Case: “I cannot give up now!”: The story of a Norwegian public sector entrepreneur’s endeavours to revolutionize communication between two healthcare organizations
Photo by National Cancer Institute on Unsplash
Petter Gullmark; associate professor at UiT and Ingebjørg Vestrum; associate professor at Nord Universitet
This story is based on a real-life entrepreneurial journey, with names and details adjusted to enhance its educational value. The purpose of the article is to illustrate the complexities of public sector innovation and the role of dynamic managerial capabilities in driving change within bureaucratic systems. It offers insights into how entrepreneurial individuals can navigate institutional resistance, mobilize resources, and push for improvements in public service delivery—highlighting both the opportunities and limitations of innovation in the public sector.
About the Article
The article is based on Chapter 23: ‘I cannot give up now!’: the story of a Norwegian public sector entrepreneur’s endeavours to revolutionize communication between two healthcare organizations, from the book REFRAMING THE CASE METHOD IN ENTREPRENEURSHIP EDUCATION.
The story revolves around “Anna” who is a determined public sector entrepreneur working in the municipality of Bodø, Norway. Over the course of several years, she strives to improve communication between local hospitals and maternity and childcare services through the development of an electronic message system. Despite technical progress and support from her municipality, she faces continuous resistance from the regional health authority. Her story is one of perseverance, frustration, and hope—as she balances innovation efforts with institutional barriers in the public sector.
If you are an educator, you can use this article as a teaching tool that serves as a an illustration of the complexities and challenges of driving entrepreneurial change within the public sector. At the end of the article, you can find case activities for your students.
Setting the Scene
In 2013, Anna, a seasoned public health nurse in Bodø, Norway, decided to shift her career toward digital transformation in public health nursing by leveraging her IT skills. She secured partial funding to become an ICT adviser, where her first project was successfully developing a digital vaccination record and communication system. In 2014, new national guidelines required earlier postnatal visits, but the maternity center’s reliance on postal services caused delays. Anna saw the need for better digital communication and proposed a custom electronic messaging system to notify the center immediately after a birth, aiming to improve care and align with national standards.
The Case Story
Stretch Goal or Utopia?
Anna’s idea—to create a tailor-made electronic message system to instantly notify the maternity and childcare centre of births at the hospital—was ambitious but realistic. Though no similar solutions existed in the literature or her network, Anna believed in its potential, drawing from her own experience and that of colleagues in other municipalities. With support from her superiors, she launched a project in Bodø, ruling out improvements to existing routines and instead starting with a temporary solution: a secretary would call the maternity ward twice a week to gather birth information, which was then relayed to the appropriate midwives. While this system worked to some extent, it faced issues such as missed calls, incorrect details, and risks related to handling sensitive information. Anna, who had joined a national network focused on healthcare digitalization, knew that a secure electronic message system was both feasible and necessary. But before moving forward, she needed to gain support and legitimacy from key local stakeholders.
Mobilizing Support and Legitimacy
Although national guidelines briefly mentioned that early postnatal visits required electronic communication between hospitals and municipal centres, this wasn’t prioritized in national plans—leaving Anna frustrated. She had expected faster progress, but maternity and childcare centres ranked low on the digitalization agenda, which mainly focused on nursing homes.
Still, Anna didn’t give up. In 2015, she began rallying support for her idea of an electronic message system, starting with the municipality of Bodø, which quickly backed her. She then turned to the more challenging stakeholder—the Northern Norway Regional Health Authority (NNRHA), responsible for specialist healthcare across the region. Convincing them was harder due to differing electronic health record systems and regional priorities.
To strengthen her case, Anna collaborated with CompuGroup Medical (CGM) to develop a prototype that enabled immediate communication between the hospital and the municipal system. Confident in its potential, she prepared a strong presentation and invited CGM to a meeting with the NNRHA.
However, the meeting was a disappointment. The NNRHA showed little readiness or interest in the project, still focused on other priorities. Anna was disheartened to learn that no development had taken place in this area, and the NNRHA had no plans to move forward with her idea at either the local or regional level.
Northern Norway Regional Health Authority (NNRHA) (Norwegian: Helse Nord)
The NNRHA is one of the four regional health authorities that the Norwegian state owns and controls. The NNRHA has a board appointed by the Ministry of Health and Care Services. The board has a mandate to ensure that the public health goals are achieved and national guidelines are followed in all four hospitals in Northern Norway, including the Nordland Hospital in Bodø. The NNRHA also owns an ICT company that is responsible for the operation, management, and development of common ICT systems for all the hospitals it covers. The NNRHA appoints the boards of the hospitals and the ICT company and develops guidelines for these boards.
Source: NNRHA (2021).
CompuGroup Medical (CGM)
CGM is a digital electronic health record system used primarily by healthcare organizations. CGM Norway is a supplier of electronic health record systems. CGM’s electronic health record systems are divided into specialized segment versions, such as CGM General, CGM Specialist, CGM Emergency Room, and CGM Health Center. Notably, the maternity and childcare centre in the municipality of Bodø used CGM Health Center as an electronic health record system.
Source: CGM (n.d.).
Mobilizing Knowledge and Resources
To keep her project moving during a period of uncertainty, Anna focused on strengthening its foundation. In 2016, she created a dedicated email address for all maternity ward correspondence to reduce the risk of lost or misdelivered messages. She also implemented a new routine where incoming hospital letters were scanned and digitized, speeding up internal communication. Pleased with the results, she saw this as progress toward her goal of an automated birth notification system.
That same year, Anna secured funding to hire a secretary responsible for managing communication with the maternity ward. She also began building stronger ties with hospital staff through regular meetings, aiming to prepare them for eventual system implementation.
Later in 2016, Anna successfully applied for ICT support from the municipality. A part-time system administrator was assigned to her project, handling technical and security issues and coordinating with the municipal IT team, CGM, and other stakeholders.
Anna also discovered that an existing service agreement between the local hospital and the municipality—specifically “Service Agreement 8”—clearly stated both parties’ responsibility to enable electronic communication and notify about births and discharges. This discovery was pivotal, reinforcing her belief that the hospital would eventually have to collaborate.
Still, she faced a pressing question: did she have the stamina to keep pushing forward until that happened?
Why Can the Others Have an Electronic System But Not Us?
In early 2017, Anna’s project was making slow but steady progress. She took some comfort in the small improvements she had introduced—regular phone calls to the maternity ward, timely sharing of essential birth details with relevant units and midwives, and the digitization of all incoming hospital mail. These changes were working fairly well, but the lack of momentum frustrated her. With strong municipal backing and a working prototype of the digital message system, she couldn’t understand why the NNRHA still wasn’t engaging—especially since they were legally obligated to implement electronic communication.
Eager to stay informed and inspired, Anna remained active in KomUT, a national network for municipal competence development, and frequently read journals for public health nurses. One winter day in 2017, she came across an article that was both encouraging and disheartening. It described how Western Norway’s Regional Health Authority had successfully developed a system for electronic communication between the maternity ward at the local hospitals and the maternity and childcare centre in Western Norway.
Although the system didn’t send immediate birth notifications—Anna’s ultimate goal—it still delivered discharge summaries electronically, which was a significant improvement over traditional mail.
Anna was glad to see proof that such solutions were possible. Yet the success story also highlighted how stuck things felt in Bodø. She and her team were ready, but without the NNRHA on board, the project couldn’t move forward. They have to put it on their agenda.
Through KomUT, Anna also learned about a similar initiative in Ålesund—a municipality with a comparable size and structure to Bodø. Inspired, she applied for travel funding to visit and learn from Ålesund’s experience. The application was approved, and she traveled with her team—the secretary and ICT system administrator—to see how Ålesund had handled their implementation. The trip deepened Anna’s understanding of both the benefits and the hurdles such projects faced.
In early 2018, she read about another success story—this time from Gjøvik, where the municipality had started electronic communication with their local hospital’s maternity ward. Her vision was becoming reality elsewhere, and she couldn’t help but question why things weren’t moving in Bodø. Was the problem her approach? Was she not persuasive enough? While innovation blossomed in other parts of Norway, Bodø remained at a standstill—and Anna was left wondering why.
NALRA (Norwegian Association of Local and Regional Authorities)(Norwegian: KS)
NALRA is the interest and employer organization for the municipalities in Norway. All municipalities and county municipalities in Norway are members of NALRA. NALRA has a mandate to negotiate and make agreements with the employee organizations on wages and other conditions. NALRA represents the municipalities’ interests during negotiations with the state and suppliers. In 2012, NALRA developed a municipal competence network called KomUT that aims to assist the municipal sector in the digitalization processes.
Source: KS (2019, n.d.).
Should I Stay or Should I Go?
More than four years had passed since Anna first began working on her entrepreneurial project. Over time, the concept had evolved significantly, and Anna was confident that her proposed electronic message system could work. But when it came to implementation, things had barely moved since 2015. The Northern Norway Regional Health Authority (NNRHA) had effectively deprioritized the development of a customized system that could instantly notify the municipal maternity and childcare centre of a birth in the local hospital.
What made things worse was the shift in attitude among local decision-makers. In informal chats with politicians and managers—and even in formal meetings—Anna began to hear that the incremental improvements already in place might be “good enough.” It was a hard pill to swallow. Frustrated and disheartened, she reflected on the issue:
> “Electronic communication and the electronic message system that immediately notifies about a childbirth have been totally downgraded by the NNRHA. They perhaps do not understand how important this electronic message is to trigger the first healthcare help, which the municipality is obliged to provide.”
Anna also pointed out how the existing discharge summary format was flawed—information meant for the mother’s medical history was being incorrectly placed in the child’s records. And the national momentum wasn’t any better. At one point, the Norwegian Directorate of Health predicted that, in the worst-case scenario, nothing would happen on this issue until 2022. Anna knew Bodø couldn’t afford to wait another four years.
Exhausted, Anna began wondering if it was time to step aside and hand the project over to someone else—someone who might be more persuasive in getting the NNRHA to cooperate. Still, there was a flicker of hope. In a meeting at the municipal administration offices, she learned that the unit responsible for digitalizing the public sector within the Norwegian Association of Local and Regional Authorities (NALRA) had shown interest in her project. If NALRA officially got involved, it could tip the scales—making it harder for the NNRHA to keep delaying the initiative.
Anna longed for the project to succeed—not for personal gain, but because she believed it would vastly improve postnatal care. Mothers and their newborns would get better, more timely support. The municipality would benefit from more efficient use of its resources.
Now, she found herself at a crossroads. It was a quiet Friday afternoon in her office, and the weight of the past years was catching up to her. As the weekend approached, she resolved to take those two days to reflect—whether to return next week reenergized and committed, or to step back and ask someone else to carry the torch.
Theoretical Insights
Theoretical insights from two research fields—literature on public sector innovation and entrepreneurship (Chen et al., 2020) and the dynamic capabilities perspective (Schilke et al., 2018; Teece, 2016)—can be of great help to solve the case.
Public sector entrepreneurship is often defined as ‘any attempt at creating new opportunities with resulting improvement in government performance characterized by risk-taking, innovativeness, and proactiveness’ (Kim, 2010, p. 784).
Notably, public sector entrepreneurship very rarely leads to new organization creation—most frequently, it involves the development and implementation of innovative services, technologies, or management methods within the established public sector organizations (Demircioglu & Chowdhury, 2021). The extant literature argues that public sector organizations engage in innovation processes to create public value (i.e. increased efficiency and effectiveness of the organization and enhanced welfare and human rights for citizens) (Chen et al., 2020).
Furthermore, entrepreneurial projects in the public sector tend to be co-created by various actors in a public sector organization’s ecosystem (Torfing, 2019). Last, research shows that public sector entrepreneurial projects lead tothe development of mission, policy, management, partner, service, and citizens’ innovations (Chen et al., 2020; Gullmark, 2021).
The literature on public sector entrepreneurship and innovation tends to attribute the success of most public sector entrepreneurial projects to the entrepreneurial and pro-innovation attitude of public sector employees and managers (Swann, 2017). Recent research notes that the existence of dynamic (managerial) capabilities in public sector organizations explains how and why public sector entrepreneurs can pursue innovations (Gullmark, 2021; Trivellato et al.,2021). Dynamic managerial capabilities are built on three groups of underlying factors.
These building blocks are (1) cognitive capabilities (i.e. knowledge structures, cognitive capabilities, and emotion regulation), (2) managerial social capital (i.e. social networks and relationships), and (3) managerial human capital (i.e. education and work experience) (Helfat & Martin, 2015; Huy & Zott, 2019).
Dynamic managerial capabilities enable managers to sense and seizeentrepreneurial opportunities, transform their organizations, and thereby direct strategic change (Teece, 2016). In other words, the interaction between cognitive, social capital, and human capital capabilities enables (public sector) entrepreneurs not only to sense entrepreneurial opportunities, but also to mobilize support, legitimacy, knowledge, and resources, which are required to seize the focal opportunity and reconfigure the organization where the focal opportunity is being implemented.
Case Activities
After reading the case, complete the following assignments.
1. Individual work. Write an individual reflection about:
Anna’s entrepreneurial journey. Imagine that you are Anna and that you are at a similar crossroads. Focus on her dilemma. List the pros and cons of continuing the work of the project. Then, based on your analysis, decide whether you would continue the project or abandon it. Justify your choice.
2. Group work. Take your notes and share your reflections with other members of your group. Before discussing the case in the group, each group member should present their reflections.
Use the group work to:
- Discuss Anna’s dilemma. Assess the progress and future predictions for the project. The group needs to jointly make the final decision on Anna’s behalf. Make a short presentation that explains why she should continue to work on her project or why she should abandon it.
- Write a short narrative that continues the story of Anna and her entrepreneurial project.
- If the group decided that Anna should continue leading her entrepreneurial project, what do you think could have happened in the following months/years with her project?
- If the group decided that Anna should abandon her project and move on, what do you think Anna could have focused on after abandoning the project?
- Based on Anna’s story, reflect on entrepreneurial processes in the public sector. The group should build the discussion around the following four questions:
- What characterizes entrepreneurial processes in public sector organizations?
- How can the co-creation perspective increase our understanding of entrepreneurial processes in the public sector?
- How can the dynamic capabilities perspective help us to better understand entrepreneurial processes in public sector organizations?
- How do the entrepreneurial activities of public sector entrepreneurs affect strategic change in public sector organizations?
During the discussion, build your arguments on the suggested theoretical insights (see the section above).
Based on
REFRAMING THE CASE METHOD IN ENTREPRENEURSHIP EDUCATION,
Karin Wigger, Lise Aaboen, Dag Haneberg, Siri Jakobsen, and Thomas Lauvås –
9781800881150
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via Open Access. This work is licensed under the Creative Commons
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Chapter 23: “I cannot give up now!”: the story of a Norwegian public sector entrepreneur’s endeavours to revolutionize communication between two healthcare organizations.
References
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Gullmark, P. (2021) Do all roads lead to innovativeness? A study of public sector organizations’ innovation capabilities. The American Review of Public Administration, 51(7), 509–525.
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