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The legitimation of a new profession implemented in
a highly institutionalized setting: A case study
Master Thesis
MSc. Business Administration – Change Management
Faculty of Economics and Business
University of Groningen
Supervisor: Dr. M.A.G. van Offenbeek
Co-Assessor: Dr. J.F.J. Vos
Marjolijn Bruggeman
m.h.a.bruggeman@student.rug.nl
Student number: s2348772
Date: 23-07-2018
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ABSTRACT
The Dutch hospital care is a highly institutionalized setting. Organizational templates and the institutional environment exert pressures which makes it difficult to implement change. In contrast, the Dutch hospital care experiences changing inter-organizational and environmental demands that require change. In order to meet these changing demands, a new profession is under development: the hospitalist. In 2014 a pilot was launched that guided and facilitated the development and implementation of the hospitalist. This study investigates the legitimation process of the newly employed hospitalist. Hospitalists and their implementers will use rhetorical legitimation strategies in order to influence the legitimacy judgments of others about the hospitalist. In order to investigate this, the research question of this study was: “Which legitimacy strategies do first entrants and
implementers of a new profession use and how do these strategies influence the legitimacy judgments by established professions’ members?”
In order to answer this question, a case study research is conducted. Earlier conducted interviews with hospitalists, medical specialists, and nurses are the input for the data analysis. The results show that rhetorical legitimation strategies used by the medical specialists were influencing the legitimacy judgments. However, the moralization strategy that is used by hospitalists themselves is perceived as the most critical legitimation strategy by the medical specialists and nurses. It had a major influence on the relational evaluations. The results of this study contribute to our understanding of the influence of rhetorical legitimacy strategies on the legitimacy judgments in situations of institutional change.
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INTRODUCTION
Current changes in our society are causing a demand for change in the healthcare sector and hospital care (McKee, Healy, Edwards & Harrison, 2002). One of those environmental changes is Europe’s increasing life expectancy of people whereas birth rates are decreasing, causing changing sizes of age groups (“Population structure and ageing,” 2017). Other factors such as shortages of human resources (Van Offenbeek, 2004), the need to lower costs and improve efficiency (Grimson, Grimson & Hasselbring, 2000), and the increasing complexity of diseased people (Grimson et al., 2000; Maurits, De Veer & Francke, 2016; Van Offenbeek, 2004) are forcing the hospital care to change. In order to solve these problems, hospitals take initiatives to redesign jobs or even implement a new profession (Van Offenbeek, ten Hoeve, Leemeijer & Roodbol, 2002). The emergence and development of new professions in the healthcare sector is a type of change aimed at improving the delivery of patient care. Literature describes the hospital care as a highly institutionalized setting as it is “a combination of
processes, systems and structures that have withstood the test of time and become deeply embedded in organizational norms and values” (Smith & Graetz, 2011, p. 74). The institutional theory is used here
in order to give an understanding of the characteristics of the hospital care and the resulting difficulties of implementing a change.
In an attempt to meet certain changing inter-organizational and environmental demands, four Dutch academic and peripheral hospitals have recently designed a new profession, called the hospitalist1. The Dutch hospitalist is being educated with medical knowledge and skills of several medical specialties. They can be deployed at several domains, plus substitute some tasks of medical specialists. However, hospitalists are not medical specialists themselves. To implement the new hospitalist profession in the Dutch hospital care, the institutional template of the hospital has to change in order for the hospitalist to be adopted within this institutional system.
For every newcomer it is important to gain legitimacy, as literature on the socialization of newcomers to organizations shows (Ibarra, 1999). Individual-level legitimacy is concerned with psychological and interpersonal processes, because the newcomer has to acquire legitimacy from established professions’ members (Montgomery & Oliver, 2007; O’Dwyer, Owen & Unerman, 2011; Preda, 2005). Since, in this situation, the profession itself is new, gaining legitimation is even more difficult because graduated Dutch hospitalists are the first entrants of the new profession (O'Dwyer et al., 2011). Until recently, extent research and case studies about the implementation of a new
5 profession inside an organization was underdeveloped (Goodrick & Reay, 2010). In addition, the process of requiring legitimacy has mainly been discussed in the service sector, like assurance companies and financial markets (O’Dwyer et al, 2011; Preda, 2005). For this reason, this study will contribute to these two literature gaps as it investigates the individual-level legitimacy process of a new developed profession that’s being implemented in a highly institutionalized organization, namely the hospital care.
To investigate the legitimation process of the hospitalist, a case study is conducted that investigates the implementation of the hospitalist at six different hospitals, both academic and peripheral. Earlier conducted interviews with the hospitalist, a medical specialist and a nurse of each hospital will be the input of the data analysis. Using the coding method, the interviews will be analysed to investigtate the individual-level legitimation process of the hospitalist. The aim of this analysis is to discover the use of rhetorical legitimation strategies (Patala, Korpivaara, Jalkala, Kuitunen, & Soppe, 2017) and investigate its influence on legitimacy judgements (Tost, 2011).
The aim of this study was to clarify the influence of rhetorical legitimation strategies on the content of legitimacy judgements. Besides, it refines our understanding of the process of legitimation of a new profession that has been implemented in a highly institutionalized setting. Therefore, the research question for this study therefore will be:
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THEORETICAL BACKGROUND
The purpose of this chapter is to present, describe and analyze the theories and concepts involved in this study. It starts with an explanation of the institutional theory because the hospital care is an institutionalized setting. Next, the concept of profession is described. Taking together this sociological concept and the institutional theory, the influential and necessary concept of legitimacy is explained. This is followed by a description of different dimensions of contents which underlie legitimacy judgments and rhetorical strategies aiming to influence these judgments. To conclude, the purpose of this research is formulated leading to the research question and visualization of the conceptual model.
Hospital care: An institutionalized setting
Multiple authors described the hospital care as an institutionalized setting which is highly complex, consisting of multiple professionals who experience a complex task structure and a wide distribution of professions (Buchan & O’May, 2002; Kathan-Selck & Van Offenbeek, 2010; McKee et al., 2002). Zucker, one of the early influential writers, defines two elements of institutionalized organizations which are recognized by the various institutional theories: they have (a) an organized pattern of action which is something like a rule or a social fact and (b) an embedding in formal structures (Zucker, 1987, p.728). Institutional theories explain why particular organizational structures and ideals endure (Weerakkody et al., 2009) and in addition provide a powerful explanation of the difficulties of organizational change (Dacin, Goodstein & Scott, 2002). The institutional theory is describing an organization as “a combination of processes, systems and structures that have withstood the test of
time and become deeply embedded in organizational norms and values” (Smith & Graetz, 2011, p.74).
7 in taken-for-granted values and beliefs of the organization (Oliver, 1992; Scott, 1995; 2001). In contrast to the informal elements of the normative pillar, the regulative pillar incorporates the formal elements such, as authority, establishing rules and subsequent sanctioning, to fully enable the organization to perform (Scott, 1995; 2001). To complete, Scott has argued that the three pillars do exist at the same time within an institutionalized template, although each with different power (Scott, 2004; Scott, Ruef, Mendel, & Caronna, 2000).
By making use of templates, organizations become increasingly similar or ‘isomorphic’ (Smith & Graetz, 2011). In that way, organizations and their practices both accommodate the expectation of the field and serve as role models for new firms (Greenwood & Hinings, 1996). Furthermore, coherent mechanisms for transmitting those templates emerge, such as professional associations, leading organizations, and regulatory agencies. In mature sectors, like the current field of study, these mechanisms are very clear and so the pressure for conforming to organizational templates is high (Greenwood & Hinings, 1996). In opposite of using organizational templates, organizations themselves also can serve as an important source for the institutionalization of an element, such as structures, actions, or roles (Scott, 1987).
Changing an established template is difficult to arrange, due to pressures of the external mechanisms and the fixed structure of established templates (Greenwood & Hinings, 1996; Zucker, 1987). Besides, in situations of institutional organizational change, members are more likely to show resistance because of the strong influence of habit, history, and tradition (Oliver, 1992). This is due to the cultural-cognitive pillar. However, according to new institutional thinking, a change of organizational structures or behavior will be supported due to the emergence of legitimacy of the alternative template (Greenwood & Hinings, 1996; Weerakkody, Dwivedi, & Irani, 2009). So next to the cultural-cognitive pillar, emphasizing the alternative regulative and normative elements and gaining legitimacy for that is key (Greenwood & Hinings, 1996).
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Profession as a social institution
This research is about the implementation of a new profession, the hospitalist, within the Dutch hospital care. Compared with occupations, professions have distinctive characteristics and therefore an explanation is valuable. The term profession has many definitions and is largely dependent on one’s perspective (Jerković-Ćosić, 2012). Sociologist Abbott (1988) researched the phenomenon of professions on the societal level and is seen as a main contributor to the research field. Especially the social status and autonomy of individuals within a profession received a lot of attention in sociological research, as they stood out as an exception to the hierarchical bureaucracies of economic life (Abbott, 1988). A general recognized characteristic of professions is their strong knowledge base, which is perceived as the substantial difference between professions and other occupations (Abbott, 1991; Starbuck, 1992; Torres, 1991). Freidson (1970) not only distinguishes profession from occupations by their expertise, but also by their autonomy, power and status. The (self-) control over education, licensing and disciplining are seen as means to assure the autonomy of professions and their expertise (Parsons, 1939). To retain the concept of professions in a broader sense, Abbott’s definition is used: ‘exclusive occupational groups applying somewhat abstract knowledge to particular cases’ (Abbott, 1988, p. 318).
The growing number of professions as social entities inside an organization became of great research interest and organizational sociologist scholars wanted to investigate the mutual influence between professions and organizations (Von Nordenflycht, 2010). As mentioned before, organizations can serve as an important source of institutionalization of (new) organizational elements as they have the power and authority to legitimate other elements (Zucker, 1987). Besides, institutional elements are easily transmitted to newcomers (Zucker, 1987). By implementing a new profession within an organization, over time this will lead to the institutionalization of that profession. In the current study, the new profession that is being implemented within an institutionalized organization is the hospitalist. Legitimation is one of the key mechanisms in the institutionalization process of (new) organizational elements (DiMaggio & Powell, 1983; Greenwood & Hinings, 1996; Meyer & Rowan, 1977; Zucker, 1987). Therefore the concept of legitimation will be explained in the next section.
Legitimation and institutionalization of a new profession
As a critical social phenomenon (Huy, Corley, & Kraatz, 2014), legitimacy is studied across many social sciences. A large body of theories about the legitimation process is constructed and the nature, origins, and consequences of legitimacy received much attention in research (Huy et al., 2014). Taking the psychological and institutional literature together, Tost (2011, p. 688) defined legitimacy as “the
judgment that an entity is appropriate for its context”. Trustworthiness, fairness, and credibility are
9 concepts and has received relatively greater attention in research, this more encompassing concept is used in this study.
Sociologist Max Weber has distinguished the concept of legitimacy with the concept of validity (Weber, 1978). He has defined the organizational, collective-level legitimacy as validity of the new profession whether the micro-, individual-level is defined as legitimacy (Tost, 2011; Weber, 1978; Zucker, 1987). According to Weber’s theory, a social entity, like a profession, is regarded as legitimated when: (a) members of established professions legitimate the norms, beliefs, and values that guide the social entity but if they don’t, then (b) members of established professions should at least be aware of others who legitimate the social entity and understand how to act to that entity appropriately (Weber, 1987). This highlights the important role of established professions in the legitimation of a new profession.
Central to the individual-level legitimacy, this process aims to justify the produced work by members of professions and how it is produced (O'Dwyer, Owen, & Unerman, 2011). A critical issue in the ease of legitimating newcomers of a profession is whether there are authorised experts who can influence the legitimation process (Gendron & Barrett, 2004; Power, 1997). Newcomers of established professions not only need to acquire new skills, they also have to adapt the social norms and reflect the culture as present in the organization (Ibarra, 1999; Scott, 1995). A failure to adopt the image and to display the professional identity as expected by established professionals, will not only lower the newcomer’s effectiveness in that role but could even lead to a non-legitimation of that person (Ibarra, 1999). From the above it can be deducted that gaining legitimation is especially important for a first entrant of a new profession as there are no authorised experts who can use their power and authority to transmit legitimacy and there is no image of that profession present (Power, 2003; Zucker, 1987).
Within an institutionalized setting, powerful actors have a second key role in the process of institutionalization (Smith & Graetz, 2011). As explained earlier, regarding the tight structures, roles, and values, institutionalized organizations are perceived as having clearly legitimated templates. The implementation of a new profession would then cause a move from one template to another (Greenwood & Hinings, 1996), as is the case within the Dutch hospital care. Powerful actors have to acquire, manage, and use legitimacy to align organizational change to bring about and move to a new template (DiMaggio & Powell, 1983; Maguire, Hardy, & Lawrence, 2004). For this study, it means that managers responsible for the implementation of the hospitalist play a central role in the process of legitimation.
10 Hinings, 1996; Tost, 2011). Individuals responsible for the implementation of the hospitalist thus have a key role in the legitimacy process. They have the power and authority to transform the existing situation, guide the implementation of the hospitalist, and transmit legitimacy. Most research on legitimation of new professions is conducted within the field of professional services like accounting, finance or law (Dacin, Goodstein, & Scott, 2002; Greenwood, Suddaby, & Hinings, 2002). The implementation of the new hospitalist profession within the Dutch health care can serve as a valuable case in order to get more insight in the legitimation process in the health care field. To get a further insight on the individual-level legitimation process, Tost (2011) has integrated the social psychological research on legitimacy with the institutional theory, resulting in three content dimensions underlying legitimacy judgments. After the explanation of these legitimacy judgements, the use of legitimacy strategies to influence these judgments is explained.
Individual’s evaluation of legitimation judgments
Tost (2011) has aimed to increase the understanding of individual-level judgments of legitimacy in times of institutional change. He has developed a theoretical framework that specifies the content underlying legitimacy judgments. In this theory he combines both the social psychological research and the institutional theory. Tost describes the content of legitimacy judgments as “the substantive
beliefs and perceptions that influence an individual’s assessment of the extent to which an entity is appropriate for its social context” (Tost, 2011, p.690). A social entity could be an organization, a
social structure, organizational policies, procedures or, in this study, the new hospitalist profession.
Investigating the content underlying individual’s legitimacy judgments, Tost (2011) has identified three dimensions: instrumental, relational, and moral. Defined as the instrumental dimension, an entity is evaluated as legitimate “when it is perceived to facilitate the individual’s or
group’s attempts to reach self-defined or internalized goals or outcomes” (Tost, 2011, p.693). This
can be linked to effectiveness or efficiency of the social entity (Huy et al., 2014; Tost, 2011). Secondly, defined as the relational dimension, an entity is evaluated as legitimate “when it is
perceived to affirm the social identity and self-worth of individuals or social groups and to ensure that individuals or groups are treated with dignity and respect and receive outcomes commensurate with their entitlement” (Tost, 2011, p.693-694). How the social entity communicates with others and the
extent to which they enhance their self-worth and identity are examples of content evaluations that will lead to relational judgments (Huy et al., 2014). Lastly, defined as the moral dimension, an entity is evaluated as legitimate “when it is perceived to be consistent with the evaluator’s moral and ethical
values” (Tost, 2011, p.694). Evaluations of the implementation process, the preservation of principles,
11 grounds, they are not mutually exclusive. Evaluations of social entities may be based on more than one dimension or even on all three dimensions. To be able to construct an evaluation of the entity, individuals are actively motivated and engage in effortful information processing by, for example, asking questions, attending to group activities or challenging the new social entity (Tost, 2011).
Table 1 – Content underlying legitimacy judgments (Tost, 2011) Dimension Examples of perceptions or beliefs
Instrumental Related to the effectiveness, outcomes, benefits, efficiency, or utility of the entity Relational Related to the fairness, goodwill, or communality that characterizes the entity Moral Related to the morality, ethicality, identity, or integrity of an entity
Validity cues Related to conforming expectations carved by existing institutions and taken-for-grantedness
In contrast, there is also a more passive mode of legitimacy judging possible, based on validity cues. Individuals then show little or no effort in order to form content for their legitimacy judgments. Resulting from the aforementioned characteristics of institutional templates, the new social entity then is being unquestioned and not being explicitly or implicitly challenged. This results in cognitive judgments of an entity’s conformation to the expectations of the established institutional template. Individuals make use of validity cues and/or passively assume the legitimacy of an entity. This can be based on someone else’s legitimacy judgment or on the mere collective validity of the social entity (Tost, 2011). Due to its taken-for-granted nature and its automatic and quick formation process, validity cues are a subtle and powerful source of legitimacy (Suchman, 1995). Theorists assume the passive mode is likely to predominate the formation of legitimacy judgments, unless individuals feel the necessity or desire to actively evaluate an entity (Tost, 2011) or receive active support during institutional change (Suchman, 1995).
Deducted from the information above, powerful actors can influence behaviors, beliefs, and opportunities in order to enact pressure for change (Lawrence, 2008). Studies show that gaining legitimacy is a key aspect of the implementation of the new hospitalist profession. Active support of powerful actors then is needed in order to influence legitimacy evaluations by members of established professions. Therefore, the next section describes how rhetorical legitimation strategies play an essential role in influencing legitimacy (Patala, Korpivaara, Jalkala, Kuitunen & Soppe, 2017).
Rhetorical legitimation strategies for institutional change
12 presentation and expectation of the alternative template that, together with the dissatisfaction, will provide the direction for change (Greenwood & Hinings, 1996; Greenwood & Suddaby, 2006). In order to create awareness among established professions of the need for change and to justify and gain legitimacy for the alternative template, legitimacy is aimed to be transmitted from the established template to the alternative template by the use of rhetorical legitimation strategies (Patala et al., 2017; Scott, 1995). Related to the three different institutional pillars, four legitimation strategies have been distinguished by Patala et al. (2017). Their focus is on the use of rhetorical legitimacy strategies when new technology investments need to be justified and regular technologies need to be used continually, within an institutionalized setting. Generalized, their work contributes to the understanding of legitimation under institutional change (Patala et al., 2017) and thereby is in the context of the current changes at the Dutch healthcare setting.
Rhetorical strategies make use of a particular way of using texts in order to persuade others (Suddaby & Greenwood, 2005). The first legitimation strategy, rationalization, emphasizes the utility, benefits, functions or outcomes of a new element. Secondly, normalization strategies emphasize on past or normal actions. New elements are presented by referencing to existing capabilities or elements or are presented as part of an overarching growth plan. Thirdly, the moralization strategy emphasizes the appropriateness of actions and presentations, according to present norms or values. It references to the impact or added value of the new element on the established community and its social reality. Lastly, the authorization strategy emphasizes the regulatory aspects of the new element. The strategy references to authority such as rules, legislation, directives or experts in order to gain legitimacy (Patala et al., 2017).
In another research about gaining legitimacy, Huy et al. (2014) examine the critical role played by middle managers in their role as both change agents and change recipients. Particularly, their analysis revealed the important influence of middle managers’ legitimacy judgments on the dynamic shifting legitimacy judgments of change recipients and their resistance to change. The emergent process model involves reciprocal interactions between middle managers and change recipients and incorporates emotional reactions (Huy et al., 2014). However, the aforementioned four rhetorical legitimation strategies provide a more accessible tool of analyzing the process of gaining legitimacy of a new profession. Besides, among the contexts in which rhetorical legitimation strategies have been studied, specifically inquiring of its use during the implementation of a new profession within an institutionalized setting is unnoticed (Patala et al., 2017).
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Using rhetorical strategies in order to influence the formation of legitimacy judgments
The aforementioned literature has explained the institutional characteristics of the Dutch hospital care and the research on the difficulties of implementing change within institutionalized organizations. Also the issue of legitimacy is discussed. The literature about professions and the challenges of implementing new professions have stressed the important role of legitimacy. What is not clear yet, is the legitimation process of a new profession that is being implemented within a highly institutionalized organization. This paper therefore will investigate the use of rhetorical legitimation strategies during the implementation of the hospitalist within the Dutch hospital care. This results in the following research question:
“Which legitimacy strategies do first entrants and implementers of a new profession use and how do these strategies influence the legitimacy judgments by established professions’ members?”
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RESEARCH METHOD
In this chapter will be explained how the research is conducted. Firstly, the research setting of the hospitalist will be explained. Next, the research design, data collection and data analysis are described. The chapter will end with an explanation about the ways in which the research quality is assured.
Research setting: The development of the hospitalist
The empirical context of this study is the hospital care for admitted patients in the Netherlands. It is a highly institutionalized organization and employees experience hierarchical working relationships (Buchan & O’May, 2002; Kathan-Selck & Van Offenbeek, 2010; McKee et al., 2002). Consequently, a hospital is a rigid organization which makes it hard to implement change. However, at the same time, the changing environmental context forces hospitals and the healthcare sector in general to change (McKee, Healy, Edwards & Harrison, 2002). One of those environmental changes is Europe’s increasing life expectancy of people whereas birth rates are decreasing, causing changing sizes of age groups (“Population structure and ageing,” 2017). As a consequence, the Netherlands will have 7 million chronically ill patients in 2030, mainly because of the increasing group of elderly people (aged 65 or over) (“Toekomstverkenning RIVM”, 2016). Especially this group faces diseases more frequently and additionally it is expected that they will have several diseases simultaneously (Van Offenbeek, Visser & Bakker, 2014). Besides, the diseases of people generally are more often extending several health domains (Maurits, de Veer & Francke, 2016), while the knowledge and skills of health specialists are becoming more focused and specific (Van Offenbeek et al., 2014). Other factors such as the need to lower costs and improve efficiency (Grimson, Grimson & Hasselbring, 2000) and the increasing complexity of diseased people (Grimson et al., 2000; Maurits et al., 2016; Van Offenbeek, 2004) are forcing hospitals to change.
16 In an aim to solve these problems, four hospitals have taken the initiative to design and implement a new profession: the hospitalist. This pilot has designed the hospitalist to be a generalist that should be able to provide and coordinate interdisciplinary care. As such, it’s intended that the hospitalist is multi-employable and can for some tasks replace the medical specialist when necessary. The main added value of this new profession is to assure the continuity of patient care within and between different health domains of the hospital, but also between the hospital and other healthcare organizations.
Research design
The aim of this paper is to answer the research question: “Which legitimacy strategies do first entrants
and implementers of a new profession use and how do these strategies influence the legitimacy judgments by established professions’ members?” In order to answer this question, a case study
method was used. This research method was chosen because it allows investigating an event within its real-world, in this study the implementation of the hospitalist (Pelham & Blanton, 2007). Next to that, it also allows getting more insight in how elements are influencing the research phenomena of interest, in this study inquiring how legitimacy strategies may influence the legitimacy judgments (Eisenhardt, 1989). The type of design that is used in this study is an embedded case study design (Yin, 2014). The design and implementation of the Dutch hospitalist is the single case that is selected based on the extreme case rationale. Due to the high institutional characteristics of the hospital, implementing change is considerable more difficult than at a non-institutional organization. Besides, studying the legitimation of a new profession at the hospital care is deviating from earlier research as those are mainly conducted at the service sector. These two distinctive case characteristics make this an extreme case.
Within this single, extreme case of implementing the hospitalist, six units of analysis were selected. These six units are Dutch hospitals where the hospitalist is being employed. The logic underlying the selection of these units is literal replication (Yin, 2014). In this study, the selected units are the hospitals at which the hospitalist is being employed at an established department. In contrast, the hospitals who designed a whole new department at which they implemented the hospitalist are not selected. The characteristics of the selected hospitals are shown in Table 2. Due to privacy considerations, the names of the hospitals are not revealed here. Instead, case numbers are used in this study to refer to the different hospitals.
17 intensively with the nurses. It was expected that the senior nurse has a clear overall picture of the changes caused by the employment of the hospitalist.
Table 2 – Characteristics of selected units Hospital characteristics and
department (unit of analysis)
Case number2 Profession (unit of observation) Interview code
Peripheral, internal medicine /
oncology 01
Hospitalist H01 Medical specialist MS01
Nurse N01
Peripheral, internal medicine 02
Hospitalist H02 Medical specialist MS02 Nurse N02 Academic, traumatology 03 Hospitalist H03 Medical specialist MS03 Nurse N03 Peripheral, surgery 04 Hospitalist H04 Medical specialist MS04 Nurse N04 Peripheral, surgery3 05 Hospitalist H05 Medical specialist MS05 Nurse N05 Academic, hematology 06 Hospitalist H06 Medical specialist MS06 Nurse N06 Data collection
This study focuses on the legitimation of the hospitalist. Secondary data is used as the data is been collected by others (Cole & Trinh, 2017). Several rounds of interviews took place in recent years to evaluate the pilot. The transcripts used for this study are the ones from interviews conducted in round four, which is the last round of interviews. These interviews have been conducted with hospitalists, medical specialists and nurses and took place four months after the graduated hospitalist began its employment.
2 For the reader’s convenience, the term ‘cases’ has been used in this study to refer to the different hospitals, which are the units of analysis.
18 The hospitals selected and used for this research are the ones where the hospitalist is executing its profession for four months. The conducted interviews were semi-structured, face-to-face and were recorded in order to make transcripts. An interview protocol was applied per actor, in order to ensure the consistency of the interviews as there were multiple investigators taking the interviews (Yin, 2004). The interview protocols of the hospitalist and medical specialist or nurse are available on request.
Data analysis
Before the data was coded, the interviews were read to become familiar with the context and content. During the coding process, Atlas.ti software was used. Codes were formulated both inductive and deductive. Inductive coding was used first to make an initial division of the data. Thereafter, the conceptual framework and key theoretical concepts were used to create deductive codes and to categorize the inductive and deductive codes. Both the formulation of inductive and deductive codes and their categorization was an iterative process. New codes were formulated throughout the process and others were deleted or merged. The complete code tree can be found in Appendix I. Next, in Appendix II a code book is presented with a description of the codes, a classification of deductive and inductive codes and examples of quotes. For the understanding of the next chapter, Table 3 and 4 show an overview of the codes and their categories.
Both a within case analysis as a cross-case analysis will be executed in order to find major influences and other patterns. The technique used for the cross-case analysis is the pattern matching (Yin, 2014). This logic compares the patterns based on the findings with the predicted ones based on the literature.
Table 3 – Rhetorical legitimation strategies codes
Category Codes
Rationalization
Employability of hospitalist Tasking of hospitalist
Expectations effects of hospitalist Aim of hiring hospitalist
Normalization
Expectations role hospitalist Reason / cause of hiring hospitalist Preparation for employment hospitalist Previous experiences with hospitalist
Moralization
Relationship management Positioning by hospitalist Vigour of hospitalist
Personal characteristics of hospitalist Authorization Independence hospitalist
19 Wage payment hospitalist
Supervision of MS not needed Passing tasks from MS to hospitalist Job description
Table 4 – Legitimacy evaluations codes
Category Codes
Relational evaluations Opinions about functioning of the hospitalist Collaboration with the hospitalist
Instrumental evaluations
Added value of hospitalist Medical knowledge
Continuity due to hospitalist
Hospitalist doesn’t meet expectations Hospitalist does meet expectations
Moral evaluations
Trusting the hospitalist
Opinion is unjustified cause of short employment
Threat of hospitalist
Validity cues
Evaluation about hospitalist is compared with established professions
Recognition and familiarisation of hospitalist No discussion needed for qualities of
hospitalist
Just accepting hospitalist as it is a graduated physician
Research quality
A challenge with using secondary data is that the data collection might not be designed in order to answer a specific research question (Cole & Trinh, 2017). However, the data used here are interview transcripts collected in order to investigate the role and functioning of the hospitalist. So the aim and interest of the interviews corresponds with the research focus of this study. Next, a pitfall of secondary data analysis is that it might not provide all the necessarily data needed (Cole & Trinh, 2017). Questions might not been asked or provided answers might not be given follow-up questions in order to clarify the answer. However, even in well-designed, own-developed data collection it is common to experience missing data (Cole & Trinh, 2017). Therefore, using secondary data is expected not to have serious shortcomings to conduct this study.
Controllability, reliability and validity. Quality criteria for research are its controllability, reliability
20 (Pelham & Blanton, 2007). To ensure its controllability, information is revealed about how the study was conducted. Besides it is a precondition for the evaluation of the reliability and validity. The tactics that were taken to ensure the reliability and validity are discussed in Table 5.
Table 5 – Research quality criteria (Pelham & Blanton, 2007; Yin, 1994)
Quality criteria Description Tactic applied
Internal validity
“The extent to which a set of research findings provides compelling information about causality” (Pelham & Blanton,
2007, p. 61)
- Used the pattern matching technique to analyse the data
- Evaluated the found patterns by reflecting on current research
External validity
“The extent to which a set of research findings provides an accurate description of what typically happens in the real world” (Pelham & Blanton, 2007,
p. 63)
The selection of the units of
observations, i.e. the hospitals, is based on the replication logic
Construct validity
“The extent to which the independent and dependent variables in a study truly represent the abstract, hypothetical variables of interest to the researcher.”
(Pelham & Blanton, 2007, p. 64)
The secondary data that was used to analyse the different concepts, was conducted at three levels of observations, i.e. interviews with a hospitalist, medical specialist, and nurse
Reliability
“The consistency or repeatability of a measure or observation.”
(Pelham & Blanton, 2007, p. 68)
- The conducted interviews made use of an interview protocol
- The interviews were conducted by two researchers
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FINDINGS
This chapter presents the results of the data analysis. Firstly, a within case analysis will describe the observed rhetorical legitimation strategies and the different contents of legitimacy judgments that are made at every case. In particular, the observed influence of the legitimation strategies on the legitimacy judgments will be stressed. A codebook with example quotes can be found in Appendix II. In Appendix III more specified data of the codes is presented. After the within case analysis, a cross-case analysis will describe the observed, general patterns of the six cross-cases. The results of the cross-cross-case analysis are also presented in Figure 2.
Within case analysis
As mentioned in the research section, six hospitals, which are employing the hospitalist, were selected to conduct the analysis. Of every hospital an analysis of the observed rhetorical legitimation strategies and the observed contents of legitimation strategies will be presented in this sub-section. The four rhetorical legitimation strategies are the rationalization, normalization, moralization, and authorization strategy (Patala et al., 2017). The three dimensions of contents of legitimacy judgments are instrumental, relational, and moral (Tost, 2011). Next, there are also validity cues that underpin the legitimacy judgments.
Case 1. This hospital has a clear strategy regarding the employment of the hospitalist. Their aim is to
have a 24/7 support of hospitalists across the whole hospital. The board of directors formulated this aim directly at the beginning of the hospitalist traineeship that also took place at this hospital (interview H01). Due to this top-management support, there is a plan on how to employ the first hospitalist entrants. The several hospitalists that are employed at this hospital, switch of department every six months (interview H01 and N01). Before the start of employment of this specific hospitalist, the medical specialist and hospitalist discussed the position that the hospitalist has to take and the tasks he has to perform. Taken together, these observations show that the rationalization strategy is used by the hospitalist and medical specialist.
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Case 2. This hospital hired the hospitalist because they were recommended by another hospital to
employ one, which means there was no concrete reason or internal demand for the hospitalist profession. Besides, this hospital didn’t have a hospitalist trainee before. This might be one of the causes that the hospital didn’t have a concrete plan or strategy for how to further employ the hospitalist, as experienced by the hospitalist herself (interview H02). On the other hand, the perspective of the medical specialist and nurse was that they gave the hospitalist the freedom, so-called ‘carte-blanche’, to develop her own position and to come with a concrete plan for it (interview N02). These observations show that the expectations of both parties about the employment and effects of the hospitalist were not in line. Moreover, the expectations of both parties were not specifically marked at the start of the employment. Consequently, these results indicate that the rationalization and normalization strategies were not used by the hospitalist and the medical specialist. Furthermore, the medical specialist and the nurse observed that the hospitalist didn’t show any sign of the moralization strategy. They state that the hospitalist showed no vigour or other actions to position herself at the department.
Turning to the legitimacy judgments, the moral, instrumental, and relational dimensions are evaluated negatively. There was a lack of trust in the hospitalist and the medical specialist was disappointed in her managing and coordination skills. The nurse experienced a lack of independence of the hospitalist and she complained about her negative attitude. Overall, the hospitalist didn’t meet the expectations of the medical specialist and nurse. In particular, the opinions about the functioning of the hospitalist are mainly evaluated with regard to established professions, like a room-physician4 or an ER-physician5. This is a sign of the use of validity cues, which are quickly formulated opinions without further grounding. Turning to the experiences of the hospitalist itself, she experienced a lack of support and help to perform her tasks and develop her role. As an example, the hospitalist didn’t receive an invitation for a team meeting (interview H02). In summary, the employment of the hospitalist at this hospital couldn’t be labelled as a success. After six months both parties decided to not extend the contract and the hospitalist applied for a hospitalist vacancy at another hospital.
Case 3. Despite the fact that the hospitalist was trained at this hospital for three years, there was no
clear employment plan yet. Mainly because of a non-agreement about the wage payment, not every department was able to employ the hospitalist. Finally, the traumatology department decided to employ this hospitalist, as they were enthusiastic about the concept and had the necessary budget to pay the hospitalist. Besides, the expectation was that the hospitalist will be best suited at this department because of the high diversity of the age of the patients and the high turnover of patients. It was expected that the hospitalist will be able to take care of this high diversity of patients and will
4
In Dutch: zaalarts
23 enlarge the continuity of the patients’ care. In time, the hospital wants to have a 24/7 support of hospitalists (interview MS03). Taken all together, these observations indicate that the normalization and rationalization strategy were substantially used by the hospitalists’ implementer6. Also, the authorization strategy, i.e. the payment of the hospitalist, is used here to give a reason and motivation whether or not to employ the hospitalist. Still, all three interviewees acknowledge the difficulties that arise with the employment of this new profession. The hospitalist has experienced that he has to show high effort into positioning himself and into relationship management. In turn, these signs of the use of the moralization strategy are identified and evaluated positively by the medical specialist and nurse. Next to the positioning, the three interviewees recognize the difficulties with enlarging the position of the hospitalist. Because of the newness, they don’t have a clear image about the employment, tasking, and role of the hospitalist. Together, they try to discuss this and are looking for the most suited and proper way to employ the hospitalist.
Still, the legitimacy judgments of the instrumental dimension are evaluated as positive. The medical specialist and nurse already experience a serious added value of the hospitalist. They describe the general and broader medical knowledge of the hospitalist, the increase in continuity of patient care, and the stability of knowledge and care. However, due to the current difficulties with enlarging the position and role of the hospitalist, the medical specialist and nurse acknowledge that a true evaluation is not possible yet. But still, they evaluate the instrumental dimension as positive. Moreover, the collaboration with the hospitalist is going very well, resulting in a positive evaluation of the relational dimension.
Case 4. The hospital of this case has had already some experience with the hospitalist profession as
they also train them. The current hospitalist, however, has been trained at another hospital but decided to apply here as there was no budget to employ him at the other hospital. Despite the fact that hospitalists are being trained at this hospital, it seems that the medical specialist and nurse don’t have a clear image of the concept of the hospitalist profession. The ideas and expectations they have about the hospitalist, don’t match with that of the hospitalist himself. According to the medical specialist, the hospitalist is employed at the surgery department because of understaffing. In contrast, the hospitalist himself states the appropriateness of his profession for such complex and diverse patients whom are receiving care at the surgery department. What both the hospitalist and medical specialist do have stated, is the symbolic goal of employing the hospitalist. The aim is to experience in what way the hospitalist can have an added value for this department. This then should be an example and statement for other departments and should give confidence to current and new hospitalist trainees (interview H03 and MS03). Consequently, these observed statements show that the rationalization,
24 normalization, and authorization strategies were used by the medical specialist, the hospitalist, and mainly by the board of directors. The hospitalist himself also showed actions relating to the moralization strategy. As identified by the nurse, the hospitalist has positioned himself very well and thereby he contributed to his own recognition (interview N04).
However, the medical specialist and nurse both indicated that it’s difficult to evaluate the performance of the hospitalist. At the moment that the interview took place, the hospitalist was employed at the surgery department for only three months. This period was mainly used to get familiar with the hospitalist profession and to explore how he could be best employed. It seems that the medical specialist and nurse have difficulties in making a decision in how they can evaluate the performance and added value of the hospitalist. The medical specialist, for example, does want to see concrete changes such as lower rates of mortality, quicker patient turnover, less patient reuptakes, or less complications. On the other hand, the medical specialist acknowledges that it’s not possible yet to have such clear changes. Another point is that the hospitalist wasn’t able to do clinical audits yet. However, the medical specialist and nurse did identify the improved continuity and the larger medical knowledge of the hospitalist. Taken these observed statements together, the medical specialist and nurse are not sure yet how to evaluate the instrumental dimension. But the evaluations they did make, were positive. Because of their high awareness of the newness of the hospitalist, the moral evaluations are also observed here. Next, the collaboration with the hospitalist was evaluated as good and pleasant, leading to a positive relational dimension. Overall, the hospitalist at this department is evaluated as positive and is accepted. However, after this first period of familiarizing, a further evaluation and plan how to best employ the hospitalist, is yet unknown.
Case 5. Just like in case 4, the hospital of this case has had previous experience with the hospitalist
25 Consequently, this led to a positive evaluation of the legitimacy judgments. It was mainly mentioned that the hospitalists meet the expectations of both the medical specialist and nurse. They see the improved coordination of care and the continuity of care. Moreover, the hospitalists have a high commitment towards the patients. However, they also recognize that the hospitalists have more to offer and that their knowledge and skills could be used better. Next to that, they acknowledge that it’s too early to make a final evaluation. All in all, the relational, moral, and instrumental dimensions are used here to come to a legitimacy judgment. Yet one criticism is made by the medical specialist, concerning the medical knowledge of the hospitalist. As a surgery physician, he stated that a hospitalist is monitoring a patient differently than a surgery physician. Therefore, he states that the hospitalist cannot replace the medical specialist, as the specific medical knowledge and skills related to surgeries are lacking. To conclude, the hospitalists were evaluated very positive at this hospital and were accepted. Together they are still working on the further employment of the hospitalist and the enlargement of the use of the profession.
Case 6. The remarkable thing about this case is that the hospitalist applied at an ANIOS vacancy and
is thus trying to position the hospitalist profession while being employed at an ANIOS position (interview H06). While the added value of a hospitalist profession, compared to an ANIOS, was clear during the job interviews, concrete expectations of the effects and the improved outcomes were not made at the beginning of the employment. Besides, the department has very complex patients which makes it difficult for the hospitalist to be independent and work without supervision. Taken together, the use of the rationalization and authorization strategies was low. However, the hospitalist showed a considerable amount of moralization strategy. She did her best to position herself as a hospitalist and put a lot of effort in relationship management with nurses and the medical specialist.
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Cross-case analysis
Now, the analysis of the six cases will be used to build a cross-case analysis. The cross-case analysis describes several patterns, which are found between the legitimation strategies and the legitimacy judgments. The technique used for the cross-case analysis is the pattern matching technique (Yin, 2014). This logic compares the patterns, based on the findings, with the predicted ones, based on the literature. At this subchapter, only the empirically found patterns will be discussed. This will be done by evaluating the presence and influence of the four legitimacy strategies. A comprehensive evaluation of the patterns will be reported in the next chapter. Concludingly, a figure will show the main patterns of the observed influences.
Rationalization strategy. The rationalization strategy is an often observed strategy that has been used
by the medical specialist and hospitalist. At this study it refers to the aim of hiring the hospitalist, the employability and the tasking of the hospitalist, and the expectations of its effects. It is observed that this strategy has a major influence on the instrumental evaluations and a minor influence on the moral and relational evaluations of the hospitalist profession. At first, the formulated aim of hiring the hospitalist provided the medical specialists and nurses a general understanding of why the hospitalist is employed here. Subsequently, the performance of the hospitalist could be evaluated. In particular, it is observed that a long-term, overarching aim of hiring the hospitalist had an important influence on the understanding and recognition of the employment. This could be the 24/7 support that was formulated (case 1 and 3) or the aim that it is a pilot or a symbolic action to employ the hospitalist (case 4 and 5). The latter also had an important influence on the moral evaluations, as at those cases they already acknowledge the difficulties and injustice to evaluate the hospitalist profession because it is too early to do so. Furthermore, the support of the board of directors was experienced as an important additional motivation of the aim of hiring the hospitalist (case 1 and 4).
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Normalization strategy. Next to the rationalization strategy, the use of the normalization strategy was
observed substantially. The normalization strategy in this study contains statements about the reason or cause of hiring the hospitalist, previous experiences with the hospitalist profession, the preparations taken before or during the first period of employment, and the expectations of the role of the hospitalist. Mainly the reason of hiring the hospitalist and previous experiences with the hospitalist profession were having an important influence on the instrumental, moral, and relational evaluations. Often, the reason of hiring a hospitalist was a lack of continuity and stability of patient care at a hospital department due to the high turnover of ANIOS-positions. When, due to the presence of the hospitalist, the continuity and stability of the patient care indeed was increased and guarded, the instrumental dimension was positively evaluated. This is a clear, direct influence that was observed at every case, except for case 2. Next, previous experience of collaborating with a hospitalist was positively influencing the instrumental, moral, and relational evaluations. This experience was gained due to the presence of hospitalist trainees at the department or elsewhere at the hospital, as was the fact in cases 1, 3, 4 and 5. In that way, the interviewed medical specialists and nurses were already somewhat familiar with the profession and were prepared for its employment. In turn, this provided the medical specialists and nurses to have a more grounded instrumental evaluation. Furthermore, it had a positive effect on the collaboration (relational evaluation) and acknowledgement of the profession’s newness (moral evaluation). The same influence and effects were observed by the other preparations that were executed before or at the first period of the employment of the hospitalist. As can be found in Appendix III, those preparations are observed quite regularly. However, half of it was observed in case 2, whereat the employment of the hospitalist failed. This indicates that such preparations were not taken regularly at the other cases, and unfortunately did not work out well in case 2.
Lastly, also expectations about the role of the hospitalist were observed at the data. However, as similar to the expectations about the effects of the hospitalist, these expectations were not jointly and concretely formulated. It seems that statements implying both expectations about the effects and the role of the hospitalist were mainly formulated during the interviews and not at the beginning of the employment of the hospitalist.
Moralization strategy. The moralization strategy was used only by the hospitalists themselves. This
28 actions they took to position the profession. The main influence this strategy had was on the relational evaluations. Due to the noticed efforts and actions of the hospitalists, the medical specialists and nurses could evaluate the relational dimension as very positive, except for case 2.
Authorization strategy. The least used strategy is the authorization strategy. This strategy contains
observed statements about the wage payment of the hospitalist, the (un)necessary supervision of the medical specialist, the transfer of tasks from the medical specialist to the hospitalist, the independency of the hospitalist, and the job description of the hospitalist profession. The wage payment of the hospitalist had in most cases led to discussions and some influence on whether or not to hire the hospitalist. However, this discussion goes mainly together with the overall support of the board of directors to hire hospitalists. Next to that, the independence given to the hospitalist had a major influence on the relational evaluation. Especially when it was clear what the hospitalist can and may do without supervision and any consult, this had a positive effect on the collaboration between the hospitalist and nurse.
Other patterns. When taking a closer look at case 2, the absence of rhetorical legitimation strategies
made it difficult to evaluate the hospitalist. The judgments being made about the hospitalist profession and the performance of the hospitalist are then mainly made by comparing the hospitalist with other established professions. This validation is defined as a validity cue, because it is a more passive mode of legitimacy judgments. Naturally, also at the other cases the hospitalist is being compared to other established professions, but that didn’t lead to a final judgment about the hospitalist profession. At those cases it was used as an argumentation rather than a judgment.
Furthermore, as already mentioned, the support of the board of directors is having an important positive influence on the legitimation process. This support goes along with decisions about the wage payment, the long-term, 24/7 aim of hiring the hospitalist, and the provision of trainee positions for hospitalists in education. At those cases, the hospitalists themselves do already feel much more accepted and the medical specialists and nurses are having a greater understanding of the profession and how to collaborate with it.
Visualization of the observed patterns
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DISCUSSION AND CONCLUSION
Now that the findings are described in the previous chapter, the study will be discussed and concluded in this chapter. First, the dominant patterns derived from the results analysis will be related to the existing literature. Next, the research question will be answered and theoretical and managerial implications will be provided. Moreover, the limitations and an evaluation of the quality of this research will be presented. The chapter will end by providing possibilities for further research.
The influence of rhetorical legitimation strategies on legitimacy judgments
In order to get an understanding of the implementation of the hospitalist profession in the Dutch hospital care, the institutional theory was used. This theory stressed the difficulty of implementing change due to internal and external pressures to persist the established organizational template. Therefore, gaining legitimacy for the alternative template is stressed as a crucial mechanism in order to succeed the change (Greenwood & Hinings, 1996). Moreover, literature about the concept of professions stressed the importance of legitimacy. The concept of legitimacy is defined as “the
judgment that an entity is appropriate or its context” (Tost, 2011, p. 688). The research of Tost (2011)
increased the understanding of the individual-level judgments of legitimacy, as he defined different content dimensions of legitimacy judgments. In order to influence and gain legitimacy, Patala et al. (2017) investigated the use of rhetorical legitimation strategies. By combining these two theories, this research provides interesting insights in the influence patterns of the legitimation strategies on the evaluations of the legitimacy judgments. Therefore, the research question this study is focusing on, is:
“Which legitimacy strategies do first entrants and implementers of a new profession use and how do these strategies influence the legitimacy judgments by established professions’ members?”
31 trainees, and thus the influence of the normalization strategy, on the prioritization of the relational dimension of legitimacy judgments, supports the ideas of Tost (2011). On the contrary, the observed difficulties of evaluating the hospitalist profession, when the medical specialist and nurse didn’t collaborate with a hospitalist trainee before, mirror this pattern.
The most surprising finding was the dominant and crucial use of the moralization strategy, which could only be used by the hospitalists themselves. Even if the rationalization and normalization strategies were used, the use of the moralization strategy still was crucial in order for the medical specialists and nurses to be able to evaluate the hospitalist profession. The strategy had a substantially great influence on the relational dimension of legitimacy judgments. This finding seems to be consistent with the literature about newcomers of established professions as described by Ibarra (1999) and Scott (1995). They stressed the importance for newcomers of established professions to adopt the profession’s image and identity in order to be legitimated. However, at this case, there is yet no image of the hospitalist profession, as it is a new profession. It was expected that the individuals responsible for the implementation of the hospitalist, which are often the medical specialists, have a key role in the legitimation process. However, the findings show that the use of the moralization strategy by the hospitalists themselves was the most crucial in order to gain legitimacy from others. As an image of the hospitalist profession is not yet established, the first entrants of the hospitalist profession need to extensively use the moralization strategy, in order to be legitimated.
Consequences when rhetorical legitimation strategies were not used
The findings further support the idea that individuals will use validity cues to reach a legitimacy judgment when they don’t receive active support during institutional change, as described by Suchman (1995). Relying on validity cues is a passive mode of the legitimacy judgment process, as individuals use shortcuts rather than actively evaluate the performance and existence of an entity (Suchman, 1995). In order to be able to actively evaluate the hospitalist profession, the medical specialists and nurses need information about and experiences with collaborating with the hospitalists. The rhetorical legitimation strategies therefore provide this to the medical specialists and nurses. As observed at case 2, these strategies were used to a small extent, causing the medical specialist and nurse to rely on shortcuts and validity cues to come to a legitimacy judgment.
Conclusion and implications
individual-32 level legitimacy judgments about a new profession. In summary, the rationalization and normalization strategies have substantial influence on the instrumental and relational dimensions of legitimacy judgments and a smaller influence on the moral evaluations. Next, the use of the moralization strategy by the hospitalists themselves is found to be the most critical. This strategy focuses on the positioning and relation management of the hospitalist and positively influences the relational dimension of legitimacy judgment. Lastly, the authorization strategy has been used to a lesser extent and does not have a big influence on legitimacy judgments. In contrast, the absence of rhetorical legitimacy strategies led to a passive mode of evaluating the hospitalist. Then the legitimacy judgments were based on validity cues and even led to the illegitimacy of the hospitalist profession.
The findings of this study stress the key role of the hospitalists themselves in order to gain legitimacy. This information can be used to improve the educational program of the hospitalist profession. Hospitalist trainees can be informed about these findings and be educated with skills to position themselves and to establish and improve the relationships with others. To a broader extent, it supports the current literature about the difficulties of first entrants of a new profession and their own key role to gain legitimacy.
Limitations and further research
This research has been subject to several limitations. First, the secondary data that has been used yield some drawbacks for the analysis. The interview transcripts not always provided enough information about the legitimacy process. For example, it was not always clear why a nurse trusted the hospitalist or which strategies the hospitalists and medical specialists used at the beginning of employment. Not only didn’t the interview protocol contain enough questions that were focused on the legitimation process, also follow-up questions were not always being asked. Further research could investigate the legitimation process more focussed by designing an interview protocol based on earlier literature about the legitimation process. Furthermore, new research could also include the top management of the hospitals. At some cases of the present research, the interviewees referred to the influence of the board of directors at the implementation process of the hospitalist profession. However, this has not been a unit of observation but could extend future research.
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