jiffy. (The audience gave a big round of applause)

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Figure 1: John and Sandra, typists, presenting future editor’s actions (in the text we provide only part of John’s speech as an example)

The analysis of the workshops demonstrated how subtle intervention and outsider discussants may play a significant role in encouraging usually invisible workers to innovate. The full potential of workers may not become visible if they are not encour-aged to use their personal voice. The story revealed also how anticipating how a fu-ture worker would act raises up the old borders of the current job descriptions to be crossed in the future.

We reflected on the outcome of the workshops with the head of unit in late March 2016. He told that he was positively surprised on how sophisticated job scenario the typists had presented in the workshop. As a result of workers’ empowerment, the managers decided to involve the workshop participators into the development pro-jects designing future documentation service.

6. Conclusion and discussion

In this paper we highlighted the workplace and job level consequences and opportu-nities of digitalization in health care organization. The results contribute to the em-ployee-driven and human-centered perspective in the digitalizing care service con-text, in particular internal support services in hospitals.

Previous research literature on the digitalization of services tends to focus on the changing role of the customer and customer needs. The employee’s role as a poten-tial innovator of her/his future work and changing services is neglected. The paper shows that the backstage worker can and must be involved in constructing future

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service work, even in such a case when the service work in its current form is disap-pearing as it becomes digitally automatized.

Developmental actions and projects in service organizations should not only be con-cerned with future customer and employee experience, but should also design cus-tomers’ and employees’ future paths symmetrically. When services become increas-ingly digitalized, it does not change the fact that both customers and employees are resource integrators in value co-creation process (Edvardsson, Tronvoll & Gruber 2011). In both positions the change is rather radical though. It demands new kind of active agency and readiness to adopt a new role without clear pre-descriptions and certainty of the future service.

Our analysis indicated that positive and empowering atmosphere, in addition to ques-tions and visioning tasks guiding into the potential future roles in the workshop proc-ess may lead employees into the insight of their future job descriptions. Godfathers of godmothers from other organizations may act as mentors in the process. Collabora-tive design in the workshops brought into daylight the relational aspects of agency, which emphasises interconnected nature of different practitioner groups. Participants were able to become aware of each others’ support and resources, and understand how the relations between them influence their choices and possibilities (e.g., Donati & Archer, 2015).

We agree with Bowen (2016) in stating that strategic human resource management should focus on specifying the future employee roles and competencies essential to customer value creation and success of the IT-based service innovations. Shifting into new roles such as innovator, enabler of coordinator, or in our case such as qual-ity control editor, may need active agency from the employees, but also future-oriented training for increasing capabilities for adopting new roles.

Management needs to be alert to providing service workers with opportunities to foresee new kind of work roles and tasks in time, when their jobs are at stake as a result of major renewals in the service process. The task of managers is to identify the often hidden capacity of the service workers, and to involve them in official devel-opment projects. As in the story of Cinderella, when Prince Charming had to search for the owner of the glass slipper.

To sum up, we identified that when services are digitalized and current jobs are at stake, employees may find new agency such as Cinderella who was raised up into new role in the fairytale. However, we need encouraging actions from the managers and even outside intervenors, such as a fairy godmother, in order to trigger it.

7 Acknowledgements

This research is supported by Tekes – The Finnish Funding agency for Innovation (Project: The revolution of service economy - Human being at the core of the digitali-zation) and the Academy of Finland (Project: Smart work in the platform economy 303669). We acknowledge the typists, their supervisors and other participants in the workshops for their positive and curious attitude towards our intervention study.

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Author(s):

Eveliina Saari , Senior Researcher, PhD, Docent Finnish Institute of Occupational Health, P.O. Box 40 FI-00251 Helsinki FINLAND eveliina.saari@ttl.fi

Mervi Hasu , Senior Researcher, PhD, Docent Finnish Institute of Occupational Health, P.O. Box 40 FI-00251 Helsinki FINLAND mervi.hasu@ttl.fi

Sari Käpykangas , Researcher, MA Finnish Institute of Occupational Health, P.O. Box 486 FI-33101 Tampere FINLAND sari.kapykangas@ttl.fi