Customers as resource integrators: styles of customer co-creation

1. Customers as resource integrators: styles of customer co-creation Janet McColl-Kennedy Steve Vargo Tracey Dagger Jillian Sweeney Janet McColl-Kennedy Professor of Marketing, Research Director UQ Business School University of Queensland, Australia 2009 Naples Forum on Service Capri, Italy 16-19 June

2. background • Traditional wisdom says value is created by a producer and purchased for consumption • Consumer behaviour literature has focussed on the consumer’s decision making process rather than on what they customer does • More recently, the producer-consumer model has begun to be replaced by a model of co-creation of value • That is, where value is created through joint activities of providers and customers but also through the activities of others in the networks of these parties (McColl-Kennedy et al 2009)

3. background • shift towards a model of co-creation of value has roots in service –marketing literature (through production and consumption being inseparable (ZBP 1983) and B2B where the producer-consumer distinction is inappropriate • But also Prahalad and Ramaswamy (2000) HBR • Vargo and Lusch 2004, 2008 • idea of co-creation of value is part of an evolution toward a general re-orientation of marketing, value creation and exchange – ie S-D Logic

4. research purpose • To investigate empirically a service provision process to tease apart multiple approaches to co-creation and suggest a schema • To begin to explore relationships between co-creation approaches and outcomes • Healthcare was chosen as the setting as it provides a full range of co-creation and co-production activities and styles

5. healthcare context • move from cure to preventative health and patient self-care which emphasizes the role of the customer in the medical service delivery (Roter et al 1988). • many advantages of inclusion of the customer in the service process eg. • reduced cost and increased efficiency of the process (Jayawardehena and Foley 2000) • the customer taking some responsibility for the outcome (Auh et al. 2007; Bitner 1990; Dellande, Gilly and Graham 2004). • reduce unnecessary health costs • improve health care outcomes and • increase trust in and commitment to the doctor (Veranec 1999; McStravic 2000; Michie, Miles and Weinman 2003; Ouschan, Sweeney and Johnson 2006).

6. healthcare literature • Early literature on participation showed that participation in an interchange leads to positive outcomes (Vroom 1960) • Compliance – taking medications • Involvement in decision making • Coping literature

7. overview • Positioning – • the research is positioned within S-D logic in a healthcare context • Part of 3 year ARC linkage project

8. contribution • 1. using 20 interviews and 4 focus groups represents the first in-depth empirical investigation of multiple approaches to co-creation of value • 2. identify range of activities (behavioural and cognitive) and six styles • 3. some styles associated with high quality of life, others with relatively low quality of life

9. definition of co-creation of value in our study • Unavoidable, multi-party nature of value creation • “joint activities in collaboration with members of the service delivery network which may include , family, friends, other patients, health professionals and the outside community ” • Essential features: • Activities are defined as “performing” or “doing” • Doing has 2 components: • cognitive + behavioural • Involves some effort on part of customer Community Others Self

10. definition of co-production • The less compulsory, more effortful involvement of customers in the process such as in design, self-service and other extra-curricula activities (ie the activities traditionally undertaken by the firm)

11. conceptual framework • Customers can no longer be regarded merely as passive recipients of services • Customers play an active part of production and delivery of services (Prahalad and Ramaswamy 2000) • Yet, little research has addressed the customer’s role – what the customer actually does • Payne etal. 2008 provide a useful framework – emotion (feeling), cognition (thinking) and behaviour (doing)

12. Payne et al., 2008) • Centrality of the process in value creation • Longitudinal nature • Recognises the customer as ‘feelers’, ‘thinkers’ and ‘doers’ • Recognises that the customer engages in activities (practices) and that value (to the customer) is embedded in these practices

13. gap to be addressed • Yet, little is known about how customers actually go about doing the co-creating (Payne et al 2008) • Little is know about how customers integrate resources (Vargo and Lusch 2008)

14. qualitative stage Study 1 • Cancer one of seven National Health Priority Areas • Increasingly ageing population, higher prevalence of cancer, increasing reliance on services devoted to cancer including ambulatory Industry partner – HOCA (Haemotology and Oncology Clinics of Australasia) • Two Cancer day clinics • 20 in-depth interviews with patients • Different stages of the patient treatment process – 1, 3, 6 and 12months

15. method • Data collection took two years across 2 clinics • Depth interviews with CEO, oncologists, Director of Nursing as well as supervisors of the clinics receptionists • Participant observation at the two clinics • 20 depth interviews with patients (either at the clinic or in their own home) • Discussions flowed like conversations

16. method • 175 pages of typed transcripts • 3 researchers plus research officer read the transcripts • NVIVO – using one researcher • Traditional content analysis – two other researchers acting entirely independently • Lincoln and Guba’s (1985) constant comparative method • Themes were then listed and categorised using the constant comparative method (Lincoln and Guba, 1985)

17. results - 10 themes (activities) • 8 behaviours • Information use clients accepting, seeking and sharing of core service information sent one-to-one, one-to-many, many-to-many • Action relating to core services – client activities that facilitate core service provision • Additional health activities – • Participation in non-essential (supplementary) eg diet, exercise, alternative therapies • Distracting with activities – distracting from realities eg overseas holiday, hobbies • Organising/managing practicalities of life • Managing the practicalities of life in the circumstances (eg keeping a diary, setting goals, time activities)

18. 10 themes (activities) • 8 behaviours (cont) • Managing physical identity – managing physical appearance to maintain sense of self (eg wig, make up) • Relationships – client putting effort into relationships with stakeholders (eg friends, family, broader community) • Regulating emotions – form of behavioural management of emotions for sake of interpersonal relationships (eg protecting/supporting family, avoiding negative situations)

19. 10 themes (activities) • 2 thinking activities • Positive thinking –choosing positive emotions and applying them (eg self talk) • Being philosophical – assessing the situation in terms of a critical and generally systematic approach which relies on reasoned argument (eg accepting, dealing with it and moving on)

20. co-creation styles • 6 profiles • Team manager • Passive compliant • Isolate controller • Partner • Spiritualist • Adaptive realist

21. team manager • typified by Linda and Barry who manage their ‘team’ which includes staff, friends and family. • Linda believes in a team approach which she coordinates. She says “you do it”, you don’t leave it up to fate, God or the doctors. Rather, she with her team will make it happen. • She has a circle of support people and is very open in her communication with her team. For example: • “You do it on your own and there is no other way for it to be and you have to do it on your own, I think you have to. It is not just about inner strength …, I have still showered myself…I think that it is very important just to have a sense that you are doing something for yourself. But I have a support team…my husband and my sister are really the center of my support then it goes out in concentric circles, the there is my children, …then the Bahai community and of course my parents… I discuss everything with everyone.” (Linda, 52 years)

22. passive compliant • The “Passive Compliant” first and foremost follows orders. They are accepting of what the doctors tell them. They do not tend to question the doctors. • They tend not to take initiatives, such as searching the Internet for more information, going to a gym, changing their diet. The “Passive Compliant” often will stay close to home as they feel safe there. They see little if any choices. • Mary is an example of this profile. She is accepting of what the doctors say. • “I am fairly accepting …there are not many choices, no no, the only real choice was do you want your chemo this week or would you want to put it off a week…but otherwise no, this is what we want to do and I am reasonably compliant so I just said (to the doctor) you know best….I prefer to be at home… …I potter in my garden. You have to be pleasant and accepting of what they have got to do and you have to get yourself there on time even though you might have to wait. So just being compliant.” (Mary, 60 years)

23. passive compliant • “My role is to front up every two weeks, and just probably proceed to treatment” (Neil, 65 years) • “ you don’t feel in control…the doctor teed up the other two specialists for me and I felt good about the amount they (doctors) knew and shared….Whenever I did see him (family doctor) he knew what was going on…It is such standard treatment in so many ways…its what every woman after breast cancer gets…I see him (the oncologist) each time or a say someone else…I didn’t have any questions or whatever…you can’t control, well I chose not to control what treatment I underwent …that was passive …you have so many tests…you are not in control.” (Tina, female, 45 years)

24. isolate controller • keeps themselves away from close family members and chose to work with only certain medical staff. • like to be alone and not to share their feelings and problems with others. • restrict the amount of details they tell others about the illness, symptoms and problems they are experiencing. • They would rather do things themselves, such as taking vitamins, doing exercise, diet, being generally healthy. • I make their job easier to make sure that I am as healthy as can be apart from what we have to deal with as far as cancer goes…I ate well, I slept well” Regarding her mother, Christine said, I had to be very careful what I said to her because it would get broadcast that night, email right around, right around, and then I would get emails the next day, and I would just have to answer emails…so I have sort of kept them at a distance.” (Christine, Spring Hill, 49 years).

25. isolate controller • Deluce has her own recovery program with a team of people that she has selected including an oncologist, surgeon, dietician, psychologist, personal trainer and gym instructor. • She believes that the power is with her and that it is up to her to get her team together. • “You’ve got to start your own health program and your own exercise program so I’ve now got on board my own team which include obviously my GP, my oncologist from HoCa, my surgeon who did the work, and my dietician and my psychologist, my gym and in the next few weeks hopefully a personal trainer might get on board. … but all that’s come from me … I feel as though that’s my own kind of recovery program that I’ve put in place.” (Deluce, 46 years)

26. partner • partners primarily work with the doctors and other service providers • “working with” her doctor, being engaged in the process, “because it’s a partnership”, “I’m working with her (doctor)” and “pulling my share of the weight”. • “I’m learning and I'm getting a lot stronger… I can now think, I can get the doctor's report, radiology report, get on the Web and I can look up stuff, …if I don't like something I ask, I went into day with my pen and paper to take no, I said to my doctor I want you to listen …I went in there, and so is the first time I really feel in control, …being in control, yes it is, to be engaged, because it's a partnership, because I now feel I am of more benefit to her as the patient as well, the relationship to me is more equal, in that, I am not a victim. I have never been a victim with a disease,… I am capable of working with her and pulling my share of the weight” (Christine, New Farm, 56 years)

27. partner • “I can do it with him (the doctor)…I share everything with Dr Paul…I do my part, I try to drink, make sure I am hydrated because I think it helps your veins and things …I do things that I can do “I can do everything in my world…with all the support things and all the psychological support, then the other part can be dealt with by the doctors.” (Pamela, 59 years)

28. spiritualist • “I’m a woman of prayer, a woman who believes in God … you know that I believe in, faith and the spirit … I think I’d prayed every scripture in the bible [chuckles] and that’s the end of that. God knows best, he does know best … I had accepted it. (Yvonne, 49 years) • Barbara believes in her faith in God and that this is her main source of peace. She speaks about taking each day at a time “being carried along on prayer”. “I am coping today and that’s all I have got to worry about”. She trusts implicitly in her doctors “I just trusted the doctors…They checked were you happy with your surgeon, were you happy with your oncologist and I said I was always happy.

29. adaptive realist • Life goes on but differently • “Right now, and when I was diagnosed with cancer I was a single mum. …it was only 48 hours from when I was diagnosed to when I had surgery….the motivation to keep on going was my ten year old. I had to do all of these things so that I could be around, to see him grow up.” (Sherryl, 52 years) • Robert - goes to the toilet 21 times in an evening, considers wearing long pants instead of shorts as he has no bladder control but not once does he consider giving up his tennis or his golf. • “…so now I can do a lot of things that I did, I can play tennis, … I remember going to a friend's place one night, the worst thing you know was white wine, so that, “ I'll just have one glass” oh all right one glass and that was it…But I have to go to the toilet 21 times some evenings. …so it had its moments. I could still play golf because there were plenty of trees, but never on a mixed day, never played mixed golf again. You have to adapt don't you?.” (Robert, 70 years)

30. Relationship to quality of life • Highest • Adaptive realist • Spiritualist • Relatively high • Partner • Team manager • Relatively low • Passive compliant • Isolate controller

31. conclusions • Co-creation extends previous conceptualisations of both participation and coping • Participation traditionally focused on compliance and decision making • Coping concerns managing and aiming toward the status quo • Co-creation includes: • Thinking and doing • Multi-party - involves various other people or groups • Multiple facets

32. moving forward…next steps • scale development • application to other health areas eg heart disease, diabetes