Interpretation of Multiple Institutional Logics on the Ground: Actors’ Position,their Agency and Situational Constraints in Professionalized Contexts

Data collection

Within our comparative cases, we used a qualitative, interpretive research design because interpretation of institutional logics constitutes a complex social process in which the causal dynamics of social interaction are not immediately evident. In both case studies, our access point for research was the Medical Director, an executive-level hybrid medical manager, who was ultimately responsible for the implementation of standardized guidelines, although they ceded this to nurse consultants, as empirically detailed later. The Medical Director identified key informants, beyond the nurse consultant, whom they thought would be involved in the implementation of the guideline chosen for this research. To extend our sample of relevant interviewees beyond those identified by the Medical Director in our two hospital cases, we used the snowballing technique. This allowed us to further explore diverse and sometimes competing interpretations of institutional logics, specifically from frontline doctors, hybrid medical managers and executive managers. In total, 52 interviews were conducted.

A total of 46 semi-structured interviews were conducted by one of the authors (the other did not carry out fieldwork) with key informants, following implementation of local guidelines on the clinical front line. This took place around the same time in each hospital, spread out over 12 months (2010–2011). Given our focus was upon changing social position of actors over time, we took the opportunity nine months following the end of our formal fieldwork (2012), to re-interview six key informants to assess whether any gain in position of the nurse consultant had been sustained (see Table 1 for details).

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Table 1.

Interviewees.

Interviewees	2010–2011		2012
	Hospital 1	Hospital 2	Hospital 1	Hospital 2
CHF nurse consultants	1	1	1	1
Other hybrid nurse managers	5	7	1	1
CHF frontline nurses	7	9	—	—
Hybrid medical managers	3	2	1	1
CHF frontline doctors	1	2	—	—
Non-clinical executive managers	4	5	—	—

Data from interviews were complemented by analysis of documentary evidence, such as the NICE guideline, meeting minutes, implementation protocols for NICE guidelines, reports and training manuals. In using multiple sources of evidence and interviewing a wide range of key informants, we aimed to enhance the credibility of our analysis, in particular to counter self-attribution by CHF nurse consultants regarding whether they enhanced their social position through enactment of institutional logics associated with implementation of standardized guidelines. We note that claims by CHF nurse consultants regarding their agency in interpreting institutional logics and subsequent enhancement of social position were supported by documentation and other interviewees. All interviews were transcribed verbatim, transcripts were anonymized and a code number was assigned for identification purposes.

Data analysis

While only one of the authors engaged in fieldwork, both authors analysed interview transcripts and documentation, and discussed emerging themes, such as the ambiguity of, and contestation over, institutional logics. As evident in our literature review, the ideal-types of institutional logics presented by commentators, such as Thornton et al. (2012), may not prove helpful in the field. For example, first, professional logics may be nuanced; i.e. doctors and nurses may hold different professional logics. Second, policy-driven reforms appear to blend and blur ideal-type corporate and market logics in a way that makes such categorization not meaningful. Given it is problematic to recognize ideal-type institutional logics empirically (Jarzabkowski et al., 2009; Reay & Hinings, 2005), data analysis was iterative, and we remained sensitive to ambiguity and contestation among multiple logics as they were interpreted on the ground throughout the analysis. Data analysis progressed in three stages, during which the level of analytical generalization was raised step by step (Mantere, 2008).

In the first step of the analysis, after transcribing each interview verbatim, transcripts were read closely, separately by each author, to identify interpretation of institutional logics and changing social position, but both remaining sensitive to limitations of ideal-types of institutional logics. Within first-stage analysis, the following dimensions emerged: the institutional context of NICE guidelines implementation, comments on adapting the CHF NICE guideline to the local context; blending the dual responsibilities of implementing national priorities and catering for the specific needs of their own populations; and integrating other types of evidence to fit the local circumstances. The two authors discussed their first-order coding, particularly where there were differences in their analysis, following which they reached agreement about first-order codes. For example, during the early stages of our analysis we identified codes such as ‘seeking information from institutional environment’, ‘raising an issue’, ‘agreement with institutional environment’, ‘disagreement with institutional environment’ and ‘negotiating professional/managerial interests’. We then decided to combine these into a more manageable code that we called ‘struggling with conflict or ambiguity between competing national policies, (first column, Figure 1).

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Figure 1.

The analysis process and the progression from simple coding to more aggregate theoretical categories.

In the second stage of analysis, we focused upon relationships across first-order codes and the synthesis of codes into broader, more theoretical categories. Our intention was to move from a descriptive to an interpretive, more explanatory mode. For example, comments on why NICE guidelines had to be adapted to the local context and how CHF nurse consultants strategically blend together multiple logics to minimize conflict within their local context led us to see that CHF nurse consultants were ‘experiencing difficulties in mediating responsibilities, agendas, boundaries and dominant institutional logics’ (second column, Figure 1). Particularly useful as we derived more theoretical codes at second and third stages of analysis, one author, who did not engage in fieldwork, had a critical distance from the data and was able to challenge and interrogate the interpretation of the other author, who was more embedded in the data (Mantere, Schildt, & Sillince, 2012). At this point, whilst we agreed on our analysis of social position of nurse consultants, such agreement was not immediately forthcoming about the nuanced nature of interpretation of multiple logics, ambiguities around which departed from ideal-types (Thornton et al., 2012), with evidence of contestation, as well as blurring and blending (Greenwood et al., 2011). Again, at the second stage, where there were differences in their analysis, the authors reached agreement about second-order codes.

The third step of the analysis involved categorization of the broader explanatory categories into aggregate theoretical categories, with consideration for how they linked to each other (Pratt, Rockmann, & Kaufmann, 2006). Three theoretical categories emerged strongly here: implementation was embedded in institutional fields; pursuit of positional gains; and the effect of, and upon, the social position of actors. Figure 1 summarizes the three stages of our analysis, which displays our first-order categories, broader explanatory categories and aggregate theoretical categories.

In the next section, we demonstrate how actors maintain or enhance their social position, as they interpreted institutional logics.

Implementation embedded in institutional fields

NICE guidelines could be implemented by hybrid medical managers, given their professional logic supported the use of evidence in developing and delivering better patient care. However, they ceded responsibility for implementation to hybrid nurse managers on the basis it was managerial work, which was mundane:

It will be a better use of my time not to be involved with the audit and monitoring of adherence to the NICE guideline. I was happy to have an advisory role within the service, discuss patients’ needs and treatment requirements, and support the nurses. But the NICE guideline had to be championed and it is a heart failure nurse service in the community. So that needed to be championed by them. The audit of the service was also left to nurses. (Lead consultant cardiologist, hospital 2)

Not all managerial work was judged as mundane by hybrid medical managers. Where they anticipated that their medical colleagues might be affected by organizational change they engaged with managerial activity much more, for example, around the management of clinical divisions and the development of clinical pathways:

Meeting financial targets has been something I pay attention to since, if we control the money, we allow clinical leaders more freedom to run their own budget and use it to develop clinical pathways in the way they want. (Medical director, hospital 1)

Interpretation of institutional logics, as guidelines were implemented, to mediate institutional complexity by CHF nurse consultants can be viewed as a response to conflict or ambiguity between competing national policies around professional and policy-driven managerial logics:

We end up with a lot of different policy frameworks. You try to make sense of how performance could be assessed and how we could monitor and evaluate it. A very good example is clinical governance and professional self-regulation, which don’t align. (CHF nurse consultant, hospital 2)

It was deemed acceptable for doctors to deviate from NICE guidelines. Informants suggested that doctors resisted guidelines where they perceived the drivers of change were managerial control from outside, rather than within, the profession:

Doctors have the right to prescribe differently. You can’t force clinicians to implement guidance, because you need to allow that freedom to act in the best interest of patients. (Director of nursing, hospital 2)

Thus doctors emphasized a professional logic to derive a more ‘bottom-up’ approach to development of new services. Guidelines to inform frontline service delivery required doctors to accept the credibility of the guidelines’ authors:

They [hospital executive management] will tell you guidelines come from the rank-and-file people, who are in touch with the suffering population. The fact that NICE guidelines are produced by experienced colleagues is not important for them [frontline CHF doctors]. It has to do with the motivation of that person who produces a guideline, and of the hospital implementing guidelines. It is all to do with whether they [frontline CHF doctors] trust the persons producing and implementing the guideline. (Doctor, chair of clinical risk committee, hospital 1)

So even where guidelines were produced by teams of clinical professionals, doctors on the front line may be sceptical of their value, where they perceive them insufficiently contextualized for frontline CHF care. While early-phase implementation across both hospitals was controlled and staged by executive management, later the process became uncontrolled, subject to unpredictability of outcomes and generally proceeded in a non-linear way from the planning phase to adoption in everyday practice:

In the early stages of the process, there was more control. We had our dissemination and training plans well organized. But I think as it progressed, it has become diluted. (Doctor, chair of NICE guideline implementation group, hospital 1)

Building upon their understanding of the complexity of the institutional environment and local context, CHF nurse consultants struggled to interpret multiple logics on the ground, as the NICE guideline was implemented:

The government assumes, because the CHF guideline was written from a kind of scientific perspective, it will be implemented in practice, but the guidelines are not tailored to my local professional situation. (CHF nurse consultant, hospital 1)

CHF nurse consultants had to allow for professional logic and doctors’ discretion, without ignoring the managerial logic more concerned with the ‘healthy’ operation of their organization:

It is important for me to facilitate clinical change, enhance patient safety, but without ignoring cost effectiveness that is implicit in the job of being clinical lead. (CHF nurse consultant, hospital 1)

I think there is an increasing level of regulation and performance management right across the NHS, which places great demands upon all of us. We have to focus on our local needs without ignoring national priorities. It is the conflict between local and national needs. And you have to take into account our clinicians’ experience as well. (CHF nurse consultant, hospital 2)

Mediating between multiple logics was seen as a major challenge. CHF nurse consultants followed documentary guidance about implementing NICE guidelines, but did so very weakly, so that professional logic was sustained, with daily work routines left unaltered. In both hospital cases, CHF nurse consultants purposefully and flexibly interpreted and enacted professional and managerial logics so they blended into organizational practices they thought could offer more effective avenues for NICE guideline implementation:

I am looking at it from a clinical perspective [professional logic]. I am also thinking financially [managerial logic], but I am also thinking about how to provide the best care for those patients [professional logic, but also managerial logic aligns with this] that is cost effective [managerial logic]. (CHF nurse consultant, hospital 1)

At the same time, executive managers invoked managerial logic as a rationale for implementation of NICE guidelines, in line with the overall organizational strategy to maintain fiscal balance:

Some guidelines are easier to implement than others, and those will be done. The ones that require particular financial investment will move to the back of the queue. (Doctor, chair of NICE implementation group, hospital 1)

CHF nurse consultants took on the role of facilitator, mediating between frontline staff, CHF senior doctors, some in hybrid middle manager roles themselves, and non-clinical executive management. In so doing, CHF nurse consultants attempted to strategically blend multiple, sometimes ambiguous, and contested institutional logics to minimize conflict within their local context, and combine managerial and clinical practices, agendas and discourse. Their aim was to use logics flexibly to mediate between executive managers’ and doctors’ interests within their organizations. This was not without challenge for CHF nurse consultants who, sometimes, can be seen to move uneasily between professional and managerial logics, so they are blurred. Our findings suggest a potential risk of confusion arising from disparities in the way CHF nurse consultants framed and elaborated their various interpretations of multiple institutional logics:

It is important for us to demonstrate that we are NICE compliant [may represent managerial logic around organizational response to regulation, but might also represent professional logic of patient care based on best evidence]. However, it is reasonable to step outside the guidelines and use your judgement, particularly for doctors, who are trained to put everything else outside, apart from the one patient you are dealing with [professional logic]. At the same time, we have got to look at how we get the best value at the best quality and the best care for the population for a limited amount of money [managerial logic]. (CHF nurse consultant, hospital 1)

Nevertheless, what is important for CHF nurse consultants, as they interpret logics, is not just implementation of NICE guidelines to take account of local context, but that others recognize and accept CHF nurse consultants as valuable strategic actors. We further discuss the enhancement of CHF nurse consultants’ social position intra-professionally, inter-professionally and within the organizational management hierarchy, in the next empirical section.

Pursuit of positional gains

The CHF nurse consultants positioned themselves as ‘knowledge expert employees’, who blended multiple institutional logics as they enacted their emerging managerial role. Following professional logic, CHF nurse consultants recognized the need to seek legitimacy, with doctors in particular, for their expert role in acquisition and using evidence as they interpreted the institutional demands of implementing NICE guidelines:

Things change in medicine very quickly, which are not in the NICE guidelines published three years ago. It can mean that you are not following best practice, so it is always important to look for new knowledge and update our practice accordingly. (CHF nurse consultant, hospital 2)

CHF nurse consultants also imitated doctors, when they stressed their legitimacy to draw from their personal experience and tacit knowledge as they made clinical decisions:

Evidence comes from different things. I would not solely rely on guidelines on how to treat a patient. My evidence comes from personal experience. (CHF nurse consultant, hospital 1)

CHF nurse consultants argued that, because NICE guidelines were ‘abstractions from context, developed at a high level in the healthcare system’, their knowledge of context was necessary to accommodate operational issues on the ground:

They [NICE guidelines] are not good for looking at practicalities of our local context. We developed our local protocol guidelines, developed from other sources because the [NICE] guidelines are very good at setting up principles, but they do not provide the how-to-do. (CHF nurse consultant, hospital 1)

As well as emphasizing their expert and contextual knowledge, CHF nurse consultants remained keen to emphasize their managerial purpose, employed to enhance and maintain improvement in organizational outcomes. As CHF nurse consultants redesigned and modified the NICE guideline to reflect local circumstances, at the same time they monitored clinical work, audited clinical performance and managed finances. Thus they enacted a managerial logic and exerted control and authority over implementation practices of their nursing peers and other professionals outside the medical cadre:

We planned financial resources, as well as deadlines to be devoted to implementation. We have a clinical risk manager and clinical facilitator reporting into me. These roles are also about audit, as well as trying to implement NICE. (CHF nurse consultant, hospital 1)

Executive managers supported the emerging managerial role enacted by CHF nurse consultants. Aligned with managerial logic, they described CHF nurse consultants as well placed to control implementation of NICE guidelines:

I take my guidance from our CHF nurse consultants. I would not dream of saying I know better than them. They signpost which direction we should take in implementing the NICE guideline. (Director of nursing, hospital 1)

They [CHF nurse consultants] are very influential within our organization. I am not too concerned if we are not NICE compliant, because we have to comply with best practices. We do this by having, in the case of CHF, our nurse consultants who are checking with our clinicians, how far they got implementing local guidelines, assessing non-compliance, process flows, cost effectiveness, new evidence and providing some information back to us. (CEO, hospital 2)

While somewhat counter to the hierarchy encompassed within their professional logic, doctors also accepted the expertise of CHF nurse consultants, because they perceived that the latter made clinical judgements, based on the particular circumstances of their patients (professional logic), rather than for managerial reasons of control, cost or meeting targets (managerial logic):

I feel that she [CHF nurse consultant] is working in the best interest of my patients and there is certain integrity between us. So I have trust in the way she is going about her work, from an integrity point of view and in her knowledge. (Frontline CHF doctor, hospital 1)

I trust [CHF nurse consultant] using her clinical judgement. She is acting in the interest of her patients and therefore she is not going to do just what the NICE guidelines are asking us. (Frontline CHF doctor, hospital 2)

Thus in interpreting institutional logics, as encompassed in clinical guidelines, CHF nurse consultants began to gain legitimacy with other higher-status actors, frontline doctors, hybrid medical managers and executive managers, the latter seeing them as expert professionals and emergent managers. CHF nurse consultants invoke a managerial logic on occasions around evidence-based practice and control of professionals. Nevertheless their social position does determine the type of argument they make, as well as which logic they use to make it. Thus they continue to orientate towards professional logics, with a focus upon clinical judgement, patient care and the local population.

The effect of, and upon, social position of actors

From our interviews with key informants nine months following the implementation of local guidelines, we found service reconfiguration and the social position of CHF nurse consultants sustained in the first hospital, but not in the second. In hospital 1, the CHF nurse consultant sustained her position as an elite actor inter-professionally, intra-professionally and managerially.

The CHF nurse consultant was trusted to ensure best clinical and cost-effective practice within CHF and so produce the best outcomes for patients and the organization. Reflecting this, the CHF nurse consultant enhanced her position beyond what would be expected if we followed professional logic enacted by doctors about clinical organization, where nurses remained overtly subordinate to doctors. She was free from external regulation and enjoyed autonomy beyond that which nurses traditionally experienced. Indeed, she might be characterized as behaving like her more powerful colleagues, doctors, in this respect:

We are not going back and checking, and this is because we assume that they [CHF nurse consultant] will carry on implementing best practices and will audit themselves all the time. (CEO, hospital 1)

Nevertheless, the interdependency of actors around professional logic was emphasized:

She [CHF nurse consultant] relies on the CHF doctors for support. They discuss treatment options and implementation plans. That is established. We pay our CHF doctors to do that. It is all formalized once a week [that] we are doing that. (Medical director, hospital 1)

To highlight, the position of the CHF nurse consultant had been enhanced to some extent inter-professionally, albeit only in relation to general practitioners (GPs), who were of lower status compared to their hospital-based medical peers:

When the NICE guideline was published [2003], the nurse consultant post was to be the champion of that change. These days, I clinically lead the community CHF services. I actually do the service development, improve the clinical standards and educate not just nurses, but GPs. (CHF nurse consultant, hospital 1)

However, any aggrandisement of the CHF nurse consultant’s position inter-professionally was one derived from the Medical Director’s interest being served by service reconfiguration. In the case of the Medical Director, we see that a hybrid medical manager at executive level did not necessarily represent their professional peers, but might indeed align with organizational interest:

I knew that if a GP was leading the service, he would devote a small amount of time to it and he would not be able to grow the service. I did not want a consultant cardiologist because he [sic] would go off and do other things and not focus on CHF in the community. In contrast, the nurse consultant is more reliable at following orders, and it is easier to influence her as opposed to GPs. (Medical director, hospital 1)

Notwithstanding the above, nevertheless, in hospital 1, frontline CHF doctors continued to transfer most of the CHF patients to the community team because this represented an opportunity to further develop the hospital cardiac department through increasing specialization:

If the cardiologists could offload the heart failure patients to a specialist team in the community, it would increase their scope to develop their particular area as well. (Frontline CHF nurse, hospital 1)

Thus, in hospital 1 at least, professional and managerial logics blurred and blended, as interpreted by different actors, including the CHF nurse consultant.

Aligning with the interest of hospital doctors and executive managers was a crucial aspect of the CHF nurse consultant’s interpretation of institutional logics in hospital 1, which reinforced and sustained their influence. We note that both the new service and an enhanced role for the CHF nurse consultant in professional and managerial hierarchy endure. On revisiting the site informally, nine months later, following the end of our study, the CHF nurse consultant described:

Our service has been running successfully for a long time now [successful in terms of cost and clinical effectiveness, possible blending of professional and managerial logic]. We already do most of the things that NICE says and many more. The NICE guideline was a good place for us to start, but we have been doing business cases year by year, developed our own guideline, gathered the evidence, treated the patients, done the trials, and you have seen what happens as a consequence [blending of managerial and professional logic]. (CHF nurse consultant, hospital 1)

In contrast, such blurring and blending of professional and managerial logics was less evident in hospital 2 over time, with greater contestation between logics in a way problematic for the organization to manage, and impacting on any positional gain for CHF nurse consultants. In the second hospital, local guidelines were not sustained. In large part, this was a consequence of performance and financial pressures faced by executive managers in hospital 2, following which they enacted managerial logic in a particular way:

We are a challenged organization, particularly financially, with little stability in executive leadership. Now senior managers are more interested in managing the money, commissioning services rather than developing services. I can see how our community clinic has been challenged by that. (Assistant director of nursing, hospital 2)

It was emphasized that, because the organization was underperforming and had a financial deficit, any organizational change needed to be consistent with very strong managerial logic around quality and cost reduction:

Obviously the implementation of the CHF guideline is important, but we cannot ignore financial balance and other financial targets, which mean that we are given resources by the Department of Health to meet imposed priorities. And we don’t exceed those resources, simply because my job would be under threat. (Director of finance, hospital 2)

In the face of financial constraints, executive managers’ priorities changed once the organization had successfully passed a national audit on CHF NICE guideline compliance:

We passed a national audit of CHF and the hospital sees our service is complying with NICE and this is enough for them, but not for me. We can still improve the service, but it is not a top priority for the hospital. (CHF nurse consultant, hospital 2)

Evidence of a particular enactment of management logic was evident in the provision of financial incentives for GPs, which underpinned local implementation of the NICE guideline. To sustain the CHF nurse consultant-led community service required extra work by GPs. Consequently, CHF nurse consultants continually requested extra financial resources to incentivize GPs for their extra work, a request that executive management had previously supported. In the face of financially challenging circumstances, however, executive management now did not support their request. Consequently GPs refused to undertake extra work to support the new service:

GPs started to refer back to them [hospital doctors] and not to the community service [professional logic]. Community service referrals were going down and the hospital asked us to review our service. It appears that our service is not cost-effective anymore [managerial logic]. If the hospital board allowed us to provide some financial incentives I think we would be in a better place. (CHF nurse consultant, hospital 2)

At the same time, we note that more powerful hospital doctors invoke a professional logic, which ‘bites back’ at the positional gain of the CHF nurse consultant. Frontline CHF doctors, represented by middle-level, hybrid medical managers, clawed back services from the community in the face of the increasing resource constraints they faced because of the perilous financial position of hospital 2. The CHF nurse consultant explained that, once CHF frontline doctors realized that resources were no longer available to develop the community CHF service in accordance with their clinical interests, they deliberately disengaged from further efforts to sustain implementation of the NICE guideline and sought to maintain resource allocation to their clinical unit:

I struggled to sell the importance of cost effectiveness for primary care prevention of CHF to our hospital doctors to get them to support me. They were interested more in treatment and not terribly well disposed to any kind of prevention. (CHF nurse consultant, hospital 2)

Thus, highlighting the often ambiguous and contested nature of institutional logics, the initial strategic intention to invest in the implementation and sustainable uptake of the nurse-led community services, which the CHF nurse consultant managed, dissolved. The CHF nurse consultant in hospital 2 enjoyed some early success in the reorganization of the community CHF clinics. However, later, it was not just that she could not develop service, but the community service which she managed was discontinued. She further explained the reason for this:

I used to make recommendations for changes. People seemed to take notice. But after a point I felt increasingly powerless, really, because we didn’t have the managers and hospital doctors on board with us. Inevitably, it was enough for our managers to comply with the basic recommendations of the NICE guideline [managerial logic]. This was not enough for me, so I am not involved in updating our local guidelines and disseminating them around. These days nobody is doing that. (CHF nurse consultant, hospital 2)

This caused some loss of her hard-won status as an elite knowledge and managerial actor in the organization of CHF care provision. However, intra-professionally, the CHF nurse consultant retained significant clinical influence. She continued to specialize clinically within nursing, without disrupting traditional professional arrangements between nurses and doctors; i.e. professional logic enacted by doctors was sustained. The CHF nurse consultant ceded clinical decision-making to doctors, at the same time she treated patients, and delegated to frontline CHF nurses any monitoring and feedback on progress towards adherence with agreed clinical outcomes, over which she retained oversight. At least intra-professionally, therefore, the CHF nurse consultant interpreted and actioned institutional logics to simultaneously change intra-professionally, and reproduce inter-professionally, power relations, establishing her role as dominant within nursing but remaining subordinate to hospital doctors.