Inciting maintenance: Tiered institutional work during value-based payment reform in oncology

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned.

Hybridity enabled: A research synthesis of the enabling conditions for hybrid professionalism in healthcare

Hybrid professionals in healthcare organizations play a critical role, the characteristics, processes and implications of which have been thoroughly studied by scholars in the field. However, not as much attention has been paid to the conditions under which such roles might be taken by professionals entering the ground of management. This gap results into a lack of conceptual clarity and eventually ends being an obstacle in framing and ameliorating the tools needed to act such a role in its different phases. This is a research area worthy of a finer-grained understanding: the ability of organizations to effectively support role hybridization, in fact, is a requisite for professionals-managers' willingness to stay in the role and cope with the complexity that such a two-fold position entails, no matter what. Based on the results of a scoping literature review, this paper presents the enabling conditions for hybrid professionalism in healthcare, and proposes a classification of them into categories corresponding to different facets of hybrid role-taking: opportunities for interaction with management, tools supporting sense-making, and provision of delegation and autonomy. For each of these categories, organizational and management tools discussed in the literature are presented. The results of the study provide a road-map of the enabling conditions for hybrid professionalism that aims to be of practical convenience for managers and policy-makers in health care. Eventually, suggestions for organizational design and personnel management, as well as directions for further research, are highlighted.

Physician entrepreneurship: A study of early career physicians' founding motivations and actions

The literature on professional socialization suggests that their training and socialization lead physicians to prioritize professionally prescribed activities over entrepreneurial activity. This leaves unexplained how and why early career physicians would engage in entrepreneurship, a behavior that many healthcare organizations now seek to encourage. To address this shortcoming, we conducted an inductive study, augmented with survey data, of UK National Health Service physicians involved in entrepreneurial projects. We detail a process of physician entrepreneurship underpinned by organizational improvement motives and identification with the organization. Entrepreneurs breached constraining roles and formed ventures which originated as intrapreneurial initiatives but shifted to individual-level resourcing. Entrepreneurial behaviors coincided with physicians' commitment to remain with the NHS albeit with adjustments to their career plans. Overall, the study suggests that physicians manage the pressure exerted by professional socialization by adapting both the kind of entrepreneurial projects and career pathways they pursue.

Coordinating multi-level collective action: how intermediaries and digital governance can help supply chains tackle grand challenges

Purpose

Driven by increasing concerns for sustainable development and digitalization, intermediaries have emerged as relevant actors who can help supply chains tackle grand societal challenges. They can also trigger significant changes in structure, shape and governance models of supply chains. The goal of this research is to advance the understanding of supply chain intermediation and digital governance as coordinating mechanisms for enabling multi-level collective action to address the world's grand challenges.

Design/methodology/approach

This is a conceptual research paper that uses a vignette approach, where real examples are described to help question and expand theoretical insights and provide a basis for future research. The examples are drawn from past and ongoing extensive primary and secondary data collection efforts in diverse types of supply chains.

Findings

Three contexts are proposed to illustrate how intermediaries and digital governance can play a key role in helping supply chains tackle grand challenges. The first and second context highlight the differences between material and support flow intermediaries in a triadic supply chain relationship. The third context illustrates intermediation within a multi-level network which can be industry-specific or span across industries. The three contexts are evaluated on the level of intervention, the focus on material or support flows, and traditional or digital governance. The specific Sustainable Development Goals which can be tackled through intermediary intervention are also indicated.

Originality/value

Intermediaries are often hidden actors in global supply chains and have received limited attention in the academic literature. The conceptual foundation provided in this manuscript serves as the basis for future research opportunities. Three main avenues for further research in this domain are proposed: (1) novel forms of intermediation beyond economic and transactional arrangements; (2) novel forms of digital governance; and (3) translating multi-level collective action into sustainable development outcomes. Research on intermediation driven by sustainable development and digitalization trends can spur empirical advances in sustainable supply chain and operations management with important societal impact.

Clinicians' psychological empowerment to engage in management as part of their daily work

PURPOSE

The purpose of the article is to analyze how physicians and nurses, as the two major health care professions, experience psychological empowerment for managerial work.

DESIGN/METHODOLOGY/APPROACH

The study was designed as a qualitative interview study at four primary care centers (PCCs) in Sweden. In total, 47 interviews were conducted, mainly with physicians and nurses. The first inductive analysis led us to the concept of psychological empowerment, which was used in the next deductive step of the analysis.

FINDINGS

The study showed that both professions experienced self-determination for managerial work, but that nurses were more dependent on structural empowerment. Nurses experienced that they had competence for managerial work, whereas physicians were more ignorant of such competence. Nurses used managerial work to create impact on the conditions for their clinical work, whereas physicians experienced impact independently. Both nurses and physicians experienced managerial work as meaningful, but less meaningful than nurses and physicians' clinical work.

PRACTICAL IMPLICATIONS

For an effective health care system, structural changes in terms of positions, roles, and responsibilities can be an important route for especially nurses' psychological empowerment.

ORIGINALITY/VALUE

The qualitative method provided a complementary understanding of psychological empowerment on how psychological empowerment interacted with other factors. One such aspect was nurses' higher dependence on structural empowerment, but the most important aspect was that both physicians and nurses experienced that managerial work was less meaningful than clinical work. This implies that psychological empowerment for managerial work may only make a difference if psychological empowerment does not compete with physicians' and nurses' clinical work.

Translating to maintain existing practices: Micro-tactics in the implementation of a new management concept

Research has demonstrated how the translation of a new management concept into organizational practices is impacted by the translators’ engagement with their local context. We expand this literature by demonstrating how a heterogenous institutional context prompts translators to create practice change but also practice maintenance. Building upon an interpretive analytical framework we offer a way forward to examine relationships between societal institutions and distributed collective work in change processes. Our longitudinal qualitative study based upon interviews and observations examines how the concept of value-based healthcare was translated at a hospital. The translators developed three micro-tactics: disregard, maintenance, and displacement, grounded in their narration of practice changes. Translators enacted institutional logics differently at the levels of meaning and practice when they framed, rationalised, and contextualised the potentialities of a new concept, and this complexity provided the possibility of various practice outcomes. We contribute to the understanding of translation by demonstrating how a heterogenous institutional context encourages translators to change selected practices but also to decouple and maintain most of the existing practices due to their enactment of institutionalised rationalities. Moreover, we discuss how translation outcomes are impacted by collaborating actors’ shared interpretations of their institutional context. Collaborating translators need to agree on whether and what practice change is valuable for the organization, and change is only possible when they interpret that they have the leverage to align a new idea with dominant institutional logics.

Triadic Advocacy Work

Scholars of street-level bureaucracy and institutional research focus primarily on the relationships between advocates and their larger bureaucratic and social systems, assuming that advocates have little need to satisfy their beneficiaries. We find otherwise in our two-year ethnographic study of public defenders advocating for disadvantaged clients in interactions with district attorneys. In our analysis of 82 advocacy opportunities, we demonstrate that, when existing bureaucratic and social systems put beneficiaries at a disadvantage, advocates may be concerned about managing fraught relationships with their beneficiaries in addition to navigating barriers within the bureaucratic and social systems. We further show a tension between the two; ironically, engaging in advocacy work on behalf of beneficiaries can lead to beneficiary mistrust. As a result, advocates engage in triadic advocacy work—managing impressions with their beneficiaries while also influencing powerful actors within the system on behalf of these same beneficiaries. Understanding the process by which advocates navigate this tension is critical to understanding beneficiary outcomes. By reconceptualizing advocacy work as a triadic process among advocate, bureaucratic system, and beneficiary rather than as a dyadic process between advocate and bureaucratic system, this paper develops new theory about how advocates can attempt to garner benefits that advance the rights and opportunities of the disadvantaged.

Family members as hybrid owner-managers in family-owned newspaper companies: handling multiple institutional logics

Purpose

This article aims to increase the understanding of the role of individual actors and arenas in dealing with multiple institutional logics in family firms.

Design/methodology/approach

This study follows a case-study approach of two family-owned newspaper companies. Based on interviews and secondary sources, the empirical material was analysed focussing on three institutional logics, that is, family logic, management logic and journalistic logic.

Findings

First, the authors show how and in which arenas competing logics are balanced in family-owned newspaper companies. Second, the authors highlight that family owners are central actors in the process of balancing different institutional logics. Further, they analyse how family members can become hybrid owner-managers, meaning that they have access to all institutional logics and become central actors in the balancing process.

Originality/value

The authors reveal how multiple institutional logics are balanced in family firms by including formal actors and arenas as additional lenses. Therefore, owning family members, especially hybrid owner-managers, are the best-suited individual actors to balance competing logics. Hybrid owner-managers are members of the owner families who are also skilled in one or several professions.

To Uncertainty and Beyond: Identifying the Capabilities Needed by Hospitals to Function in Dynamic Environments

Hospitals operate in increasingly complex and dynamically uncertain environments. To understand how hospital organizations can cope with such profound uncertainty, this article presents a multiple case study of five hospitals during the COVID-19 crisis in a heavily hit region of the Netherlands. We find that hospitals make adaptations in five key categories, namely: reorganization, decision-making, human resources, material resources, and planning. These adaptations offer insights into the core capabilities needed by hospitals to cope with dynamic uncertainty. Our findings highlight the need for hospitals to become more flexible without sacrificing efficiency. Organizations can accomplish this by building in more sensing and seizing capabilities to be better prepared for and respond to environmental change. Furthermore, transforming capabilities allow organizations to be more resilient and responsive in the face of ongoing uncertainty. We make recommendations on how hospitals can build these capabilities and address the core challenges they face in this pursuit.

New avenues for HRM roles: A systematic literature review on HRM in hybrid organizations

In recent decades, the emergence of hybrid organizational forms has placed new demands on the role of human resource management (HRM) contributing to organizational goals. Moreover, research emphasizes that the increasing hybridity of contexts, stakeholder requirements, and goals lead to organizational tensions that, if not properly addressed, can lead to organizational downfall. However, although organization and management research recognize the importance of elaborating HRM roles for hybrid contexts, drawing upon findings from the hybrid literature has been widely neglected. Thus, by mapping the research landscape regarding hybridity, this article provides insight into the configuration of organizational HRM roles and functions that contribute to the development of hybrid goals and are associated to the management of tensions. Significantly, this article introduces three specific HRM roles— hybrid strategist, capability adapter, and identification generator—as essential HRM roles for hybrid contexts.

Persistent institutional breaches: Technology use in healthcare work

Various mobile phone applications (hereafter apps) challenge instituted ways of working in healthcare. This study explores the institutional breaches arising from the use of apps in doctor-patient interactions. This paper argues that institutional breaches, however small, are important occasions for observing the contextual intersections between healthcare, regulation and technology in a hospital setting. Based on healthcare professionals' normative judgements, the paper offers an empirically grounded understanding of institutional legitimacy-claiming; safeguarding responses deployed by the instituted regime, and the case-building responses deployed by the instituting persuaders. Institutional breach persistence arises from the moral dimension of legitimacy and is grounded in asymmetrical dynamics between two virtuous healthcare narratives. The paper concludes with a discussion of the contextual intersections between healthcare, regulation and technology, paying particular attention to institutional breaches as experimentation, the contestation of normativity and patterns of technology indulgency in healthcare work.

Hijacking institutional logics in the implementation of a cancer trial

Practice-based studies have demonstrated how institutional logics function as repertoires of cultural resources that actors may use strategically for professional (re-)positioning. This article focuses on the concept of hijacking based on a qualitative study of the implementation of a randomized controlled trial (RCT) in specialized cancer palliation. Using the logics-as-resources perspective as theoretical framing, we describe the negotiations and hijacking of logics that followed the introduction of the RCT and the temporary reversal of home logics between professional subgroups in cancer treatment and care. The analysis shows how hijacking unfolds in a highly institutionalized and complex professional healthcare setting characterized by intra-institutional heterogeneity. We contribute to the literature by highlighting how hijacking is related to power differentials and identity work and may contribute to obscuring underlying conflicts, in this case between science and care logics. The article develops our understanding of hijacking as a theoretical concept and an empirical phenomenon.

The relational road to voice: how members of a low-status occupational group can develop voice behavior that transcends hierarchical levels

Members of frontline low-status occupational groups often have access to a vast pool of knowledge, expertise, and experience that may be valuable for organizations. However, previous research has shown that members of these occupational groups are often reluctant to exhibit voice behavior due to their low position in the organizational hierarchy and perceived status differences. Drawing on in-depth interviews with auxiliary nurses (ANs) who participated in a development trajectory, as well as with their colleagues and supervisors, we demonstrate how members of this low-status occupational group develop voice behavior. Our findings show how acquiring three different types of knowledge and acting on this knowledge can lead to forming new and different types of relationships with members of higher status occupational groups in the organization. Subsequently, these relational changes enhanced voice behavior, as the ANs under study became more skillful in navigating the organization and felt better equipped to share their ideas, concerns, and perspective. We contribute to the literature on voice behavior by members of low-status occupational groups by moving beyond the findings of previous studies that have shown that low-status employees are unlikely to exhibit voice behavior. We detail how the development of knowledge, as well as relationships between different occupational groups, is crucial for the enhancement of voice behavior that transcends hierarchical levels. Moreover, we add to the literature on upward influence of subordinates by showing how such voice allows subordinates to exert upward influence in their organizations and initiate change that benefits their own occupational group.

Keeping institutional logics in arm’s length: emerging of rogue practices in a gray zone of everyday work life in healthcare

We set out to explore the practice-level cognitive structures and associated practices characterizing the daily routine work of physicians by conducting a qualitative study in the Turkish healthcare field, in which a recent government-led healthcare reform was implemented causing logic multiplicity. Contrary to the accumulated knowledge in institutional logics literature, a bulk of which suggests that actors craft and enact various practices in managing plural and at times conflicting institutional templates strictly within the confines of higher order societal logics, this study shows that while ground level actors may not exercise complete freedom and maneuverability in relation to pre-established social structures, they do incorporate unconventional schemas of action; namely rogue practices, into their embodied practical activity, which over time become routinized in their day-to-day work lives. Unraveling the dynamics of micro-level practices of highly professionalized ground level actors as they pertain to atypical logical orientations substantially advances our understanding of the unknown or unseen side of how and under which conditions certain or various combinations of institutional logics are employed during day-to-day activities.

Coordination of paediatric oncology care: an explorative Swedish case study

Purpose

The aim of this paper is to empirically describe and analyze factors deemed to be relevant for the successful provision of coordinated paediatric oncology care by physicians and nurses involved.

Design/methodology/approach

A qualitative case study primarily consisting of interviews.

Findings

The paper's findings indicate that certain factors (i.e. distinct mission, clear treatment protocols and support from external stakeholders) relevant for the provision of coordinated paediatric oncology care have not received sufficient attention in previous research. In addition, emphasis is placed on the necessity of facilitating constructive working relationships and a bottom-up perspective when pursuing improved care coordination.

Originality/value

The factors described and analyzed may act as insights for how paediatric oncology might be improved in terms of care coordination and thus facilitate care integration. In addition, the paper's findings identify factors relevant for further empirical studies in order to delineate their generalizability.

The Failure of Hybrid Organizations: A Legitimation Perspective

Organizational hybridity refers to the combination of multiple institutional logics and identities that, within an organizational setting, do not conventionally complement one another. In such conditions, organizations must develop strategies to combine logics and sustain their hybrid forms. Success, however, is not inevitable. In this article, we take a legitimacy-as-process perspective to focus on a failed Microfinance Organization (MFO) in the African context of Zambia. MFOs represent a fascinating context because of their hybrid nature and need to balance several competing institutional demands. We utilise field interviews to analyse the process through which MFOs fail, analysing actor legitimation responses to emerging hybridity demands. We identify three phases associated with these changes: 1) dependent coupling, (2) misaligning legitimation, and (3) circumnavigating over conformity. Our findings emphasise that legitimation efforts in a failed hybrid are not simply the reverse of those that succeed. We observe adaptive processes consistent with successful hybrids but that ultimately sow the seeds of eventual failure. This demonstrates the need to re-think the role of legitimation strategies in hybrids alongside their potential deleterious consequences.

Duality and Social Position: Role expectations of people who combine outsider-ness and insider-ness in organizational change

A person’s social position shapes whether and how they can influence organizational change. While prior research establishes people whose social position combines outsider-ness and insider-ness as important change agents, we know little about how they influence change. We analyse a peer coaching initiative in Canadian hospitals to explain how outsider-insiders – in this case, organizational outsiders with professional proximity – advance change. Peer coaches were able to influence change by establishing and enacting a dual outsider-insider role and associated role expectations. We advance theory by showing that role expectations emphasizing duality that are rooted in social position, but created through social interaction, are a key mechanism by which the potential of outsider-insider social positions can be activated and mobilized to influence change. We advance theory on social position generally by highlighting the potential for integrating a symbolic interactionist perspective – focused on role expectations – into Bourdieu’s theory of fields.

Change is never easy: How management theories can help operationalise change in medical education

CONTEXT

Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change.

PROPOSAL

In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory.

CONCLUSIONS

We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

Red tape and psychological capital: a counterbalancing act for professionals in street-level bureaucracies

Assuming that red tape is inevitable in institutions, and drawing on positive organizational behavior, we compare the impact of individual psychological capital on the ability of street-level bureaucrats (SLBs) with different professional backgrounds to work within the confines of red tape. The two SLB professions investigated here are nurses and local government employees; and the work outcomes of interest to this study are well-being and engagement. The findings show that red tape has a different impact on each professional group but, encouragingly, they also indicate that psychological capital has a compensatory effect. Implications include nurses requiring more psychological resources than local government employees to counteract the negative impact of red tape. A practical implication for managers is that, if perception of red tape in organizations is set to increase or to stay constant, enhancing the psychological capital of professionals in SLB roles, through specific interventions, may be beneficial to professionals and organizations alike.

The balancing act of organizing professionals and managers: An ethnographic account of nursing role development and unfolding nurse-manager relationships

Scholars describe organizing professionalism as ‘the intertwinement of professional and organizational logics in one professional role’. Organizing professionalism bridges the gap between the often-described conflicting relationship between professionals and managers. However, the ways in which professionals shape this organizing role in daily practice, and how it impacts on their relationship with managers has gained little attention. This ethnographic study reveals how nurses shape and differentiate themselves in organizing roles. We show that developing a new nurse organizing role is a balancing act as it involves resolving various tensions concerning professional authority, task prioritization, alignment of both intra- and interprofessional interests, and internal versus external requirements. Managers play an important yet ambiguous role in this development process as they both cooperate with nurses in aligning organizational and nursing professional aims, and sometimes hamper the development of an independent organizing nursing role due to conflicting organizational concerns.

Professional Values and Managerialist Practices: Values work by nurses in the emergency department

Interest in values work – the purposeful effort of actors to create, maintain and disrupt the values of organizations, professions and other institutions – is growing among scholars. We ask: How do frontline professionals engage in values work while enacting managerialist practices inside organizations? We investigate this question using a case study of nurses enacting managerialist practices associated with time-efficient work flow in a hospital emergency department in Australia. Our findings show that professionals engage in values work by categorizing the values of the profession and taking actions within the managerialist practice to (1) defend a superordinate value category, (2) contain erosion of a subordinate value category, and (3) integrate a basic value category. Our study brings attention to how multiple values complicate the processes of values work when particular values become implicated in organizational practices. Frontline professionals become motivated and take actions to accomplish values within a relational system of multiple values according to relative importance and relevance to the local context. Our study offers a way forward for understanding the performance of values work within the ‘new normal’ for professions in contemporary organizational contexts.

Institutional stress and job performance among hospital employees

Purpose

The purpose of this study was to investigate if institutional stress is related to job performance among hospital employees, and if institutional stress is fully or partly mediated by motivational resources with regards to the relation with job performance.

Design/methodology/approach

A self-completion survey was distributed to four public hospitals in Norway, and had a response rate of 40% (N = 9,162). Structural equation modelling was conducted on two groups of hospital employees with (N = 795) and without (N = 8,367) managerial responsibilities.

Findings

Institutional stress was negatively related to job performance for hospital employees without managerial responsibilities. The motivational resources autonomy, competence development and social support partly mediated the relationship between institutional stress and job performance in the group of employees without managerial responsibilities. In the leader group, the motivational resources fully mediated the relationship between institutional stress and job performance. Social support from leaders had a non-significant influence on job performance in both groups.

Research limitations/implications

The main limitation with this study is its cross-sectional design.

Originality/value

The study enables us to extend how work-related stress is related to job performance and the mediating role of the job resources autonomy, competence development and social support. The focus on productivity, and top management’s wish to improve hospital performance, may have unintended consequences, leading to a gap between managerial and clinical worldviews and understanding of goals, policies, values and prioritizing. This can lead to institutional stress. The findings of this study suggest that institutional stress has negative effects on hospital employees’ work motivation and job performance.

Changing Logics in Healthcare and Their Effects on the Identity Motives and Identity Work of Doctors

Recent literature on hybridity has provided useful insights into how professionals have responded to changing institutional logics. Our focus is on how shifting logics have shaped senior medical professionals’ identity motives and identity work in a qualitative study of hospital consultants in the United Kingdom’s National Health Service. We found a binary divide between a large category of traditionalist doctors who reject shifting logics, and a much smaller category of incorporated consultants who broadly accept shifting logics and advocate change, with little evidence of significant ambivalence or temporary identity ‘fixes’ associated with liminality. By developing a new inductively generated framework, we show how the identity motives and identity work of these two categories of doctors differ significantly. We explore the underlying causes of these differences, and the implications they hold for theory and practice in medical professionalism, medical professional leadership and healthcare reform.

Multiple Vulnerabilities in Medical Settings: Invisible Suffering of Doctors

While there is a substantive amount of literature on vulnerability of different kinds of patients in different settings, medical professionals are usually considered as the ones who possess power and gain a privileged position. In this paper, we aim to demonstrate that in a certain context physicians—a social group which is usually referred to as “powerful”—consider themselves vulnerable, and this positioning may influence patients in turn. This perspective highlights the complexity of interactions within medical organizations and contributes to the studies of sensitive topics and vulnerable groups. We conceptualize vulnerability of doctors and discuss what can be problematic in powerful doctors’ position. We describe some features of the post-Soviet context of Russian healthcare system and maternity care, both of which can be conceptualized as a hybrid of legacy of Soviet paternalism and new neoliberal reforms, managerialism and marketization. Empirical research is based on the ethnographic evidence from the study of a Russian perinatal center. In this article, we explore specific “existential” and “moral” vulnerabilities of medical professionals who routinely have to cope with multiple challenges, such as complicated clinical tasks, rigid control of different state bodies and emotional responses of suffering patients. We argue that there is a bond between the vulnerability of doctors and that of patients, whose position becomes more problematic as professionals become more vulnerable. At the end, we discuss methodological and theoretical implications of our research.

Twenty-five years of national health IT: exploring strategy, structure, and systems in the English NHS

Objective

There is global interest in implementing national information systems to support healthcare, and the National Health Service in England (NHS) has a troubled 25-year history in this sphere. Our objective was to chronicle structural reorganizations within the NHS from 1973 to 2017, alongside concurrent national information technology (IT) strategies, as the basis for developing a conceptual model to aid understanding of the organizational factors involved.

Materials and Methods

We undertook an exploratory, retrospective longitudinal case study by reviewing strategic plans, legislation, and health policy documents, and constructed schemata for evolving structure and strategy. Literature on multi-organizational forms, complexity, national-level health IT implementations, and mega-projects was reviewed to identify factors that mapped to the schemata. Guided by strong structuration theory, these factors were superimposed on a simplified structural schema to create the conceptual model.

Results

Against a background of frequent NHS reorganizations, there has been a logical and emergent NHS IT strategy focusing progressively on technical and data standards, connectivity, applications, and consolidation. The NHS has a complex and hierarchical multi-organization form in which restructuring may impact a range of intra- and inter-organizational factors.

Discussion

NHS-wide IT programs have generally failed to meet expectations, though evaluations have usually overlooked longer-term progress. Realizing a long-term health IT strategy may be impeded by volatility of the implementation environment as organizational structures and relationships change. Key factors influencing the strategy-structure dyad can be superimposed on the tiered NHS structure to facilitate analysis of their impact.

Conclusion

Alignment between incremental health IT strategy and dynamic structure is an under-researched area. Lessons from organizational studies and the management of mega-projects may help in understanding some of the ongoing challenges.

Working out What Works: The Role of Tacit Knowledge Where Urban Greenspace Research, Policy and Practice Intersect

Policymakers and practitioners working in urban greenspace management want to know what kind of interventions are effective in promoting mental wellbeing. In practice, however, they rely on multiple forms of knowledge, often in unwritten form. This paper considers how such knowledge is interpreted and used by a range of stakeholders to identify greenspace interventions to support residents’ health and wellbeing in one UK city. It examines the interface between academic research, policy and practice, drawing on the findings of a three-year study in Sheffield, UK. The Improving Wellbeing through the Urban Nature project investigated the links between ‘urban nature’ and mental health. One strand of the research sought to influence policy and practice, and this article presents findings and reflects on some of the processes of this exercise. It highlights the role of tacit knowledge in practice and its influence on practitioners’ choice of greenspace interventions and the challenges in drawing on such knowledge to influence policy. The findings affirm practice-based knowledge as socially situated, interpretively fashioned and politically weighted. This paper concludes by demonstrating the importance of considering the local context when devising policy prescriptions for greenspace provision and management.

The Moral Microfoundations of Institutional Complexity: Sustainability implementation as compromise-making at an oil sands company

Research on institutional complexity has overlooked the fact that moral judgements are likely involved when individuals face a plurality of logics within organizations. To analyse the moral microfoundations of institutional complexity, we build on Boltanski and Thévenot’s economies of worth framework and explore how individuals produce moral judgement in response to the institutional complexity triggered by a major shift in the sustainability strategy within an oil sands company. Fifty-two interviews with employees, managers and executives reveal how actors rely on four types of justification that combine different moral principles and related objects with the aim of either forming (sheltering and solidifying work) or challenging (fragilizing and deconstructing work) a new compromise with regard to sustainability within the organization. Our results show how the economies of worth framework can enrich institutional complexity theory by bringing morality back into the analysis as a core dimension of inhabited institutions while advancing the microanalysis of compromise-making around sustainability in organization studies.

White Coats at the Coalface: The Standardizing Work of Professionals at the Frontline

This study advances theory on professionals by introducing a novel ‘coalface perspective’ to study frontline professionals’ standardizing work. Our multimethod quantitative and qualitative approach explores when, why and how medical professionals in German university hospitals actively maintain care pathway enactment – a technique to standardize day-to-day medical work – in their everyday patient treatment. Professionals’ actively standardizing their work is an understudied yet highly relevant phenomenon that the established ‘autonomy perspective’ – which covers how professionals resist standardization – falls short of explaining. Introducing a coalface perspective overcomes this shortcoming by uncovering novel links between professionals’ day-to-day problem-driven motivations for standardizing work, the characteristics of everyday situations of frontline professional work and practices of standardizing work at the frontline. This study has implications for research on frontline professionals and coalface-perspective research in general.

Healthcare scandals and the failings of doctors

PURPOSE

The purpose of this paper is to explore whether official inquiries are an effective method for holding the medical profession to account for failings in the quality and safety of care.

DESIGN/METHODOLOGY/APPROACH

Through a review of the theoretical literature on professions and documentary analysis of key public inquiry documents and reports in the UK National Health Service (NHS) the authors examine how the misconduct of doctors can be understood using the metaphor of professional wrongdoing as a product of bad apples, bad barrels or bad cellars.

FINDINGS

The wrongdoing literature tends to present an uncritical assumption of increasing sophistication in analysis, as the focus moves from bad apples (individuals) to bad barrels (organisations) and more latterly to bad cellars (the wider system). This evolution in thinking about wrongdoing is also visible in public inquiries, as analysis and recommendations increasingly tend to emphasise cultural and systematic issues. Yet, while organisational and systemic factors are undoubtedly important, there is a need to keep in sight the role of individuals, for two key reasons. First, there is growing evidence that a small number of doctors may be disproportionately responsible for large numbers of complaints and concerns. Second, there is a risk that the role of individual professionals in drawing attention to wrongdoing is being neglected.

ORIGINALITY/VALUE

To the best of the authors' knowledge this is the first theoretical and empirical study specifically exploring the role of NHS inquiries in holding the medical profession to account for failings in professional practice.

Regulatory Measurements in Policy Coordinated Practices: The Case of Promoting Renewable Energy and Cleaner Transport in Sweden

International organisations, such as the Organization for Economic Co-operation and Development (OECD) and the European Union (EU), are seeking to implement a cohesive Regulatory Impact Assessment (RIA) system in order to achieve better regulation and increased unity and transparency. Central to these evaluations is the use of cost-benefit analysis (CBA) and related tools. A comprehensive analysis of the use of impact assessment in the EU shows that many assessments lack important economic components. This paper draws on an extensive document study of the Swedish policy making process related to the EU Directive 2009/28/EC on the promotion of the use of energy from renewable sources. The aim of the paper is to examine how CBA is presented, negotiated and accounted for by central actors within a policy setting influenced by negotiation and policy coordination. The paper departs from a theoretical perspective on policy coordination and shows how this factor must be considered when explaining the low use of CBA. It concludes that the Swedish policy tradition, wherein the national government relies on consensus-based coordination between agencies, might counteract a more explicit assessment of different policy options. The paper also proposes a model that can be used for further studies on CBA and policy coordination.

Complementary work in the hospital: How infection preventionists perceive opportunities for cooperation with higher status physicians

Social scientists and management scholars have tended to see workplace interaction through the lens of hierarchy. However, modern workplaces include many people who do not fit neatly into such hierarchies because their work is designed to assess, support, sanction, or monitor other workers who already have well-established positions. Motivated by this observation, we conducted interviews with 193 infection preventionists—healthcare workers whose job it is to work with higher status physicians to monitor and suppress healthcare-acquired infections—to assess how workers outside of existing hierarchies can integrate their work. Inductive analyses of these interviews suggest three strategies: deference; relying on bureaucracy’s routines and practices; and recruiting higher status confederates, which we call side-channeling. From these analyses, we introduce the concept of complementary work to describe labor that seeks to supplement existing workplace hierarchies.

Academics’ experience of contradicting institutional logics of publishing

Purpose

The purpose of this paper is to explore whether and how Ukrainian scholars recognize and react to a situation of an absence of two major institutional logics of academic writing and publishing, namely the logics of science advancement and personal career promotion and the dominance of the logic of coercive pressures to publish regardless of quality and resonance and with no material and reputational rewards. Two fundamental and essential logics that drive research activity at any university in western societies seem to be almost absent in Ukrainian context, where symbolic publishing for accountability only is taken-for-granted.

Design/methodology/approach

The study adopts qualitative interpretative research methodology. The scholars from seven universities were interviewed, including 16 senior scholars and 15 PhD students.

Findings

The study shows the dominance of a single logic of accountability which is persisted due to coercive pressures exerted on scholars. Despite the absence of instrumental value behind publishing requirements in Ukrainian higher education system, most academics do not question this policy and largely take it for granted as the only possible system.

Originality/value

Research conducted in this study contributes to institutional logics and institutional complexity literature by highlighting a unique situation of institutional complexity when logic that offers neither economic nor social benefits dominates the field. It is shown how actors recognize, interpret and respond to this situation, identifying three types of responses that range from blind adherence to taken-for-granted institutional definitions to strategic balance between coercive pressures and desired logics.

Neo-Institutional Theory and Organization Studies: A Mid-Life Crisis?

We trace the development of neo-institutional theory in Organization Studies from a marginal topic to the dominant theory. We show how it has evolved from infancy, through adolescence and early adulthood to being a fully mature theory, which we think is now facing a mid-life crisis. Some of the features of this mid-life crisis include over-reach, myopia, tautology, pseudo-progress and re-inventing the wheel. To address these problems, we argue that institutional theorists should limit the range of the concept, sharpen their lens, avoid tautologies and problematize the concept. By doing this, we think institutional theorists could develop a narrower and more focused conception of institutions.

Professional employees’ strategic employment of the managerial logic in healthcare

Purpose

The purpose of this paper is to describe and analyze how physicians and nurses strategically employ the managerial logic.

Design/methodology/approach

A qualitative case study incorporating interviews and observations.

Findings

Neither physicians nor nurses were prone to strategically employing the managerial logic. However, when doing so nurses were able to acknowledge the legitimacy of managerial impact on practice, whereas the physicians were not. Consequently, physicians might find other, more subtle, ways to strategically employ the managerial logic.

Originality/value

This paper argues for and makes explicit the applicability of qualitative methods in order to delineate actors’ strategic use of available and accessible institutional logics, the conditions for such usage, as well as the multiplicity of actors’ interactions that needs to be taken into account when conducting qualitative data analysis of such occurrences. By the merits of the qualitative research approach utilized in this study, novel insights concerning the strategic use of the managerial logic in the everyday work of physicians and nurses were obtainable. These insights emphasize the necessity of acknowledging situational, organizational and institutional context, incorporating inter-professional power discrepancies and relationsvis-à-vismanagers.

Personalisation - An Emergent Institutional Logic in Healthcare? Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare"

This commentary on the recent think piece by Mannion and Exworthy reviews their core arguments, highlighting their suggestion that recent forces for personalization have emerged which may counterbalance the strong standardization wave which has been evident in many healthcare settings and systems over the last two decades. These forces for personalization can take very different forms. The commentary explores the authors' suggestion that these themes can be fruitfully examined theoretically through an institutional logics (ILs) literature, which has recently been applied by some scholars to healthcare settings. This commentary outlines key premises of that theoretical tradition. Finally, the commentary makes suggestions for taking this IL influenced research agenda further, along with some issues to be addressed.

Are Logics Enough? Framing as an Alternative Tool for Understanding Institutional Meaning Making

Understanding institutions requires attending both to their social fact qualities and to the bidirectional nature of institutional processes as they influence and are influenced by actors. We advocate for frames and framing as tools to elucidate meaning making activities, and to explain whether and how meanings subsequently spread, scale up, and perhaps become widely institutionalized. Frames as cognitive structures provide resources for actors and shape what they see as possible, while framing as an interaction process is a source of agency that is embedded in the everyday activities of individuals, groups, and organizations. In making the case for the framing approach, we consider how the extensive use of the logics approach in organization theory research has created confusion about what logics are and how they accommodate both structure and agency. We conclude with a discussion of the phenomenological and ontological potential of frames and framing.

(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare

Recent years have witnessed a parallel and seemingly contradictory trend towards both the standardization and the customization of healthcare and medical treatment. Here, we explore what is meant by 'standardization' and 'customization' in healthcare settings and explore the implications of these changes for healthcare delivery. We frame the paradox of these divergent and opposing factors in terms of institutional logics - the socially constructed rules, practices and beliefs which perpetuate institutional behaviour. As the tension between standardization and customization is fast becoming a critical fault-line within many health systems, there remains an urgent need for more sustained work exploring how these competing logics are articulated, adapted, resisted and co-exist on the front line of care delivery.

Institutional Complexity and Individual Responses: Delineating the Boundaries of Partial Autonomy

Research highlights how coexisting institutional logics can sometimes offer opportunities for agency to enterprising actors in organizational fields. But macro- and micro-level studies using this framework diverge in their approach to understanding the consequences of institutional complexity for actor autonomy, and correspondingly in the opportunities they identify for agents to resist, reinterpret or make judicious use of institutional prescriptions. This paper seeks to bridge this gap, through a longitudinal, comparative case study of the trajectories of four ostensibly similar change initiatives in the same complex organizational field. It studies the influence of three dominant institutional logics (professional, market and corporate) in these divergent trajectories, elucidating the role of mediating influences, operating below the level of the field but above that of the actor, that worked to constrain or facilitate agency. The consequence for actors was a divergent realization of the relationship between the three logics, with very different consequences for their ability to advance their interests. Our findings offer an improved understanding of when and how institutional complexity facilitates autonomy, and suggests mediating influences at the level of the organization and the relationship it instantiates between carriers of logics, neglected by macro- and micro-level studies, that merit further attention.

Translating Institutional Logics: When the Media Logic Meets Professions

This article presents results from a case study of media activities in a Swedish governmental agency where we illustrate a) how the media logic is translated and become embedded in the studied agency, and b) how different professional groups inside the organization shape the translation process. Theoretically we do this by re-visiting the notion of translation. Translation theory focuses on the local enactment and embeddedness of institutional models, ideals and practices. Institutional logics literature, on the other hand, focuses on the creation and flow of field-level meaning systems. By combining these two theoretical perspectives we are able to form a framework for understanding the local embeddedness and enactment of field-level institutional logics. The result of our study suggests that institutional logics – once they become introduced in a given context – consist of four elements that are interpreted and enacted differently inside organizations. We identify three local, profession-based value systems that shape the translation of the media logics, and we use this finding to theorize the role of professional value systems in shaping local translation processes.