Operating room: relational spaces and microinstitutional change in surgery

Voice is not enough: A multilevel model of how frontline voice can reach implementation

ISSUE

When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

CRITICAL THEORETICAL ANALYSIS

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

INSIGHT/ADVANCE

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

PRACTICE IMPLICATIONS

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Reframing the Community: How and Why Member Participation Shifts in the Face of Change

How and why do people reframe their understanding of the communities and organizations to which they belong? I draw on the case of a collegiate religious fellowship that moved online during the COVID-19 pandemic to examine how individuals' frames and participation patterns evolved as their community underwent a collective shift. I argue that reframing is triggered by temporal disconnect between past frames and present circumstances, present circumstances and imagined futures, or all three. My findings add nuance to existing theorizing on how members' frames shape participation by revealing how positive frames that sustain high levels of participation in "settled times" can become a liability in "unsettled times." My findings have relevance for understanding participation trajectories in a variety of group contexts, and advance theorizing on micro-level framing as a dynamic, fundamentally temporal process.

Conflict, Chaos, and the Art of Institutional Design

The metaphor of an organization as a garbage can is often invoked as a playful insult. However, as was recognized early on by management theorists studying garbage can ideas, the unpredictability arising from garbage can decision making has the potential to be adaptively rational for organizations facing complex task environments. The chaos produced by preference conflict and fluid participation in collective decision making can aid in search by enabling organizations to escape local performance peaks or competency traps. The decades-old hypothesis that conflict and chaos could promote adaptively rational search, however, has largely been overlooked in research on organizational design. This paper uses an agent-based model to evaluate these competing views and, in the process, identify conditions under which garbage can decision making is adaptively rational for executives searching for high-quality strategies. I show that the biased and chaotic outcomes that emerge as a result of garbage can decision making—the very features of garbage cans that lead them to be perceived to be dysfunctional—can facilitate short-term exploitation and long-term exploration of uncertain technical landscapes when organizations engage in serial judgment of local alternatives if internal conflict over desired outcomes is not too extreme. I conclude that decision-making routines that encourage chaotic conflict are robust to bounded rationality and complex task uncertainty and thus should be included in the organizational designer’s portfolio.

Supplemental Material: The online supplement is available at https://doi.org/10.1287/orsc.2023.1662 .

Legitimating Illegitimate Practices: How Data Analysts Compromised Their Standards to Promote Quantification

Prior studies that examine how new expertise becomes integrated into organizations have shown that different occupations work to legitimate their new expertise to develop credibility and deference from other organizational groups. In this study, we similarly examine the work that an expert occupation did to legitimate their expertise; however, in this case, they were legitimating practices that they actually considered illegitimate. We report findings from our 20-month ethnography of data analysts at a financial technology company to explain this process. We show that the company had structured data analytics in ways similar to Bechky’s idea of a captive occupation: They were dependent on their collaborators’ cooperation to demonstrate the value of data analytics and accomplish their work. The data analysts constantly encountered or were asked to provide what they deemed to be illegitimate data analysis practices such as hacking, peeking, and poor experimental design. In response, they sometimes resisted but more often reconciled themselves to the requests. Notably, they also explicitly lowered their stated standards and then worked to legitimate those now illegitimate versions of their expert practices through standardization, technology platforms, and evangelizing. Our findings articulate the relationship between captive occupations and conditions wherein experts work to legitimate what they consider illegitimate practices.

Work Un(Interrupted): How Non-territorial Space Shapes Worker Control over Social Interaction

Organizational research has long emphasized the importance of physical space in structuring opportunities for social interaction among workers. Using 14 months of field research during an office redesign at a large team-based sales company, I find that the adoption of non-territorial space—a change from assigned cubicles to an unassigned mix of spaces—substantially increased worker control over social interaction. Whereas the old territorial space rendered workers constantly accessible to others, the new non-territorial space altered information about workers’ location and availability preferences, enabling new strategies for hiding in the space and signaling availability to others through workspace selection. This led to greater reliance on virtual or asynchronous communication technologies, and less unwanted interruption in the new non-territorial space. The findings identify how the non-territorial dimension of office space affects worker control over social interaction. They also reveal the social practices through which individuals actively use material and symbolic resources in the physical environment to avoid cognitive and temporal costs of unwanted interruption. The study complements dominant structural accounts with a richer theorization of individual agency—while physical spaces certainly structure opportunities for social interaction, they also structure the strategies that individuals can use to actively manage social interaction.

Gliding on the edge of the iron cage: performing rationality and artistry in the sport of figure skating

Prior studies on growing formal rationalization in evaluation systems have overwhelmingly shown that they operate as "iron cages," which redefine standards of excellence around quantifiable metrics. However, existing literature may have overestimated the extent of isomorphism in individual or organizational practices under highly rationalized systems of assessment. The judging system in figure skating both rewards quantifiable technical merit and valorizes a circumscribed notion of artistry characterized by maturity and authenticity. It constitutes a combination of formal rationalization and culturally specific productions of artistry, offering participants a distinct set of options in constructing their competition routines. Drawing on exclusively obtained interview data with 40 Olympic-level figure skaters from the U.S. and 5 other countries, and following Alexander's (Sociol Theory 22(4):527-573, 2004) social performance theory, I explore the contingent process by which figure skaters maneuver between conformity to the formally rationalized rulebook and the non-isomorphic yet culture-structured performances of artistry. In doing so, I identify three types of skaters based on their embodiment of artistry: the emerging phenoms, the athletic performers and the "authentic" artists. My article reveals that despite rationalizing tendencies of the scoring system, skaters strive for social performances of artistry based on shared cultural scripts of greatness in the sport.

Rank Has Its Privileges: Explaining Why Laboratory Safety Is a Persistent Challenge

Environmental, health, and safety management systems have become common in research settings to improve laboratory safety through systematic observation and self-regulation. However, there is scant empirical evidence assessing whether these surveillance and inspection systems meet their intended objectives. Using data from safety inspections in research laboratories at a large university, we investigate whether conducting inspections, and recording and reporting findings back to the formally responsible actors (i.e., principal investigator scientists) lead to the improvement of regulatory compliance. Our analyses identify a population of well-funded, high-status, tenured researchers whose non-compliant practices persist. Our interviews with environmental, health, and safety personnel suggest that higher-status actors disengage from the regulatory system, the compliance officers, and the system's feedback process by their variable recognition and acknowledgment of relevant regulations, attention to the inspection reports, and responses to the feedback concerning repair of the unsafe situation. This study extends previous literature on regulatory compliance by providing evidence for the role of power and status in explaining actor-level non-compliant behavior.

Public Opinion and Impression Management in the Communication of Performance During the Second Iraq War

Although studies show that organizations engaged in controversial actions often aim to minimize the release of threatening information, scholars know relatively little about what may prompt organizations to increase transparency in these situations. In this study, we focus on support from public opinion as a condition that may influence the disclosure of sensitive performance information to the public. Using the second Iraq War as an empirical context, we focus on the extent to which public officials—Pentagon spokespersons—release and frame information about war performance. This outcome is critical because the way in which organizations communicate their performance to outsiders has often been regarded as a key defensive impression management tactic. We hypothesize that high public support for the war will increase the likelihood that Pentagon officials release information about sensitive combat performance indicators in their press briefings and identify contingencies, such as adversity and organizational spokespersons’ power, that moderate this relationship. We also explore whether high public support decreases the strategic use of alternate performance frames that emphasize metrics that signal progress toward a desirable end state. Using a unique data set based on the coding of press briefings, public opinion data, and other public sources, we find support for several of our hypotheses. We discuss implications for understanding the relationship between public opinion and impression management and highlight the importance of extending this research to nongovernmental organizations.

Positioning and Fit in Designing and Executing Qualitative Research

In this paper, we aim to help researchers think, design, and execute their empirical journey by mapping the terrain of choices common in qualitative research. We offer a matrix that relates to various dimensions—the level at which to study the phenomenon (level of analysis), types of field materials, time orientation of research and data, the analytic approach, and the unit of data (unit of analysis). This matrix is intended to support making informed decisions that result in specific research designs and the continuous process of reflection as to how these choices open and limit the ability to answer the research question and offer an analytic generalization based on the findings.

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.

Coworking spaces and collaborative practices

Collaborative practices underlie the creation of innovation yet how and when these practices emerge is not well understood, particularly given the presence of flexible and open workspaces. Based on seven case studies of entrepreneurial Tech/FinTech firms in London, we explore how collaborative spaces lead to collaborative practices, when they do. Our findings suggest the enabling and inhibiting role of interstitial spaces (e.g. informality and spatiality) and identify catalysts in the emergence of collaborative practices in a coworking space. A theoretical and critical contextualisation advances our understanding of how collaborative practices emerge and articulates the conditionality of openness in the form of underlying mechanisms for collaboration and, subsequently (open) innovation outcomes. We discuss implications for future research and management of coworking spaces.

Feeling rule management and relational authority: Fostering patient compliance in palliative care consultations

Once conferred by jurisdictions, hierarchies, or credentials, professional authority is now considered relational and probabilistic, drawing attention to actions that professionals can take to encourage client compliance. In this paper, we use ethnographic observations of palliative care consultations to show that professionals suggest feeling rules that correct patients’ lay understandings and in doing so facilitate compliance. Palliative care professionals suggested three corrective feeling rules that validate patients’ emotions and reattribute them to circumstances aligned with professionals’ expert recommendations for care: that patients should fear curative treatment, that patients should hope for pain relief, and that patients and family members should feel guilty for prolonging misery. We argue that authority depends, in part, on professionals’ ability to manage broader feeling rules instead of individual emotions. Given that feeling rule management involves altering meanings of what is considered appropriate, we contend that professionals’ symbolic power and emotional capital underpin their authority in the professional-client encounter.

Relational Work and the Knowledge Transfer Process: Rituals in Rural Ghana

We advance understandings of knowledge transfer by showing the central role of symbolic action, taking the form of ritual, in contexts characterized by worldview differences. Using qualitative data from interactions between farming communities in rural Ghana and agriculture development specialists, we examine how rituals do relational work that enables informational work. We find that rituals (i.e., visits, value affirmations, gift-giving, prayer, performing, storytelling) do so by means of their functions–bracketing worldview differences, modeling collaboration between farmers and agriculture development specialists, and packaging new knowledge in displays of compatibility. Our work also expands scholarship on the role of rituals in organizations and on management practices in Africa. Overall, our paper offers a complex, comprehensive view of knowledge transfer as involving both relational and informational work and relying on both symbolic action and tangible elements.

Employee Social Network Strategies: Implications for Firm Strategies and Performance in Future Organizations

Employee social network strategies play a key role in firm strategies and organizational performance. Currently, scholars underestimate the contributions of employee social strategies in firm strategies. Little is known how informal employee social networks, group entitativity and competition could shape and direct firm strategies and organizational performance. The article examines social network theory and strategic management's content, process and open schools of thought to propose a new interpretation for managing firm strategies. More specifically, the author examines alternate causal paths, underlying processes and structures as mechanisms in employee social network strategies within a theoretical framework. The article proposes 4 theoretically driven propositions and makes two contributions. First, the article contributes to organizational behavior literature by focusing on the literature gap in network dynamics and competitive actions through employee social networks. Second, although there is immense literature on positive and negative employee competition in business, the article makes a contribution to the strategic management literature by moving beyond formalized structures and roles within an organization to focus on the multilevel informal workplace social interactions and processes that impact strategizing activities. Overall, the article extends strategy research in relation to how employee social networks operate through competition and group entitativity in firm strategies.

Co-Opting Regulation: Professional Control Through Discretionary Mobilization of Legal Prescriptions and Expert Knowledge

The governance of front-line professionals is a persistent organizational problem. Regulations designed to make professional work more legible and responsive to both organizational and public expectations depend on these professionals’ willing implementation. This paper examines the important question of how professional control shapes regulatory compliance. Drawing on a seventeen-month ethnographic study of a bioscience laboratory, we show how professionals deploy their discretionary judgment to assemble environmental, health, and safety regulations with their own expert practices, explaining frequently observed differential rates of regulatory compliance. We find that professional scientists selectively implement and blend formal regulations with expert practice to respond to risks the law acknowledges (to workers’ bodies and the environment) and to risks the law does not acknowledge but professionals recognize as critical (to work tasks and collegiality). Some regulations are followed absolutely, others are adapted on a case-by-case basis; in other instances, new practices are produced to control threats not addressed by regulations. Such selective compliance, adaptation and invention enact professional expertise: interpretations of hazard and risk. The discretionary enactment of regulations, at a distance from formal agents, becomes part of the technical, practical, and tacit assemblage of situated practices. Thus, paradoxically, professional expert control is maintained and sometimes enhanced as professionals blend externally imposed regulations with expert practices. In essence, regulation is co-opted in the service of professional control. This research contributes to studies of professional expertise, the legal governance of professionals in organizations, regulatory compliance, and safety cultures.

In the Midst of Hiring: Pathways of Anticipated and Accidental Job Evolution During Hiring

In this paper, we examine the evolution of jobs in the midst of the hiring process: how jobs change between the decision to bring in someone to do a body of work and hiring someone. We analyze data from interviews, observations, and documents about start-up hiring and find that, during hiring, tasks are added and removed from jobs; jobs are abandoned, replaced, and moved; and hiring processes are relaunched. We describe two pathways that this evolution takes: the pathway of anticipated evolution, shaped by the unknown nature of the jobs being filled, and the pathway of accidental evolution, shaped by unanticipated factors surrounding jobs. Although the pathways lead to many of the same immediate consequences, there are differences in the longer-term consequences. Across the pathways, many jobs continue to evolve. On the pathway of anticipated evolution, many job incumbents leave within a year and are not replaced. On the pathway of accidental evolution, the longer-term consequences for job incumbents, structures, and organizations range from stability in structures and incumbents to ongoing conflict and incumbent departure. Not surprisingly, most evolving jobs are new to their organizations, but contrary to common conceptions, job evolution is not the product of managers who lack experience or use lax hiring practices. Our observations provide evidence of the emergent nature of jobs, hiring, and organizations.

Building an Equilibrium: Rules vs. Principles in Relational Contracts

Effective collaboration within and between organizations requires efficient adaptation to unforeseen change. We study how parties build relational contracts that achieve this goal. We focus on the “clarity problem”—whether parties have a shared understanding of the promises they make to each other. Specifically, (a) a buyer and seller play a trading game in several periods; (b) they know their environment will change but do not know how; and (c) before any trading occurs, they can reach a nonbinding agreement about how to play the entire game. We hypothesize that pairs whose initial agreement defines a broad principle rather than a narrow rule are more successful in solving the clarity problem and in achieving efficient adaptation after unforeseen change. In our baseline condition, we indeed observe that pairs who articulate principles achieve significantly higher performance after change occurred. Underlying this correlation, we also find that pairs with principle-based agreements were more likely to both expect and take actions that were consistent with what their agreement prescribed. To investigate a causal link between principle-based agreements and performance, we implement a “nudge” intervention that induces more pairs to articulate principles. The intervention succeeds in coordinating more pairs on efficient quality immediately after the unforeseen change, but it fails to coordinate expectations on price, ultimately leading to conflicts and preventing an increase in long-run performance after the shock. Our results suggest that (1) principle-based agreements may improve organizational performance but (2) high-performing relational contracts may be difficult to build.

Social Exchange and the Reciprocity Roller Coaster: Evidence from the Life and Death of Virtual Teams

Organizations are riddled with cooperation problems, that is, instances in which workers need to voluntarily exert effort to achieve efficient collective outcomes. To sustain high levels of cooperation, the experimental literature demonstrates the centrality of reciprocal preferences but has also overlooked some of its negative consequences. In this paper, we ran lab-in-the-field experiments in the context of open-source software development teams to provide the first field evidence that highly reciprocating groups are not necessarily more successful in practice. Instead, the relationship between high reciprocity and performance can be more accurately described as U-shaped. Highly reciprocal teams are generally more likely to fail and only outperform other teams conditional on survival. We use the dynamic structure of our data on field contributions to demonstrate the underlying theoretical mechanism. Reciprocal preferences work as a catalyst at the team level: they reinforce the cooperative equilibrium in good times but also make it harder to recover from a negative signal (the project dies). Our results call into question the idea that strong reciprocity can shield organizations from cooperation breakdowns. Instead, cooperation needs to be dynamically managed through relational contracts.

Social Movements, Collective Identity, and Workplace Allies: The Labeling of Gender Equity Policy Changes

Social movements seek allies as they campaign for social, political, and organizational changes. How do activists gain allies in the targeted institutions they hope to change? Despite recognition of the importance of ally support in theories about institutional change and social movements, these theories are largely silent on the microdynamics of ally mobilization. We examine how the labeling of organizational policies that benefit women influences potential workplace allies’ support for these policies. We theorize that one barrier to mobilizing workplace allies is a misalignment of the labels that activists use to promote new policies and employees’ affiliation with collective identities. We conducted five experiments to test our hypotheses and 26 qualitative interviews to provide illustration of our core concepts. We demonstrate that employees high in feminist identification are more likely to support feminist-labeled (feminist and #MeToo) than unlabeled policies, whereas those low in feminist identification are less likely to support feminist-labeled than unlabeled policies (Studies 1–3). However, we find that participants for whom organizational identification was high (whether measured or manipulated) and feminist identification was low supported organizationally labeled policies more than feminist-labeled polices (Studies 4 and 5). This illustrates that policies whose aims may not align with one collective identity can still garner support by activating another relevant collective identity. Within our studies, we provide evidence that these effects are mediated via feelings of pride in the organization (and not fear or anger), suggesting that positive emotions are a central mechanism in mobilizing workplace allies.

Patient participation in cancer network governance: a six-year case study

Background

Patient participation in decision-making has become a hallmark of responsive healthcare systems. Cancer networks in many countries have committed to involving people living with and beyond cancer (PLC) at multiple levels. However, PLC participation in network governance remains highly variable for reasons that are poorly understood. This study aims to share lessons learned regarding mechanisms that enable PLC participation in cancer network governance.

Methods

This multiple case study, using a qualitative approach in a natural setting, was conducted over six years in three local cancer networks within the larger national cancer network in Quebec (Canada), where PLC participation is prescribed by the Cancer Directorate. Data were collected from multiple sources, including individual and focus group interviews (n = 89) with policymakers, managers, clinicians and PLC involved in national and local cancer governance committees. These data were triangulated and iteratively analysed according to a framework based on functions of collaborative governance in the network context.

Results

We identify three main mechanisms that enable PLC participation in cancer network governance: (1) consistent emphasis on patient-centred care as a network objective; (2) flexibility, time and support to translate mandated PLC representation into meaningful participation; and (3) recognition of the distinct knowledge of PLC in decision-making. The shared vision of person-centred care facilitates PLC participation. The quality of participation improves through changes in how committee meetings are conducted, and through the establishment of a national committee where PLC can pool their experience, develop skills and establish a common voice on priority issues. PLC knowledge is especially valued around particular challenges such as designing integrated care trajectories and overcoming barriers to accessing care. These three mechanisms interact to enable PLC participation in governance and are activated to varying extents in each local network.

Conclusions

This study reveals that mandating PLC representation on governance structures is a powerful context element enabling participation, but that it also delineates which governance functions are open to influence from PLC participation. While the activation of mechanisms is context dependent, the insights from this study in Quebec are transferable to cancer networks in other jurisdictions seeking to embed PLC participation in decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06834-1.

How Managers Maintain Control Through Collaborative Repair: Evidence from Platform-Mediated “Gigs”

This paper develops a new understanding about how “client managers”—those using platform labor markets to hire and manage workers—attempt to maintain control when managing skilled contractors. We conducted an inductive field study analyzing interactions between client managers and contractors in software development “gigs” mediated by a platform labor market. The platform provided multiple tools client managers could use for control, including in response to unexpected events. We found that, when managers used the tools to exert coercive control over contractors acting unexpectedly, it backfired and contributed to uncompleted project outcomes. In contrast, when they refrained from using the tools for coercive control in such circumstances and instead engaged in what we call collaborative repair, their actions contributed to completed project outcomes. Collaborative repair refers to interactions that surface misaligned interpretations of a situation and help parties negotiate new, reciprocal expectations that restore trust and willingness to continue an exchange. Client managers’ attempts at collaborative repair yielded fuller understanding of project-related breakdowns and shared investment in new expectations, facilitating effective control and completed projects. This study extends prior theories of control by characterizing the new client manager role created by platforms and demonstrating how initiating repair is integral for managers’ capacity to accomplish control in these comparatively brittle work relationships.

Coaching as a Mechanism to Challenge Surgical Professional Identities

BACKGROUND

The "surgical personality" is a mostly negative academic and cultural image of the surgeon as egotistical, paternalistic, and inflexible. Because of this image, surgeons have been viewed as resistant to change and some behaviors, vulnerability, for example, are viewed as "suspect" because they seemingly threaten professional competency. We report on exit interviews of surgeons who participated in a coaching program and demonstrate how their narratives challenge the surgical "personality" and forge an evolving and more open professional surgical identity.

METHODS

We interviewed n = 34 bariatric surgeons at the end of a 2-year surgical coaching program. Transcribed interviews were analyzed in NVivo, computer-assisted qualitative data analysis software. Coding of transcripts was approached through iterative steps. We utilized an exploratory method; each member of our team independently examined 3 transcripts to evaluate emergent themes early in the investigation. The team met to discuss our independent themes and develop the codebook collectively. We created a descriptive framework for our first round of coding based on emerging themes and employed an interpretive framework to arrive at our themes.

RESULTS

Three major themes emerged from our data. Participants in this study discussed the ways that participation in the coaching program initially conflicted with their identity as a competent professional. Surgeons were acutely aware of how participation might have destabilized their surgical identity because they might be viewed as vulnerable. Despite these concerns about image, surgeons found impetus for improvement because of poor outcome scores or because they desired early career affirmation. Finally, surgeons report that the safe spaces of intentional coaching contributed to their ideas about how surgeons, and ultimately surgery, can change.

CONCLUSIONS

Participation in a coaching program challenged how surgeons thought of themselves in relationship to social and peer expectations. Our results indicate that surgeons do feel peer and social pressures related to identity but are much more complex and nuanced than has been previously discussed. The safe space of intentional coaching allowed participants to practice vulnerability without the pressures of sometimes caustic professional norms. Participants in this study viewed coaching as the way to improve the culture of surgery.

We’re Not Like Those Crazy Hippies: The Dynamics of Jurisdictional Drift in Externally Mandated Occupational Groups

External actors often advocate for organizations to address a wide range of societal concerns, such as diversity, equality, and sustainability, and organizations have frequently responded by establishing new positions to oversee these demands. However, calls to address social problems can be broad and unrelated to an organization’s primary objectives, so the external mandates that underpin these new positions do not easily translate to clear task jurisdictions inside organizations. Furthermore, previous studies have found that the tasks that are pursued by occupations established through external pressure often diverge from what external groups had envisioned for these new roles. This study addresses the question of why this divergence occurs. It does so by examining the formation of the occupational group of sustainability managers in higher education. Through fieldwork, interviews, and analyses of longitudinal archival data, this paper uncovers the dynamics of jurisdictional drift and shows how jurisdictional drift unfolded first through sustainability managers’ confrontation of their jurisdictional ambiguity, and then through their efforts at performing neutrality, in particular by trading external Politics for internal politics and trading values for standards. Additionally, it uncovers how the sustainability managers attempted to partially realign their jurisdiction with their external mandate, but did so in a concealed manner. This study illuminates the process of how jurisdictions can come to drift away from mandates, highlights the importance of studying how mandates are translated into jurisdictions, and also furthers our understanding of the formation of externally mandated occupational groups.

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.

Organization and organizing in revolutionary times: The case of Tunisian General Labor Union

Adopting Barker’s (2011) Marxist approach of a social movement “as a whole”, this article addresses the question of whether and how mass-membership movement organizations can break out of oligarchic authority and support a radical political protest movement. Using an ethnographic approach, this article explores how the UGTT (the Tunisian General Labor Union) responded to organizational challenges during the Tunisian popular uprising in 2010 by examining its intra-organizational processes as well as its interactions with other parts of the protest movement and how their struggles mutually aided the fall of Ben Ali’s regime. The findings highlight that two correlated aspects were critical to a radical transformation of UGTT’s conservative goal. First, unionists with activism experience outside the labor organization played a key role as “mediators,” deriving meaning from the organizational culture of the union to interpret the course of the event, supporting the popular uprising, and forcing the union leadership to join the revolutionary process. Second, the unpredictable and unprecedented regime repression radicalized the protest movement and its claims, and ruptured the union’s traditional bureaucracy. The article concludes by elaborating on the potential of organizational studies to help us understand the role of trade unions in protest movement organizing and, more broadly, the role of formal mass-membership organizations in social movements.

Peer Interaction and Pioneering Organizational Form Adoption: A tale of the first two for-profit stock exchanges

Building on a historical case study on the first two stock exchanges to adopt the now globally dominant for-profit organizational form, the Stockholm Stock Exchange in 1993 and the Helsinki Stock Exchange in 1995, we argue that interaction among socially proximate peers contributes to pioneering organizational form adoption within an industry, particularly when such forms are introduced by established organizations. Peer interaction can induce a search for technically efficient organizational forms through the sharing of collective experiences, the establishment of collective assumptions, and a joint search for solutions. Together, these factors contribute to the legitimization of novel organizational forms in the local setting before the adoption of the first instantiation of those forms. We propose a context-sensitive multilevel model of peer-interaction-induced pioneering organizational form adoption that considers shared macro environmental drivers, idiosyncratic local environmental drivers, and peer interaction as central social mediators between the two.

Institutional logics and organizational change: the role of place and time

This paper investigates the case of a hybrid organization located in Northern Italy with the aim of providing an understanding of the role of the context, defined in terms of ‘place’ and ‘time’, in shaping organizational changes. A dynamic institutional approach focused on both ‘place’ and ‘time’ as key explanatory factors can provide a valuable framework to understand both the changing institutional demands on the firm and the rationalities behind the changes that occur at organizational, strategic and governance level. Consequently, this paper aims to contribute to the institutional logics literature by describing how these two contextual elements can be used to interpret institutional logic pressures on the organization under investigation as well as govern changes at micro level. The results indicate that the changes were produced by dynamics that are exogenous and endogenous to the organization in the case study and strongly influenced by the context in which it operates. The paper also highlights how changes in terms of service provision, accountability and organizational setting are the results of the ‘place’ and ‘time’ in which these events occur.

Marching to Different Drum Beats: A Temporal Perspective on Coordinating Occupational Work

In this paper, we contribute a temporal perspective on work coordination across collaborating occupations. Drawing on an ethnographic study of medical specialists—surgeons, pathologists, oncologists, and radiologists—we examine how their temporal orientations are shaped through the temporal structuring of occupational work. Our findings show that temporal structuring of occupational practices develop in relation to the contingencies and materialities of their work and that this shapes and is shaped by specialists’ temporal orientations. Further, we show that differences in occupations’ temporal orientations have important implications for coordinating work. More specifically, our study reveals how the domination of one temporal orientation can lead to recurrent strain, promoting a competitive trade-off between the different temporal orientations in guiding interaction. This temporal orientation domination is accompanied by a persistent emotional strain and potential conflict. Finally, we suggest that, alternatively, different temporal orientations can be resourced in solving coordination challenges through three interrelated mechanisms, namely juxtaposing, temporal working, and mutual adjusting. In so doing, we show how temporal resourcing can be productive in coordinating work.

Moving Violations: Pairing an Illegitimate Learning Hierarchy with Trainee Status Mobility for Acquiring New Skills When Traditional Expertise Erodes

We explore how members of a community of practice learn new tools and techniques when environmental shifts undermine existing expertise. In our 20-month comparative field study of medical assistants and patient-service representatives learning to use new digital technology in five primary care sites, we find that the traditional master-apprentice training model worked well when established practices were being conferred to trainees. When environmental change required introducing new tools and techniques with which the experienced members had no expertise, third-party managers selected newer members as trainers because managers judged them to be agile learners who were less committed to traditional hierarchies and more willing to deviate from traditional norms. This challenged community members’ existing status, which was based on the historical distinctions of long tenure and expertise in traditional tasks. In three sites, the introduction of this illegitimate learning hierarchy sparked status competition among trainees and trainers, and trainees collectively resisted learning new tools and techniques. In the other two sites, managers paired the new, illegitimate learning hierarchy with the opportunity for trainee status mobility by rotating the trainer role; here, trainees embraced learning in order to exit the lower-status trainee group and join the higher-status trainer group. Drawing on ideas of status group legitimacy and mobility, we suggest that managers’ pairing of an illegitimate learning hierarchy with the opportunity for trainee status mobility is a mechanism for enabling the situated learning of new techniques when traditional expertise erodes.

From Templates to Heuristics: How and Why to Move Beyond the Gioia Methodology

Researchers are exposed to multiple interpretive challenges in the journey from field data to theoretical understanding. A common response to these challenges is to turn to the guidance of templates such as the Gioia methodology—currently a preferred template for interpretive management research. Given its popularity, we examine how this methodology approaches the interpretive process of fieldwork. We find that the inductive route to theory that it offers does not address the challenges of interpretation. As an alternative, we propose a return to the epistemological tradition of hermeneutics. We argue that fieldwork informed by a hermeneutic orientation is able to generate credible and novel theory by confronting the challenges of interpretation head on. This process cannot be represented by the orderly steps of a template. We argue that a return to a hermeneutic orientation opens the way to more plausible and insightful theories based on interpretive rather than procedural rigor, and we offer a set of heuristics to guide both researchers and reviewers along this path.

The organization’s synaptic mode of existence: How a hospital merger is many things at once

Different perspectives on organizations have alternatively sorted them on the side of the social / human / linguistic or that of the material / non-human / technical, reducing the question of what an organization may be to attempts to (re)connect these two realms. Literature adopting a relational view, however, has offered a way out of this opposition, by embracing the multiplicity of beings that may make up organizations. We extend this approach by engaging with French philosopher Étienne Souriau’s discussion of modes of existence to suggest that organizations are “synaptic,” which means they exist in the passages between modes, as they articulate the actions of entities existing under different modalities. By analyzing the case of a hospital merger in Denmark, we show that this work of articulation amounts to organizing, and that viewing organizations as synaptic recognizes not only their ontic pluralism, but also their existential pluralism. By doing so, our study contributes to relational understandings of what organizing means and provides a sensitivity to the politics involved in deciding who or what may exist within organizations.

Whose experience is it anyway? Toward a constructive engagement of tensions in patient-centered health care

Purpose

Healthcare delivery faces increasing pressure to move from a provider-centered approach to become more consumer-driven and patient-centered. However, many of the actions taken by clinicians, patients and organizations fail to achieve that aim. This paper aims to take a paradox-based perspective to explore five specific tensions that emerge from this shift and provides implications for patient experience research and practice.

Design/methodology/approach

This paper uses a conceptual approach that synthesizes literature in health services and administration, organizational behavior, services marketing and management and service operations to illuminate five patient experience tensions and explore mitigation strategies.

Findings

The paper makes three key contributions. First, it identifies five tensions that result from the shift to more patient-centered care: patient focus vs employee focus, provider incentives vs provider motivations, care customization vs standardization, patient workload vs organizational workload and service recovery vs organizational risk. Second, it highlights multiple theories that provide insight into the existence of the tensions and how they may be navigated. Third, specific organizational practices that engage the tensions and associated examples of leading organizations are identified. Relevant measures for research and practice are also suggested.

Originality/value

The authors develop a novel analysis of five persistent tensions facing healthcare organizations as a result of a shift to a more consumer-driven, patient-centered approach to care. The authors detail each tension, discuss an existing theory from organizational behavior or services marketing that helps make sense of the tension, suggest potential solutions for managing or resolving the tension and provide representative case illustrations and useful measures.

Financial Incentives and Professionals’ Work Tasks: The Moderating Effects of Jurisdictional Dominance and Prominence

This research addresses the important question of how organizations can use financial incentives to influence the work tasks of their professional workforce—a constituency that is notoriously difficult to manage because of their specialized knowledge, considerable autonomy, strong socialization, and powerful professional norms. In particular, I explore how a baseline incentive effect is moderated by two features of professionals’ tasks and jurisdictions: jurisdictional dominance (i.e., how much the profession controls the provision of the task relative to other professions) and jurisdictional prominence (i.e., how commonly provided the task is within a profession relative to other tasks). Using data on thousands of physician tasks from Ontario, Canada, and a difference-in-differences empirical design, I find that professionals’ incentive responses are smaller when a profession has higher jurisdictional dominance over a task, but are larger when the task has higher jurisdictional prominence within the profession. This research contributes to the literature on professions and professionals in multiple ways. First, I introduce the concepts of jurisdictional dominance and jurisdictional prominence, distinguishing them from each other and from existing conceptions of professional control. Second, this study shows that financial incentives can be an effective tool for influencing professionals, but highlights that their efficacy is shaped by a task’s jurisdictional dominance and jurisdictional prominence. Finally, I show that these new conceptions of jurisdictional control influence professionals’ behaviors in meaningful ways and should therefore be considered in future studies of professions.

Role Distancing and the Persistence of Long Work Hours in Professional Service Firms

This paper examines how and why individuals distance themselves from the prescribed professional role that – like the ‘ideal worker’ image – centres on long work hours. Our study of audit and law professionals demonstrated that although many people complied with the professional role, some came to distance themselves from the professional role centred on long work hours. We develop a model of role distancing as consisting of two interrelated microprocesses: apprehension, involving a cognitive and emotional shift as individuals start envisaging their professional role as provisional and potentially changeable, and role redefinition, private and/or public, where individuals modify their work practices. In the firms we studied, although both men and women redefined their roles for themselves (private role redefinition), women were more likely than men to also redefine the professional role for external audiences (public role redefinition). Together, these findings highlight the importance of apprehension and role redefinition for role distancing, offer new insights into the role of emotions and material constraints, and thus enrich theory on role distancing.

Improvisation during a crisis: hidden innovation in healthcare systems

Background

Crises, such as the COVID-19 pandemic, risk overwhelming health and social care systems. As part of their responses to a critical situation, healthcare professionals necessarily improvise. Some of these local improvisations have the potential to contribute to important innovations for health and social care systems with relevance beyond the particular service area and crisis in which they were developed.

Findings

This paper explores some key drivers of improvised innovation that may arise in response to a crisis. We highlight how services that are not considered immediate priorities may also emerge as especially fertile areas in this respect.

Conclusion

Health managers and policymakers should monitor crisis-induced improvisations to counteract the potential deterioration of non-prioritised services and to identify and share useful innovations. This will be crucial as health and social care systems around the world recover from the COVID-19 pandemic and head into another potential crisis: a global economic recession.

Revisiting the unholy alliance of health-care operations: payor–provider integration of occupational health services

Purpose

To investigate the effects of payor–provider integration on the operational performance of health service provision. The research explores whether integration governs agency problems and tilts the incentives of diverse actors toward more systematic outcomes.

Design/methodology/approach

A two stage multimethod case study of occupational health services. A qualitative stage aimed to understand the reasons, mechanisms, and outcomes of payor–provider integration. A quantitative stage evaluated the performance of the integrated hospital against fee-for-service partner hospitals with a sample of 2,726 patients.

Findings

Payor–provider integration mitigates agency problems on multiple levels of the service system by complementing formal governance mechanisms with informal mechanisms. Compared to partner hospitals, the integrated hospital yielded 9% lower the total costs of occupational injuries achieved primarily by emphasizing conservative care and faster recovery.

Research limitations/implications

Focuses on occupational health services in Finland. Provides initial evidence of the effects of payor–provider integration on the operational performance.

Practical implications

Vertical integration may provide systematic outcomes but requires mindful implementation of multiple mechanisms. Rigorous change management initiative is advised.

Social implications

For patients, the research shows payor–provider integration of health services can be implemented in a manner that it reduces care costs while not compromising care quality and customer satisfaction.

Originality/value

This study provides a rare longitudinal analysis of payor–provider integration in health-care operations management. The study adds to the knowledge of operational performance improvement of health services.

Maintaining Places of Social Inclusion: Ebola and the Emergency Department

We introduce the concept of places of social inclusion—institutions endowed by a society or a community with material resources, meaning, and values at geographic sites where citizens can access services for specific needs—as taken-for-granted, essential, and inherently precarious. Based on our study of an emergency department that was disrupted by the threat of the Ebola virus in 2014, we develop a process model to explain how a place of social inclusion can be maintained by custodians. We show how these custodians—in our fieldsite, doctors and nurses—experience and engage in institutional work to manage different levels of tension between the value of inclusion and the reality of finite resources, as well as tension between inclusion and the desire for safety. We also demonstrate how the interplay of custodians’ emotions is integral to maintaining the place of social inclusion. The primary contribution of our study is to shine light on places of social inclusion as important institutions in democratic society. We also reveal the theoretical and practical importance of places as institutions, deepen understanding of custodians and custodianship as a form of institutional work, and offer new insight into the dynamic processes that connect emotions and institutional work.

Improving together: collaboration needs to start with regulators

Nicola Burgess and colleagues argue for a move away from top-down regulation to a new approach that facilitates rather than hinders learning across organisations

Overcoming the Shadow of Expertise: How Humility and Learning Goal Orientation Help Knowledge Leaders Become More Flexible

Although experts are valuable assets to organizations, they suffer from the curse of knowledge and cognitive entrenchment, which prevents them from being able to adapt to changing situational demands. In this study, I propose that experts' performance goal orientation resulting from pressures to perform contributes to their flexibility, but this mechanism can be moderated by learning goal orientation and humility. Data from a small sample of healthcare professionals suggested that performance goal orientation partially explained the mechanism of why experts may be inflexible. Humility, both as self-report and other-report measures, was found to be the most consistent moderator of this indirect effect. Experts with low levels of humility suffered from the negative effects of performance goal orientation, leading them to be less flexible compared to their counterparts with higher levels of humility. Experts who reported high levels of humility, on the other hand, were perceived to be more flexible as their expertise increased. Meanwhile, learning goal orientation partially moderated the indirect effect of expertise on flexibility through performance goal orientation. These findings lead to new conversations on how to get experts unstuck and highlight the importance of developing humility as both a personal virtue and a strategic advantage for organizations.

Frontline meetings as support for cross-boundary coordination in hospitals

Purpose

The purpose of this paper is to investigate frontline meetings in hospitals and how they are used for coordination of daily operations across organizational and occupational boundaries.

Design/methodology/approach

An in-depth multiple-case study of four purposefully selected departments from four different hospitals is conducted. The selected cases had actively developed and embedded scheduled meetings as structural means to achieve coordination of daily operations.

Findings

Health care professionals and managers, next to their traditional mono-professional meetings (e.g. doctors or nurses), develop additional operational, daily meetings such as work-shift meetings, huddles and hand-off meetings to solve concrete care tasks. These new types of meetings are typically short, task focussed, led by a chair and often inter-disciplinary. The meetings secure a personal proximity which the increased dependency on hospital-wide IT solutions cannot. During meetings, objects and representations (e.g. monitors, whiteboards or paper cards) create a needed gathering point to span across boundaries. As regards embedding meetings, local engagement helps contextualizing meetings and solving concrete care tasks, thereby making health care professionals more likely to value these daily meeting spaces.

Practical implications

Health care professionals and managers can use formal meeting spaces aided by objects and representations to support solving daily and interdependent health care tasks in ways that IT solutions in hospitals do not offer today. Implementation requires local engagement and contextualization.

Originality/value

This research paper shows the importance of daily, operational hospital meetings for frontline coordination. Organizational meetings are a prevalent collaborative activity, yet scarcely researched organizational phenomenon.

Collaborative institutional work to generate alternative food systems

Recently, there has been a proliferation of alternatives to the global food system. Yet, there is still an ongoing debate on their potential to transform the food system and challenge its globalization. This research introduces institutional analysis to the food system literature in order to comprehend actors’ efforts to scale up alternatives and transform the food system at the local level. Such efforts are explored from an inductive research of the organization called M-Local Food Project, which gathers a range of diverse actors to work on expanding alternative food and transforming the food system in eastern France. Based on this organization’s analysis and its collaborative institutional work, this research highlights how to organize collective agency from the collaboration of multiple actors to co-build an alternative food system and extends the debate on alternative food potential to challenge the dominant global food system. It also provides an emerging model of collaborative institutional work that enriches the institutional analysis on the coalition for institutional changes and offers practical advice on tensions for alternative organizations that cannot be overcome.

What drives hospital wards' ambidexterity: Insights on the determinants of exploration and exploitation

OBJECTIVES

Hospital wards are required to exploit current knowledge and explore for new knowledge. Ambidexterity (i.e., the capability to combine both exploitation and exploration) is a major issue in healthcare as result of the growing expectations that hospitals wards have the capability to manage the trade-off between high-quality delivery of care and cost-containment. This study sheds novel light on the determinants of ambidextrous behaviours in hospital wards.

METHODS

A theoretical framework has been built on the extant literature. The main determinants of ambidexterity are opening/closing leadership, organisational support, organisational creativity and environmental dynamism. The model has been tested empirically through data collected via survey administered to head physicians in charge of hospital wards. After the quality check, 80 questionnaires were available for the statistical analysis based on a hierarchical sequential linear regression model (with enter methodology).

RESULTS

Results showed that opening (β = 0.389;p < 0.001) and closing (β = 0.288;p < 0.01) leadership, as well as organisational creativity (β = 0.499 p < 0.001) are necessary to materialize ambidextrous behaviours (Adj.R² = 0.529). Environmental dynamism does not moderate these relationships. While opening leadership (β = 0.375;p < 0.01), organisational creativity (β = 0.270;p < 0.05) and environmental dynamism (β = 0.224;p < 0.1) are determinants of exploration, closing leadership (β = 0.506;p < 0.001) and organisational creativity (β = 0.529;p < 0.001) are determinants of exploitation.

CONCLUSIONS

Head physicians' leadership style as well as organizational creativity play a pivotal role in materializing ambidextrous behaviours in wards.

A drifting phenomenon: organizational change failure in a becoming view

Purpose

The purpose of this paper is to study the phenomenon of organizational change failure through an emic approach. Grounded in empirical examples, the paper unfolds why the phenomenon seems to be missing from the literature of the becoming view (e.g. Tsoukas and Chia, 2002).

Design/methodology/approach

Inspired by the methodological strategy of “studying through,” organizational changes are followed through space and time within the setting of a Nordic bank, from where the empirical data have been collected via longitudinal study. The empirical data are generated through a combination of methods: shadowing, interviews, in situ observations and desk research in order to capture the ever-changing phenomenon of organizational change.

Findings

The paper finds that organizational changes drift away, either by slipping into the everyday practices of the organization, or by drifting away in time when history is reinterpreted. The paper concludes that organizational change failures suffer the same fate as organizational changes more generally and drift away in space and time.

Originality/value

The paper contributes to the becoming view by illustrating how methodologically an ever-changing phenomenon such as organizational change can be studied. Further, it contributes to the field of organizational change failure by unpacking the fate of organizational change failure when change is natural and slippery in nature. The paper includes reflections on what the consequences might be for praxis.