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doi 10.1287/orsc.1100.0574
2011 INFORMS
his study examines the relationship between social position, both within the field and within the organization, and the
likelihood of individual actors initiating organizational changes that diverge from the institutional status quo. I explore
this relationship using data from 93 change projects conducted by clinical managers at the National Health Service in the
United Kingdom. The results show social position, both within the field and within the organization, influences actors
likelihood to initiate two types of organizational change that diverge from the institutional status quo, namely, (1) changes
that diverge from the institutionalized template of role division among organizations and (2) changes that diverge from the
institutionalized template of role division among professional groups in a field. The findings indicate that these two types
of divergent organizational change are likely to be undertaken by individual actors with different profiles in terms of social
position within the field and the organization.
Introduction
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
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Figure 1
Organizations
Primary care trusts (PCTs)
Organizations
Hospitals
Mental health services
Ambulance services
Professionals
Physicians (General practitioners (GPs))
Nurses
Allied health professionals (AHPs)
Managers
Staff
Professionals
Physicians (Consultants)
Nurses
Allied health professionals (AHPs)
Managers
Staff
different categories of actors in the NHS have been governed by the model of medical professionalism for more
than five decades (Giaimo 2002). This template for organizing prescribes specific role divisions among professionals on the one hand and organizations on the other
hand. The model of role division among professional
groups is predicated on physician dominance over all
other categories of health-care professionals. Physicians
continue to be the key decision makers, controlling not
only delivery of services but also, in collaboration with
successive governments, the organization of the NHS
(for a review, see Harrison et al. 1992, pp. 3033). They
are powerful both collectively at the national level and
individually at the local level (Harrison et al. 1992),
with their power deriving from both the social legitimacy of their mission and their exclusive ability to apply
expert knowledge to particular cases (Freidson 1986;
Abbott 1988, pp. 99100). Physicians command deference from the general public as well as from most
other groups of health-care professionals. Nurses, for
example, are expected to act as physicians assistants,
and allied health professionals, termed medical auxiliaries when the NHS was created, are expected to act
on physicians instructions (Jones 1991). Managers not
only refrain from contradicting physicians but often act
in the capacity of diplomats to smooth internal conflicts in organizations and facilitate the physicians work
(Giaimo 2002).
The model of role division among organizations prescribed by medical professionalism places hospitals and
administrative organizations at the heart of the healthcare system (Peckham and Exworthy 2003). Hospitals often enjoy a monopoly position as providers of
secondary care services in their health communities
(Le Grand 1999), providing most of the health-care services and ultimately receiving most of the resources.
PCTs are supposed to serve as gatekeepers to the secondary care sector, but primary and secondary care organizations tend to operate in isolation (Peckham and
Exworthy 2003). PCTs are newer organizations that still
depend on hospitals for many aspects of care provision and on administrative organizations for budget allocation. The emphasis in patient care on treating acute
episodes of disease in the hospital setting rather than
providing follow-up and preventive care in the home
or community setting, which is under the responsibility
of primary care organizations, corresponds to an acute
episodic health system. Table 1 presents the model of
medical professionalism.
Setting the Stage for Change
Different governments have attempted to infuse the NHS
with new models for organizing that challenged the institutionalized model of medical professionalism. The set
of reforms implemented by Margaret Thatchers Conservative governments aimed to impose a new model of
quasi-market that prescribed that health-care services be
manager-driven rather than profession-led and that the
balance of power shift from the secondary to the primary care sector (Pettigrew et al. 1992, Klein 1998). In
turn, Tony Blairs Labour governments tried to infuse
the NHS with a new model of market managerialism
that promoted collaboration across professions and sectors (Le Grand 2002, Peckham and Exworthy 2003).
The objective of the public authorities was to effect a
shift from an acute episodic health-care system to a system that would provide continuing care by integrating
services and increasing cooperation among professional
groups.
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Table 1
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
Organization Science 22(4), pp. 817834, 2011 INFORMS
Organization Status. Research has shown that lowstatus organizations are more likely to introduce new practices that diverge from the existing institutions and highstatus organizations are more likely to mobilize resources
to maintain the status quo (e.g., Tushman and Anderson
1986, Leblebici et al. 1991, Kraatz and Zajac 1996,
Haveman and Rao 1997, DAunno et al. 2000). In most of
these studies, divergent organizational changes introduced
in low-status organizations diverged from the institutionalized model of role division among organizations. Although
organizations were the unit of analysis in the latter stream
of research, it is apparent that individual members of lowstatus organizations initiated these changes.
Within a given field, actors who belong to low-status
organizations are in a challenger position (Fligstein
1997, Hensmans 2003) relative to actors who belong to
high-status organizations. Maguire et al. (2004) found
that individual actors who belonged to organizations less
advantaged by the institutionalized model of role division among organizations were more likely to initiate
changes that diverged from that model. In the NHS,
individual actors who belong to PCTs, which are lowerstatus organizations compared with hospitals and administrative organizations, are in a challenger position compared with individual actors who belong to hospitals
or administrative organizations (Peckham and Exworthy
2003). Because PCTs, being less privileged by the institutionalized model of organizations role division, have
less to lose from social deviance, members of PCTs are
more likely to be willing to transform to a greater extent
the existing model of role division among organizations.
The pattern of value commitments (Greenwood and
Hinings 1996, p. 1036) in PCTsthat is, the extent to
which members of PCTs are committed to the prevailing
institutionsis also likely to facilitate the initiation of
changes that diverge to a greater extent from the institutionalized model of role division among organizations.
Other organization members are indeed likely to be less
committed than are actors who belong to higher-status
organizations to the institutionalized model of role division among organizations.
To initiate a change that diverges to a greater extent
from the institutionalized model of role division among
organizations, members of lower-status organizations
must believe that such change is possible within the field
in which they are embedded (Turner and Brown 1978,
Tajfel 1981, Tajfel and Turner 1986). In the NHS, within
which at least two alternative organizing models successively infused by public authorities prescribe models
of role division among organizations that differ from
the institutionalized model prescribed by medical professionalism, individual actors who belong to PCTs are
likely to believe that change is possible and therefore are
more likely to take action.
Hypothesis 1A (H1A). Within the NHS, individual
actors who belong to PCTs (i.e., lower-status organizations) are more likely than other individual actors
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Organization Science 22(4), pp. 817834, 2011 INFORMS
Method
Participants
The participants in the present study were 93 NHS
clinical managers (i.e., actors with both clinical and
managerial responsibilities) who had attended an executive education program entitled Clinical Strategists Programme, a two-week residential learning experience
conducted by a European business school. The first week
focused on improving participants effectiveness within
their immediate sphere of influence and leadership ability within clinical bureaucracies by developing individuals skills and awareness. Principles and practices of
effective organizational change were also featured in the
first weeks curriculum. The second week focused on
developing participants strategic change capabilities at
the levels of the organization and the community health
system. When applying for the program, applicants were
asked to provide a description of a change project they
would be required to begin to implement within their
organization after attending the second week of the program. Project implementation was a requirement of the
program. Participants were asked to refine these change
project descriptions to reflect any modifications after
three months of implementation.
The program, available to all clinical strategists within
the NHS, was advertised both online and in NHS
brochures. Participation was voluntary. All who applied
were selected. Although participation in the present
study was also voluntary, all 95 attendees agreed to
participate. The final sample of 93 observations, corresponding to 93 change projects, reflects the omission of
two participants for whom data were incomplete. Participants ranged in age from 34 to 56 years (average
age was 43) and included 71 women (76%) and 22 men
(24%). All had clinical backgrounds (24% were physicians; 28%, allied health professionals; and 48%, nurses)
as well as managerial responsibilities, with levels of
responsibility varying from mid- to top-level management. The participants also represented a variety of NHS
organizations (44% worked within PCTs; 45%, in hospitals or other secondary care organizations; and 11%,
in NHS administrative units).
Although program attendees undeniably had an interest in change, a number of factors alleviate empirical concerns related to potential sample selection bias.
823
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
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goals, resources required to implement the project, people involved, key success factors, and measurement of
the outcomes. Interrater reliability, as assessed by the
kappa correlation coefficient, was 0.90, suggesting a
high degree of agreement among the three raters (Landis
and Koch 1977, Fleiss 1981). To resolve coding discrepancies, we noted passages in the change project descriptions deemed relevant to the codes and discussed them
until we reached consensus (Larsson 1993).
I ran a confirmatory factor analysis on the results of
the coding to assess the validity of scales 1 and 2. For
scale 1, which measured the degree of divergence of
the change projects from the institutionalized model of
role division among professionals, the confirmatory factor analysis had a goodness-of-fit index (GFI) of 0.98,
suggesting that a single factor represented this scale very
well. This scale also exhibited an acceptable reliability
value (Cronbachs alpha, 0.79). For scale 2, which measured the degree of divergence of the change projects
from the institutionalized model of role division among
organizations, the GFI was 0.80, representing a lower fit
compared with scale 1.2 However, Cronbachs alpha for
the six-item scale was quite high (0.91), increasing my
confidence in using all six variables for scale 2. The low
level of correlation (0.106) between scales 1 and 2 suggests that they should be treated as two distinct dependent variables. All change projects were assigned a score
on each of the two scales ranging from 1 (no extent) to
3 (great extent) and corresponding to the average of the
items included in each scale.
Among the 93 change projects that I studied, a project
aimed at transferring stroke rehabilitation services such
as language retraining from a hospital-based unit to a
PCT (i.e., from the secondary to the primary care sector)
is an example of a project that diverges from the institutionalized model of role division among organizations
to a great extent. Prior to the change, people experiencing strokes were stabilized and rehabilitated in the
acute ward in the hospital, thus incurring long stays and
tying up resources more appropriate for the acute treatment phase. As a result of this organization, there were
insufficient beds to admit all stroke patients on the acute
ward because many beds were being used for patients
who were undergoing post-acute rehabilitation. The service transfer involved physical relocation of post-acute
patients to a unit operated by the PCT. The objective was
to maintain the acute unit in the hospital and develop a
specialist rehabilitation service in the primary care sector. Patients would be transferred to the rehabilitation
unit operated by the PCT once they were medically stable and ready for rehabilitation. This would ensure that
the acute unit would only deal with patients that were
really acute patients and that these patients would then
receive appropriate rehabilitation services for as long as
necessary in the PCT. This transfer of resources and
responsibility for the delivery of rehabilitation services
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
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Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
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variable coded 1 for nondoctors (low-status professionals) and 0 for doctors (high-status professionals).
Hierarchical Position. I measured actors hierarchical
position by means of a rank-ordered categorical variable.
Positions ranged from middle to top-level managers,
ranked low to high as follows: 1 = deputy head/assistant
director, 2 = head of service, 3 = nonexecutive director,
and 4 = executive director with a seat on the organizations board. As a government-run set of organizations,
the NHS has standardized definitions and pay scales
for all positions, which ensured that participants roles,
responsibilities, and hierarchical positions were uniform
across organizational sites (Department of Health 2004).
Because the individuals in my sample occupied positions ranging from middle managers to top managers,
and none occupied lower positions in the organizational
hierarchy, I centered the hierarchical position variable
around its mean, thereby using the mean rather than
zero as a benchmark (Aiken and West 1991, Kam and
Franzese 2007).
Control Variables
Because clinical managers in my sample might have initiated divergent organizational changes for reasons other
than their social position within the field and the organization, in particular as a consequence of the extent
and diversity of their managerial experience, I controlled
for the impact of three career-specific variables: tenure
in management positions, tenure in the current formal
position, and level of interorganizational mobility.
Tenure in Management Positions. Tenure in management positions was measured straightforwardly as the
number of years spent in management positions. Management experience is likely to make an actor more
comfortable initiating change, especially divergent organizational change that breaks with practices widely
accepted and used not only within a given organization
but throughout a field (Huber et al. 1993). Actors with
longer tenure in management positions might be more
confident of their ability to initiate organizational change
that diverges to a greater extent from the institutional
status quo and therefore be more likely to do so.
Tenure in Current Position. Tenure in current position
was measured, again straightforwardly, as the number of
years spent in the current position. Actors who would
persuade other organizational members to abandon practices widely accepted and used not only in their organization but throughout the field must have legitimacy
in the eyes of those other organizational members. They
also need in-depth knowledge of their organization to
overcome the obstacles likely to be encountered during
the implementation of divergent organizational change.
Actors with longer tenure in their current position usually command greater legitimacy in the eyes of both
subordinates and superiors and tend to be highly knowledgeable about specificities of their organizations (Huber
Results
I report below results associated with the two dependent
variables, the degree of divergence from the institutionalized model of role division among organizations and
the degree of divergence from the institutionalized model
of role division among professionals. Table 2 reports
means, standard deviations, and correlations. There are
in my data set no critically collinear variables, that is,
none greater than 0.8 in absolute value (Kennedy 2003).
Diverging from the Institutionalized Model of
Role Division Among Organizations
Table 3 reports results from three ordered logit regressions predicting actors likelihood to initiate a change
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
827
Table 2
Variables
Mean
Min
Max
[1]
10387 00520
10000
20833
10000
10449 00509
10000
20500
00106 10000
00441
00763
00000
110624
20677
40796
S.D.
[2]
[3]
[4]
[5]
[6]
[7]
[8]
10000
00117 10000
00046 00344 10000
00171 00542 00215 10000
00143 00037 00064 00032 10000
00014 00104 00331 00055 00137 10000
Note. N = 93.
Tenure in management
positions
Tenure in current
position
Interorganizational
mobility
Low-status organization
(1)
(2)
(3)
00007
4000365
00070
4000755
00134
4000655
00020
4000405
00046
4000765
00168
4000645
10155
4004475
00259
4001905
00019
4000405
00042
4000745
00169
4000635
10156
4004445
00301
4001805
Hierarchical position
Hierarchical position
Low-status organization
Log pseudolikelihood
Wald chi-squared
LR testa
00134
4004535
170080
6042
166002
17032
9057
165097
18011
9067
Significant at 10%, significant at 5%, significant at 1%. Statistical significance is based on one-tailed tests for all independent
variables and interaction terms.
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
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Table 4
Tenure in management
positions
Tenure in current
position
Interorganizational
mobility
00083
4000325
00064
4000715
00043
4000625
Low-status professional
group
Hierarchical position
(2)
(3)
00079
4000395
00092
4000755
00026
4000765
00071
4000405
00118
4000845
00005
4000815
00739
4005505
00530
4002345
20083
4100665
20291
4101715
10871
4102235
Hierarchical position
Low-status professional
group
Log pseudolikelihood
Wald chi-squared
LR testa
145093
10008
143001
12073
5084
141056
19021
8074
Significant at 10%, significant at 5%, significant at 1%. Statistical significance is based on one-tailed tests for all independent
variables and interaction terms.
the institutionalized model of role division among professionals and that the first independent variable corresponds to the status of the professional group to which
actors belong (nondoctors, i.e., low-status professionals).
Hypothesis 1B, which states that individual actors who
are not doctors are more likely than doctors to initiate
changes that diverge to a greater extent from the institutionalized model of role division among professionals,
was supported (see column 2). The results also supported H2B, which states that individual actors higher in
the hierarchy of their organization are more likely than
other individual actors to initiate changes that diverge to
a greater extent from the institutionalized model of role
division among professionals (see column 2).
Although the interaction effect of the status of the professional group and hierarchical position of the individual actors on the likelihood that the latter will break to
a greater extent with the institutionalized model of role
division among professionals was statistically significant
(see column 3), the sign of the coefficient indicated that
the effect was counter to the one hypothesized in H3B.
Indeed, this latter hypothesis states that individual actors
who are not doctors and are higher in the hierarchy of
their organization are more likely than other individual
actors to initiate changes that diverge to a greater extent
from the institutionalized model of role division among
professionals. In fact, there was a negative relationship
between the likelihood that individual actors will break
with the institutionalized model of role division among
professionals and the interaction term between the status of the professional group to which actors belong and
their hierarchical position.
As for control variables, tenure in management positions had the expected positive and significant impact on
the likelihood that individual actors will initiate changes
that diverge to a greater extent from the institutionalized model of role division among professionals. Neither tenure in the current position nor interorganizational
mobility was significantly related to the likelihood that
actors will initiate organizational change that diverges to
a greater extent from the institutionalized model of role
division among professionals.
Robustness Checks and Supplementary Analyses
In supplemental regression models (not reported here), I
included as additional control variables gender, age, educational background, and organizational budget. These
variables (whether added separately or together) were
not significant in any model and did not affect the
sign or significance of any variables of interest. Separately, to alleviate concerns related to potential selfreport bias (i.e., participants potential tendency to
describe their change projects as being more divergent
than they actually were), I also checked for the influence of one dispositional characteristic, overconfidence
of the individual (using self-report versus others data
from 360 leadership surveys participants had to fill out
before they attended the executive program). Results
remained robust even when controlling for this dispositional characteristic.
I also examined (1) the relationship between the status of the organization to which actors belonged and the
likelihood that they would initiate changes that diverged
to a greater extent from the institutionalized model of
role division among professionals, and (2) the relationship between the status of the professional group to
which actors belonged and the likelihood that they would
initiate changes that diverged to a greater extent from
the institutionalized model of role division among organizations. Neither of these relationships was significant,
which strengthens the finding that different positional
characteristics influence the likelihood that actors will
initiate one or the other of the two types of divergent
organizational change.
Because the interaction term between the low-status
professional group and the hierarchical position variables was significant only at the 10% level, to crosscheck the validity of this finding, I also estimated the
regression with fewer variables. More specifically, I
reran model 3 (see Table 4) without nonsignificant control variables. In this regression, all the remaining variables kept their sign and were statistically significant.
It is important to note that the model fit increased, as
expected, and the interaction term was now significant
at the 5% level, thus bolstering my confidence in the
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implementation of major restructuring, such as healthcare sector reforms. It indeed suggests that instead of
viewing such reforms as monolithic blocks, one should
identify the different types of divergent change that they
entail so as to then identify the actors who will be more
likely to champion them. Further examination of the
dynamics of these changes is crucial because it will help
us better understand how actors can break with the institutional status quo and thereby contribute to changing
their institutional environment.
Acknowledgments
The author thanks Tina Dacin and three anonymous reviewers
for their valuable comments on earlier versions of this paper.
The author also thanks Thomas DAunno and Metin Sengul
for their continuous feedback. Finally, the author acknowledges
the helpful comments received from Jeffrey Alexander, Michel
Anteby, Rodolphe Durand, Amy Edmondson, Robin Ely,
Mattia Gilmartin, Ranjay Gulati, Herminia Ibarra, Katherine
Kellogg, Christopher Marquis, Anne-Claire Pache, Leslie
Perlow, Jeffrey Polzer, Jean-Claude Thoenig, Patricia Thornton, Michael Tushman, participants in the Harvard Business
School workshop on organizations, participants in the MIT
Harvard economic sociology seminar, and participants in the
Subtheme 15 on institutional change and the transformation of
public organizations. For excellent assistance, the author thanks
Tal Levy, Melissa Ouellet, and Julie Mirocha.
Endnotes
1
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Julie Battilana is an assistant professor of business administration in the Organizational Behavior Unit at Harvard Business School. She holds a joint Ph.D. in organizational behavior from INSEAD and in management and economics from
Ecole Normale Suprieure de Cachan. Her research examines
the process by which organizations or individuals initiate and
implement changes that diverge from taken-for-granted practices in a field of activity, that is, the process of institutional
entrepreneurship.