Transforming New Ideas into Practice: An Activity Based Perspective on the Institutionalization of Practices

Transforming New Ideas into Practice: An ActivityBased Perspective on the Institutionalizationof Practices

Trish Reay, Samia Chreim, Karen Golden-Biddle,Elizabeth Goodrick, B. E. (Bernie) Williams, Ann Casebeer,Amy Pablo and C. R. (Bob) HiningsUniversity of Alberta; University of Ottawa; Boston University; Florida Atlantic University; University of

Lethbridge; University of Calgary; University of Calgary; University of Alberta

ABSTRACT We develop an activity-focused process model of how new ideas can betransformed into front line practice by reviving attention to the importance of habitualizationas a key component of institutionalization. In contrast to established models that explain howideas diffuse or spread from one organization to another, we employ a micro-level perspectiveto study the subsequent intra-organizational processes through which these ideas aretransformed into new workplace practices. We followed efforts to transform theorganizationally accepted idea of ‘interdisciplinary teamwork’ into new everyday practices infour cases over a six year time period. We contribute to the literature by focusing onde-habitualizing and re-habitualizing behaviours that connect micro-level actions withorganizational level theorizing. Our model illuminates three phases that we propose areessential to creating and sustaining this connection: micro-level theorizing, encouraging tryingthe new practices, and facilitating collective meaning-making.

Keywords: diffusion, habitualization, institutionalization, practice change

INTRODUCTION

How do new practices become accepted, adopted, and eventually institutionalized in theworkplace? This question lies at the heart of research efforts attempting to understandinstitutional change. There is a relatively large volume of literature that has examinedthis topic from the macro perspective, usually focusing on the spread of practices fromone organization to another, and ending the study with organizational adoption of a newpractice. This process has been labelled ‘diffusion’ (e.g. Greenwood et al., 2002;Westphal et al., 1997). And yet, by focusing on the inter-organizational spread of new

Address for reprints: Trish Reay, University of Alberta, 3-23 Business Building, Edmonton, Alberta T6G 2R6,Canada ([email protected]).

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© 2013 John Wiley & Sons Ltd and Society for the Advancement of Management Studies

Journal of Management Studies 50:6 September 2013doi: 10.1111/joms.12039

practices and the concepts underpinning them, scholars have given relatively littleattention to the intra-organizational diffusion or uptake of new practices at the front line(Ansari et al., 2010). This is a critical shortcoming in the existing literature since we knowthat organizational adoption of a new idea is not necessarily accompanied by associatedchanges in workplace practice (Zbaracki, 1998).

Another body of literature, Scandinavian institutionalism, provides a different con-ceptualization of how new practices are institutionalized. It has primarily come to‘highlight the dynamic aspects of circulating ideas; how and why ideas become wide-spread, how they are translated as they flow and with what organizational consequences’(Sahlin and Wedlin, 2008). Assuming that new practices develop in line with new ideas,this ‘travel of ideas’ involves a necessary translation of one idea to another that is moresuitable for a particular context and can be influenced by actors with specific interests(Boxenbaum and Strandgaard Pedersen, 2009; Czarniawska and Sevon, 2005; Zilber,2006). However, with its focus on how ideas change as they travel from one context toanother, the Scandinavian institutional literature has also avoided consideration of howideas accepted at the organizational level are transformed into front line practice.

To address this gap, we draw on results from our six year comparative case study offour health care organizations in a Western Canadian setting. In each case, the idea ofinterdisciplinary teamwork was adopted at the organizational level, but we observeddifferences in the degree to which actual practices changed. Our study highlights a phaseof institutionalization that we label the ‘transformation’ of ideas into practice, thusdrawing attention to the critical change from an abstract conceptualization of a newpractice to observable patterns of behaviour. In developing our conceptual model, werevive attention to Berger and Luckmann’s (1967) focus on activity and habitualizationas essential components of institutionalization. While research has tended to view insti-tutionalization as a cognitive process (DiMaggio and Powell, 1991), we build on theconcept of habitualization to draw renewed attention to the importance of the tightconnections between activity and meaning construction.

Because of the limits to top management’s authority, a professional context is particularlyappropriate for investigating how new ideas accepted at the organizational level can betransformed into new practices. In professional settings, top management is unable to imposechange because professionals hold discretion to openly or secretly resist change in theirpractices (e.g. Currie et al., 2012; Ferlie et al., 2005; Kellogg, 2009). The relatively few studiesthat have attempted to understand the development of new professional practices at the frontline show that professionals themselves instigate changes through a bottom-up process (e.g.Reay et al., 2006; Smets et al., 2012). There has been even less research attention ontop-down attempts to transform field or organizational level conceptualizations into profes-sional practice. In those few studies (e.g. Currie et al., 2012), the ability of professionals tomaintain their well-established and comfortable practices is clearly illustrated.

In the following section, we review the literature relevant to understanding how ideasadopted at the organizational level (i.e. accepted by top management) are transformedinto front line practice. Next, we describe our research settings and methods. Based onour results, we develop a conceptual model of how new ideas are transformed intopractice. Finally, we discuss what our revival of an activity-based view of the institution-alization process contributes to the literature and derive managerial implications.

T. Reay et al.964


INSTITUTIONALIZATION OF NEW PRACTICES

Research investigating institutional change has primarily taken a macro-level perspectiveon the diffusion of new ideas from one organization to another. Some scholars have beeninterested in understanding variation in the speed and extent of diffusion while othershave focused more on the process of institutionalization. Variance oriented studies haveexamined contextual conditions (Haveman and Rao, 1997; Sanders and Tuschke, 2007),the characteristics or motivations of potential adopters (Burns and Wholey, 1993;Kennedy and Fiss, 2009; Tolbert and Zucker, 1983; Westphal et al., 1997), and thenature of the new practice or innovation (Meyer and Goes, 1988). Other studies haveexplained variation in the pattern of diffusion by drawing attention to the presence (ornot) of significant external actors (e.g. Kaufman and Patterson, 2005; Lounsbury, 2001).In the context of professional settings, studies have explained variation in the spread ofpractices by highlighting the degree to which new practices are compatible with existingvalues or past experiences of the professional (e.g. Ferlie et al., 2005; Gibbons, 2004;Greenhalgh et al., 2004).

Macro-level process oriented studies have tended to view institutionalization in termsof stages, beginning with the destabilization of established practices and ending whennew practices are institutionalized. Particularly in the past decade, these process orientedstudies have highlighted the importance of theorization (Greenwood et al., 2002; Strangand Meyer, 1993). As set out by Strang and Meyer (1993) and later elaborated(Greenwood et al., 2002; Hinings et al., 2004), theorization is the development andspecification of abstract categories that serve to inform broad audiences and justify newpractices. Strang and Meyer (1993) suggested that the development of an elegant andmeaningful abstract categorization could provide the foundation for rapid communica-tion of a new concept that leads to adoption of an associated new practice. Greenwoodet al. (2002) proposed that new practices are first theorized, and then diffused to otherorganizations, resulting in the development of new practices across an organizationalfield.

In contrast to a focus on theorization, Scandinavian institutionalism has highlightedtranslation, co-construction, and editing activities as ways to understand the spread ofnew practices (Sahlin and Wedlin, 2008). Scholars from this perspective have shown howideas are adapted as an inherent component of organizational adoption; the ‘travel ofnew ideas’ involves a necessary translation of ideas for a particular context (Czarniawskaand Sevon, 2005; Zilber, 2006). Thus, the Scandinavian approach focuses on theimportance of local settings to understand how new ideas are adapted with a resultingchange in practice (Munir, 2005; Zilber, 2006). More recently, Scandinavian scholarshave introduced a sense of agency into the translation of ideas by highlighting exampleswhere actors influenced the way in which ideas were translated (Boxenbaum andBattilana, 2005; Boxenbaum and Strandgaard Pedersen, 2009). This work opens upattention to the process of translation, but maintains a focus on changing ideas as the keyto understanding change in practices.

We suggest that returning to the sociological roots of institutional theory (Berger andLuckmann, 1967) and a focus on habitualization holds promise in understanding theconnection between organizational level ideas and micro level practices. As pointed out

Transforming New Ideas into Practice 965


by Tolbert and Zucker (1996), the concept of habitualization is critical to the process ofinstitutional change but has received little attention in the institutional literature. Habitu-alization involves the repeating of actions which become cast into a pattern that becomesperpetuated and economizes effort (Berger and Luckmann, 1967, p. 53). Habitualizedactivity is the origin of institutions; however, in our current understanding of institution-alization, the emphasis on cognition has largely overshadowed the role of physical andbehavioural activity. As noted by Zucker (1983, p. 25), institutionalization has beenconceptualized as ‘fundamentally a cognitive process’. While Berger and Luckmann’s(1967) work also reflects the cognitive turn in social theory (DiMaggio and Powell, 1991),their emphasis on the importance of activity and habitualization distinguishes them fromother institutional approaches.

While neither the North American nor Scandinavian institutional literature haveexplicitly focused on the link between ideas adopted at the organizational level andfront line practice, there are a few studies pointing to the importance of transformingideas into practice and the potential relevance of habitualization. Zbaracki (1998), forexample, studied how managers generated ‘success related rhetoric’ to facilitate fieldlevel institutionalization of Total Quality Management (TQM), but noted significantdisparity between organization adoption of TQM and front line practice. Ansari et al.(2010) and Fiss et al. (2012) proposed that fit between the diffusing practice and theadopting organization can explain variation in practice. And Barley (1986) showedhow adoption of the same idea by two different organizations resulted in very differentpractices at the front line. All of these studies are consistent with the idea that insti-tutionalization of new practices is related to connections between the organizationaland micro-level, but although they draw attention to the actions of individuals, nonehave explored the potential role of behaviour and activity in explicating the process ofinstitutionalization.

Habitualization draws attention to the tight relationship between activity and meaningconstruction, and helps to conceptualize the way that meanings develop through theenactment of behaviour. As actions are repeated, they ‘retain their meaningful characterfor the individual although the meanings involved become embedded as routines inhis general stock of knowledge, taken for granted by him and at hand for his projectsin the future’ (Berger and Luckmann, 1967, p. 53). However, meaning-making atthe individual level can differ from that at the collective level (Love and Cebon, 2008;Weick, 1995). According to Berger and Luckmann (1967), collective meanings arebuilt up in the course of shared history and ongoing interactions. It is the emergenceof collective meanings from shared experience that is fundamental to the process ofinstitutionalization.

While there has been little attention to an activity based perspective on institutionali-zation, others have recognized the importance of a tight intertwinement between behav-iour and meaning. Weick (1995), for example, has long maintained that meaningsdevelop through the enactment of behaviour. Zilber (2002) provided empirical supportby showing how new leadership with different conceptualizations of work practices led tothe development of new meaning for the work of employees at a rape crisis centre. Inaddition, both Munir (2005) and Zilber (2006) argued that ongoing meaning-making iscritical to establishing new practices at the front line.

T. Reay et al.966


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Berger and Luckmann used the example of shipwrecked men stranded on a desertisland to explicate how habitualized behaviours developed over time can lead to thecreation of institutions. These men found themselves in a new context that was com-pletely divorced from their previously taken-for-granted activities of daily life, and theyhad no choice but to start over. However, most individuals work in a context wherethey are already engaged in a set of habitualized actions. If ideas accepted at theorganizational level are to be transformed into work practices, old practices must bede-habitualized before they can be replaced with new ones. Yet, institutions once formedhave a tendency to persist (Berger and Luckmann, 1967; Scott, 2008a). Consequently,re-habitualization may be a more difficult and complicated process than the one expe-rienced by the shipwrecked men.

As Scott (2008b) noted, the resilience of institutionalized practices is particularlyevident in professionalized settings since professionals themselves control the work ofthose around them to support the continuation of established patterns (Leicht andFennell, 2008). This is clearly illustrated in Currie et al.’s (2012) longitudinal study ofhow physicians managed to continue their established practices, in spite of agreeing tochange. Some studies have shown how professional practice can change, but in thosecases, it is because professionals themselves determined the rationale for change andengaged in bottom-up processes of legitimation and institutionalization that ultimatelyreconnected new practice at the front line with organizational or field level conceptu-alizations of that practice (e.g. Kellogg, 2009; Reay et al., 2006; Smets et al., 2012).While these studies suggest that meaning and activity are connected for front lineprofessionals, and show the resilience of established and habitualized behaviours, they donot address the need for de-habitualizing established practices and re-habitualizing newones.

In contrast, we develop an activity based process model that illuminates the criticalrole of disrupting previously habitualized behaviours in transforming ideas (once theyhave diffused or travelled from one organization to another) into practice. Our modelhighlights the tight connection between actions and meaning that is at the heart ofinstitutionalized practices (Zilber, 2002), and explicates the significance of habitualiza-tion in transforming ideas adopted at the organizational level into new day-to-day workpractices. In doing so, we showcase the important role of managerial action both inencouraging new behaviour and in facilitating the development of meanings that aretightly connected to practices.

RESEARCH SETTING

We followed four cases in the Canadian health care context where services are availableto residents free of charge through a publicly funded system. At the time of our study,health services were delivered through geographically determined Regional HealthAuthorities (RHAs). Our comparative cases were four different RHAs located in thesame province. RHAs were an amalgam of formerly separate hospitals, long-term carefacilities, community health centres, and other health units within geographically definedboundaries. Each RHA was under the authority of a government appointed executiveteam with responsibility for provision of all health services except physician visits.




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Physicians were remunerated directly by the provincial government and remainedindependent of the RHA although they interacted with many other service providersemployed by RHAs. As part of continual efforts to ‘do more with less’, leadership of allRHAs decided to adopt interdisciplinary teamwork (an approach believed to improveefficient use of health care providers), giving us comparable research settings where wecould observe the micro-level field dynamics involved in transforming an organizationallevel idea into practice.

Our study draws on findings from two separate programmes of research that eachoccurred over a five year time period. Within these two programmes, we had collectivelyinvestigated four cases concerning the attempted institutionalization of new work prac-tices designed to improve patient care. After following the process over six years, weobserved that in two cases interdisciplinary teamwork was widely reflected in workpractices while in the other two cases there was far more limited practice change. Below,we briefly describe each of the four cases (with pseudonyms for the RHAs). The keycharacteristics are summarized in Table I while the extent of practice change over timeis shown in Table II.

RHA1 (Interdisciplinary Team Including Nurse Practitioners)

Nurse practitioners (registered nurses with advanced education and experience who arelicensed to diagnose, prescribe, and treat ‘normal’ medical conditions) are a relativelynew profession in Canada. In the late 1990s, RHA1 employed a few nurse practitioners(NPs) on a trial basis. They were introduced as part of developing an interdisciplinaryteam approach to patient care. Prior to the introduction of the NP role, physicians werethe only health professionals with authority to diagnose, treat, and prescribe. In the oldway of working, registered nurses took orders from physicians and carried out thosedirectives. In the desired new teamwork approach, physicians and other health profes-sionals had to learn to allow NPs to diagnose medical conditions, prescribe appropriatemedications, or determine other treatments. All team members had to adopt newpractices as part of including NPs on the team.

This move towards a new interdisciplinary team was not easy. Senior RHA managerssupported the initiative, but did not take a strong role. The new practices were adoptedgradually (unit by unit) with the active involvement of mid-level managers who persist-ently took slow but steady action to remove barriers and encourage local trials. By 2005,there were 65 NPs employed as part of various teams throughout the RHA. Thatnumber increased to 70 NPs by 2006, and at that time, RHA informants told usthe NP position was in place on almost 100 per cent of units where it was consideredappropriate.

RHA2 (Interdisciplinary Team in Primary Health Care)

In 2000, senior management in RHA2 engaged with a physician clinic to change the wayof providing primary health care services by moving to an interdisciplinary teamapproach. This clinic was designated as a pilot project that would serve as an experi-mental site and foundation for future expansion. The underlying rationale for changing

T. Reay et al.968


Tab

leI.

Sum

mar

yof

case

s

RH

AIn

itiat

ive

Old

prac

tice

(aut

onom

ous

prof

essi

onal

s)N

ewpr

actic

e(i

nter

disc

iplin

ary

team

wor

k)St

atus

in2

00

6

RH

A1

Nur

sepr

actit

ione

rsin

trod

uced

–sh

iftto

inte

rdis

cipl

inar

yte

amap

proa

ch

Onl

yph

ysic

ians

diag

nose

,pre

scri

bean

dtr

eat

patie

nts.

Nur

ses

take

orde

rsfr

omph

ysic

ians

and

carr

you

tth

edi

rect

ives

.

NPs

adde

dto

heal

thca

rete

amto

diag

nose

,pre

scri

bean

dtr

eat

patie

nts.

Phys

icia

nsal

low

NPs

tota

kere

spon

sibi

lity

for

port

ions

ofpa

tient

care

.R

egis

tere

dN

urse

sre

allo

cate

wor

kto

inco

rpor

ate

NPs

.

Key

info

rman

tsre

port

that

99%

ofap

prop

riat

eun

itsha

vein

terd

isci

plin

ary

team

incl

udin

gN

Ppo

sitio

n.

RH

A2

Prim

ary

heal

thca

rere

form

–de

velo

pin

terd

isci

plin

ary

team

for

deliv

ery

ofpr

imar

yca

re

Aut

onom

ous

phys

icia

npr

actic

e.O

ther

heal

thpr

ofes

sion

als

insi

decl

inic

supp

ort

phys

icia

ns.

Hea

lthpr

ofes

sion

als

outs

ide

clin

icw

ork

sepa

rate

lyfr

omph

ysic

ians

(e.g

.wel

l-bab

ycl

inic

s;pu

blic

heal

thcl

inic

s).

Hea

lthpr

ofes

sion

als

wor

kin

colla

bora

tive,

inte

rdis

cipl

inar

yte

ams

that

incl

ude

phys

icia

ns.

Phys

icia

nsal

low

othe

rhe

alth

prof

essi

onal

sto

take

resp

onsi

bilit

yfo

rpa

tient

care

and

resp

ect

thei

rab

ility

tom

ake

deci

sion

s.

Gov

ernm

ent

reco

rds

indi

cate

that

99%

offa

mily

phys

icia

nsin

the

RH

Abo

unda

ries

are

part

icip

atin

gin

Prim

ary

Car

eN

etw

orks

base

don

inte

rdis

cipl

inar

yte

ams.

RH

A3

Prim

ary

heal

thca

rere

form

–de

velo

pin

terd

isci

plin

ary

team

for

deliv

ery

ofpr

imar

yca

re

Inde

pend

ent

phys

icia

nsw

orki

ngin

clin

ics

dist

inct

from

RH

A.

Aut

onom

ous

phys

icia

npr

actic

e.O

ther

heal

thpr

ofes

sion

als

wor

kse

para

tely

from

fam

ilyph

ysic

ians

(e.g

.pub

liche

alth

clin

ics).

Form

al,c

olla

bora

tive

rela

tions

hips

betw

een

phys

icia

nsan

dR

HA

.H

ealth

serv

ices

prov

ided

byin

terd

isci

plin

ary

team

s.Ph

ysic

ians

and

othe

rhe

alth

prof

essi

onal

sw

ork

toge

ther

inpr

ovis

ion

ofse

rvic

es.(

e.g.

hom

eca

repr

ovid

ers

com

mun

icat

ecl

osel

yw

ithde

sign

ated

phys

icia

n).

Gov

ernm

ent

reco

rds

indi

cate

that

25%

offa

mily

phys

icia

nsin

the

RH

Abo

unda

ries

are

part

icip

atin

gin

Prim

ary

Car

eN

etw

orks

base

don

inte

rdis

cipl

inar

yte

ams.

RH

A4

Lon

g-te

rmca

rere

form

–de

velo

pin

terd

isci

plin

ary,

clie

ntce

ntre

dte

amfo

rde

liver

yof

long

-ter

mca

re

Lon

g-te

rmca

rese

rvic

esse

para

ted

from

rest

ofhe

alth

/soc

ials

ervi

ces

syst

em.E

ach

prov

ider

deliv

ers

serv

ices

inde

pend

ently

.Se

rvic

em

odel

base

don

inst

itutio

nalc

are.

Hea

lthpr

ovid

erte

amw

orks

toge

ther

with

the

clie

nt(p

atie

nt)t

om

eet

‘un-

met

’nee

ds.

Clie

nts

dete

rmin

eth

ew

ayin

whi

chse

rvic

esar

eco

mbi

ned

and

prov

ided

.

Key

info

rman

tsre

port

that

inte

rdis

cipl

inar

ycl

ient

-cen

tred

team

sex

ist

inap

prox

imat

ely

10%

ofun

its.



practices was general dissatisfaction with physicians seeing large numbers of patients,and research evidence that patient care could be improved by integrating services andemploying interdisciplinary teams. The new desired practice required physicians andother professionals to change from autonomous physician roles to a team approachwhere multiple health care professionals provided appropriate services. For example, theold way of working associated with asthma care involved physicians diagnosing, pre-scribing, and modifying treatments through a series of office visits. The new teamworkapproach consisted of initial diagnosis by the physician during an office visit, but thenreferring the patient to the ‘asthma team’ where asthma experts (e.g. respiratory tech-nologist, nurse practitioner, registered nurse) provided education and developed a treat-ment plan (including medications). Modifications to the regime were managed by theteam.

After the designated three-year trial period was completed, physicians, other healthprofessionals, and RHA managers agreed to continue. Physicians reported their beliefthat patient care improved and other indicators supported this. By 2004, RHA2 man-agers began to search for ways to encourage the teamwork approach at other sites. Theyconnected this initiative with a newly developed government programme (primary carenetworks) and were able to quickly engage almost all family physicians working withinthe boundaries of the RHA. By 2006, approximately 99 per cent of family physicians inRHA2 joined primary care networks and therefore adopted the interdisciplinary teamapproach.

RHA3 (Interdisciplinary Team in Primary Health Care)

As part of ongoing improvement initiatives, the senior management of RHA3 set out toimprove primary health care (services delivered by family physicians and other commu-nity health providers) through the development of interdisciplinary teams. Senior man-agers took a prominent role in communicating this desired new practice by investingsignificant time and energy to explain the value and justify its importance. Early in theprocess, managers connected their efforts with a federal initiative to establish a smallnumber of local experiments based on interdisciplinary teams with redistributed respon-

Table II. Indicators of new practice prevalence (interdisciplinary teamwork)

2000 2001 2002 2003 2004 2005 2006

RHA1: % of appropriate units with NP as partof interdisciplinary teamwork

20 20 25 50 70 80 99

RHA2: % of physicians involved ininterdisciplinary team approach

0 8 8 15 20 30 99

RHA3: % of physicians involved ininterdisciplinary team approach

0 2 2 5 10 15 25

RHA4: % of continuing care sites followinginterdisciplinary team model

0 0 0 10 10 10 10

T. Reay et al.970


sibilities among health professionals. For example, one local experiment was designed toimprove home care services by bringing physicians together with a particular group ofhome care nurses, dieticians, and others who visited their patients. Instead of the old wayof working based on an autonomous physician–patient relationship in parallel with ahome care nursing group, the new way was based on an interdisciplinary team approachcentred on the patient and involving integrated service provision by physicians, nurses,and other health professionals.

Within these experimental sites, physicians and other professionals reported increasedsatisfaction with the new practices. However, in spite of efforts by RHA3 managers, therewas virtually no adoption outside the experimental sites. When the federal initiativeended after three years, the practices disappeared. In 2005, new leadership within RHA3refocused attention on the interdisciplinary team approach and linked it to a newprovincial initiative (primary care networks). RHA3 managers, physicians, and otherhealth professionals responded with verbal enthusiasm, and by 2006, 25 per cent offamily physicians working in RHA3 had adopted these new practices.

RHA4 (Interdisciplinary Team in Long-Term Care)

In the late 1990s, as part of provincial initiatives to improve long-term care for the elderlyand disabled, senior managers in RHA4 decided to introduce an interdisciplinary team(professionals and non-professionals) and a patient-centred approach to service delivery.In the old way of working, care was provided to disabled, infirm, or frail adults by a seriesof health care providers who were, at best, loosely connected with each other. RHA4managers developed an organizational plan to move away from the old practices, to thenew teamwork approach. For health care providers, this meant a shift in attitude andpractice. Instead of each caregiver determining what care was required, a team inconsultation with the patient would determine overall needs and develop a plan formeeting those needs. This required that providers work collaboratively to deliver appro-priate services and maintain as much independence as possible for their elderly clients.Managers decided to call this ‘meeting un-met needs’.

By 2006, in spite of focused managerial attention, there was only minimal adoption.Management had decided to integrate the new practices with the development of new‘assisted living’ facilities where seniors or the disabled could live relatively independentlyand receive health care services as needed. When the construction of these buildings wasdelayed, the established patterns of care continued, and the old ways of working per-sisted. By the end of our study, RHA4 documents showed that approximately 10 per centof seniors or disabled were cared for through the new team approach – and this wasbecause a manager at one of the smaller sites had gone ahead and developed a teamapproach in spite of the senior management strategy to wait until new buildings wereconstructed.

RESEARCH METHODS

In order to combine and compare data from the four cases described above, we drew ona multiple case study design (Eisenhardt, 1989; Stake, 1995, 2006). Since we were



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https://www.researchgate.net/publication/224952183_Building_Theory_From_Case_Study_Research?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==

interested in how ideas at the organizational level were transformed into practice, wefollowed a process approach within each case (Langley, 2007, 2008; Poole, 2004). Thelarge volume of data allowed both in- and across-case analysis since all four cases existedin a single health care system with common financial structures and governance mecha-nisms. Our research design included both a longitudinal dimension (investigating specificchanges over time) and a processual dimension (examination of concurrent changes asthey occur in real time) (Glick et al., 1990; Golden-Biddle et al., 2006; Langley, 1999;Pettigrew, 1985, 1990).

Our data for this paper come from three sources: open-ended interviews, meetingobservations, and archival materials. The primary data source is our observations of 396hours of meetings and 239 open-ended interviews, distributed across the four cases (seeTable III for the distribution). We also reviewed associated documents and other archi-val material. For example, each RHA produced annual reports and business plans whichwe read for background information about the overall context and to understand theemphasis given to each initiative. We interviewed knowledgeable health care profession-als, organizational leaders, or managers who were directly involved in the teamworkinitiative under study. Interviews ranged from 60 to 90 minutes in length, and wereconducted by members of the research team with support from graduate students andresearch associates. Interviews were recorded, transcribed, and formatted for analysis.Researchers also observed planning groups, steering committees, or task forces that hadbeen formed as part of the initiative. When attending meetings, we kept detailed notesconcerning the issues discussed, the exchange of ideas, and contextual information aboutthe meetings themselves. Our hand-written notes were transcribed into textual materialsand analysed in parallel with interview data.

Propelled by interesting similarities and differences occurring across the four cases,researchers met regularly over the first three years of research to discuss findings. Thesediscussions became more formalized and focused over time, leading to our collectiveobservations about how the adoption of new practices was unfolding over time. Allresearchers approached their projects from an interpretivist stance, and gathered datawith a view to understanding the process over time. Continuity across cases was facili-tated through the first author’s involvement in all four projects.

Raw data (interview transcripts and observational notes from meetings) were reviewedby all authors and entered into a qualitative analysis database (NVivo) to facilitate thedevelopment of preliminary codes and the grouping of data into meaningful categories

Table III. Data sources

Organization Interviews (1 to 1.5 hours) Meeting observations

RHA1 55 35 meetings (2 hours average length)RHA2 74 17 meetings (2 hours average length)RHA3 75 45 meetings (2.5 hours average length)RHA4 25 30 meetings (6 hours average length)Total 239 interviews 396 hours (approx.)

T. Reay et al.972


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(Miles and Huberman, 1994). This process relied on iterative phases of reading tran-scripts and the established literature, utilizing a constant comparative frame within agrounded theory approach (Glaser and Strauss, 1967; Locke, 2003). We saw variety inboth the speed and extent to which organizational level ideas about interdisciplinaryteams were transformed into new practices, and further analysis suggested that mana-gerial work played an important role. This micro-level approach to data analysis even-tually led to the development of our process model. In the next section we present ourdata and analyses.

TRANSFORMING NEW IDEAS INTO PRACTICE

We wanted to understand how professionals adopted new practices in response toorganization-level ideas about the advantages of engaging in interdisciplinary teamwork.As we analysed our data from the four cases over time, we began to see that whilemacro-level theorizing was important in spreading the idea and rationale for the newpractices, the transformation of ideas into practice was accomplished through concertedefforts of managers. In the cases where widespread practice changes occurred, managersengaged with professionals at the frontline in an iterative and dynamic series of actionsthat enabled meaning-making associated with actually trying the new practices. In thosesame sites, managers also facilitated the development of collective meaning by solidifyingand standardizing the new ways of accomplishing work.

Below we present our findings organized by phases of managerial actions we observedas critical in the transformation of new ideas into practice: (1) Micro-Level Theorizing,(2) Encouraging ‘Trying It’, and (3) Facilitating Collective Meaning-Making. Consistentwith established models of institutional change, and to close the circle, we looked forevidence that the new practices were becoming taken-for-granted. In two of our fourcases (RHA1 and RHA2), interviewees consistently told us about managerial actionstaken across these phases. They also provided descriptions of behaviours that indicatedthe new practices were becoming taken-for-granted. In RHA3 we heard primarily aboutMicro-Level Theorizing, but in the later years of our study, we began to hear more abouthow managers encouraged individuals to try the new practice, and some indications thatthey were also facilitating collective meaning-making. In RHA4, where the practiceswere adopted only minimally, we heard only about theorizing activities, except for onesite where a mid-level manager seemed to push ahead somewhat independently of therest of the management team. In this one small site we saw a similar pattern of micro-level theorizing, encouragement to try new practice, and facilitation of collectivemeaning-making, but it was evident only on this very small scale (approximately 10 percent of expected new practices).

Although 2005 is the last year in which we collected interview and meeting obser-vational data, we continued to follow the adoption of new practices until 2006 byreviewing documents such as RHA annual reports and other government publications.In explaining our findings below, we incorporate a small number of representativequotations and other data into the text. In Table IV, we include additional examplesfrom our dataset.



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Table IV. Additional examples of data

1. Micro-level theorizingRHA1 Framing and justifying

• It [introducing the NP role] is part of a philosophy of care change. The whole unit is changing howthey provide care so we’re going to a primary health care model. This means that we are focusing onimproving patient care overall, and part of that is the introduction of the NP.

• The Advanced Nursing Task Force is established to develop the definition of advanced practice rolesfor nurses in the RHA; the creation of position descriptions for nurse practitioners and clinical nursespecialists, as well as advocate for the full and appropriate utilization for these roles within health careteams. (Terms of Reference for ANP Task Force, 2001)

Proselytizing• So, I’ve done a lot in terms of community education and developing ideas about interdisciplinary

health care teams and dialoguing with physicians and advocating for change within the system.RHA2 Framing and justifying

• There’s a lot of facets to health care . . . And it’s when you buy into the paradigm, you buy into thebelief that . . . people are very complex, and health issues or people issues are very complex andmulti-faceted . . . And we need to buy into the belief that those kinds of issues . . . are better dealt withby a number of people, by the combined resources of multiple people.

• The overall mission is to provide better health service and standards of care by changing therelationship between the providers. It’s to offer better service through integration as opposed to betterservice through added dollars.

Proselytizing• I encourage story-telling. Every time I hear a health provider tell a story about how working as a team

provided better care for patients, they’re role modelling. They are inspiring. They are energizingeverybody to keep working in that direction.

RHA3 Framing and justifying• We began by looking at different ways in which we could align all of the disparate elements around a

common vision and purpose. One of the recommendations was that we focus on primary health care,with primary care providers in partnership.

• The steering committee continued to look at what working groups could best oversee the initiative.The committee was composed of a broad range of health professionals and managers who were wellplaced to coordinate efforts and keep things on track.

Proselytizing• I am going to be part of spreading the message myself. Most of the people on the Steering committee

are going to be at all the orientation sessions, talking about the new model, trying to give them anidea of what it’s about, why it’s a good idea.

RHA4 Framing and justifying• We want to develop a new way of providing long-term care that improves access for people because

they won’t have to fight their way through the system anymore. There will be a model that will allowthem to access services easily. And we can determine which services are most appropriate for whichpeople through a team approach.

Proselytizing• We keep talking about the philosophy, explaining it to staff and others, and saying that we need the

housing environment where it will be conducive to putting the philosophy into action.

2. Encouraging ‘trying it’RHA1 Co-locating professionals in interdisciplinary work arrangements

• We had to get the NPs out on different teams and get them trying it. And as the other team memberssaw the clinical credibility and competence, they started to be ok with it. They needed to make sureNPs could do the skills, and they had to figure out how it would all work.

Highlighting non-financial incentives• We used the inherent incentives to get the NP position started. They [physicians] were looking at the

benefit for themselves. And the benefit for themselves was they would have a person who couldfunction essentially at the level of a resident or a fellow, who could participate in night call and casemanagement.

• Once physicians see how the NP can complement their care, or when you shorten their assessmenttime, or their social time so that they can focus on medical issues, they like the interdisciplinary teammore and more.

T. Reay et al.974


Table IV. Continued

RHA2 Co-locating professionals in interdisciplinary work arrangements• Providers told us that co-location makes all the difference in the world. We knew that the people who

had to change their practice the most were the physicians. So we asked them, ‘What would help youchange your practice?’ And they did identify that despite the frustrations, they were better able tochange when they were co-located with other professionals. It made it a lot easier for them to involveother professionals in treating the patient.

• We’ve . . . brought people together working in the same environment . . . What we’ve done is we’vebrought the public health nurses over to the clinic to do the well-baby visits and immunizations. So thatwe’re more in close proximity, so that we can rub shoulders with one another and communicate betterthat way and be more available to one another.

Highlighting non-financial incentives• One of our goals was to improve physician work–life balance, so as physicians agreed to give up

particular work tasks, they wanted to be reminded that this gave them more time to spend with theirfamilies.

RHA3 Co-locating professionals in interdisciplinary work arrangements• [quote from the final year of our study] We did have a change in direction for the primary health care steering

committee. They decided that the previous approach wasn’t quite right, and they shifted to a clearlyphysician-led approach. The whole idea changed to focus on getting physicians to participate – whetherthey fully believed in the initiative or not – and they even set goals about getting 50% of physiciansinvolved within the next year. By getting the physicians involved, we thought we could get otherprofessionals on-side too.

RHA4 [intentions to broadly ‘try it’ did not materialize]• Our goal is to change the culture for continuing care through the construction of environments that are

appropriate and conducive to a client-centred, team based approach. But all of this is on hold.• Our philosophy is that we need to have multi-skilled team members who buy into the idea of ‘meeting

un-met need’. We keep talking about it, and we’re trying to train people, but until you can get them intothe right environment – it just doesn’t work.

3. Facilitating collective meaning-makingRHA1 Creating occasions for reflection and discussion

• (notes from taskforce meeting) Discussion regarding future initiatives required of the taskforce:Manager 1: Is it the taskforce’s responsibility to do education and discussion sessions throughout the

region?Chair: Yes, we do need to plan for that.Manager 2: We need to set up forums that bring together NPs, physicians and others. It will help everyone

to talk about the work that’s being done – give them an opportunity.Chair: OK, who’s going to organize this?Introducing system-level structures• (notes from taskforce meeting) Discussion continues to revolve around what the key components of the job

description should be.NP1: Well, we just can’t use the same job description in NICU as they do in geriatrics. Our work is just

too different.Manager 1: I’m not so sure about that. We do it for all registered nurses. Why can’t we do it for NPs?NP1: I don’t see how it will work.NP2: I have an idea. Maybe [NP1] and I and some other NPs can get together and write down the parts

of our work that are similar, and then we’ll come back to the committee and talk about what we’ve got.At the next meeting, NP2 and NP1 had developed a substantial list and committee members used this to

get started with a common job description.• (notes from taskforce meeting) Discussion regarding performance evaluations of NPs:NP1: (regarding a new document) We should have guidelines that say particular programmes should have

particular numbers and levels of NPs depending on acuity of patients.Chair: I agree that we should have benchmarking – in the future.NP2: We have the evaluation tool now, and I think we need to match the evaluation criteria with [RHA1]

performance evaluation ratings.After further discussion, Committee agrees to go ahead with regional evaluation criteria.



(1) Micro-Level Theorizing

In all our cases, we observed that managers took on the responsibility of moving themacro-level theorizing of interdisciplinary teamwork to the micro (front line) levels. Toaccomplish this, they engaged in the following actions: framing and justifying (explainingand presenting the rationale for) interdisciplinary teamwork, and proselytizing (spread-ing the message) to all potentially important audiences. Below we describe and showexamples of each of these actions.

Framing and justifying. This phase of the institutionalization process was similar in all theRHAs we studied. Our interviewees told us about their efforts to carefully frame the

Table IV. Continued

RHA2 Creating occasions for reflection and discussion• It’s hard for people to go through the internal process of challenging their own beliefs in terms of their

practice patterns. Ultimately each provider has to change his or her thought processes, and change whatthey have at the forefront of their minds when they’re dealing with a client. It’s a slow process for peopleto change their own thought patterns . . . but we are now seeing that change

• We find that once they actually do work together, then it makes all the difference in the world, and thenthe trust level goes up. Then I typically try to just bring people together for very short meetings –sometimes just 10 minutes, and then they take it from there.

Developing new system-level structures• There’s a whole other level we’re working on now – getting a regional level diabetes educator team. It’s

successful because we had a regional manager [use our team] as an opportunity to learn, and then roll itout in other places in the region.

• Based on the experiences of the people in the first site, it made it easier to change our view [at the RHAlevel] to a patient perspective – looking at the whole person, and looking at the whole system. Thatallowed us to support some visioning that was happening at the RHA level towards team developmentand a new programme that is called building healthy lifestyles. This allows for a common access pointand a common point of triage.

RHA3 Creating occasions for reflection and discussion• There was a concern that we were taking up too much of doctors’ time by engaging in team building

activities, but I see that we need to take time so we understand each other and can collaborate on thatbasis.

RHA4 [within our timeframe, examples of facilitating collective meaning-making observed only in one site]Creating occasions for reflection and discussion• I see that we’re a really strong team. Our team leader is incredibly community based, and I think she

has moulded us in her image. [She’s done that] through lots of discussions and working with us. Whenyou’ve got that kind of cohesion –[it meant] we were set up well for the new approach.

Indicators that interdisciplinary teamwork had become taken-for-grantedRHA1 • We see that developing this job description with input from NPs themselves, has served as an important

foundation for moving the position into more locations. Now that we can explain it in words, and showit to people on paper, it seems like it’s pretty much set.

• We’re looking at it more broadly now. Instead of just getting NPs on the unit, we’re looking at how wecan impact services throughout the hospital. We’re trying to figure out what kind of things we couldstart to improve RHA-wide service delivery – not just on this particular unit, but in surgery, emergency– everywhere.

RHA2 • So now we learned that having doctors and team members located together is critical. That’s prettymuch set in stone, and we’ve incorporated that into our challenges in other communities. We decidedthat we needed to plan right from the start that doctors and other health professionals will be co-located.

• Some of the physicians have told me that the ability to work in a team environment has increased thecapacity of what they are able to get done. And my understanding is that they want to build on that.Now they just want to make some expansions to the (accepted) team approach.

RHA3 [No indicators by end of our study that multidisciplinary teamwork was becoming taken-for-granted]RHA4 [No indicators by end of our study that multidisciplinary teamwork was becoming taken-for-granted]

T. Reay et al.976


desired new practices in a manner that fit with the context and explained the desirabilityof adopting the new practice. Managers chose their words carefully to focus on thepositive factors. For example, in RHA2, managers focused on the overall value of aninterdisciplinary team approach.

The goal of our project is to change the way we’re doing things. We’re doing it toimprove our mode of delivery so that we can manage patients differently – so that notonly physicians are involved in the care, other health professionals can see them too.We really think this will allow us to provide better care and focus on prevention ofillness.

In RHA3, where the goal was also to develop a team approach to primary health care,managers developed and communicated a consistent message about the desired model ofcare. The following quotation illustrates this approach:

[The label] ‘Primary health care’ was very carefully chosen to be much more inclusiveof nurses and other health professionals as having a major role in a new kind of healthsystem – one that is not just physician focused. This is opposed to the term ‘Primarycare’ that is much more physician based – really just the services patients receivein their doctor’s office. We wanted to appeal to as many health professionals aspossible.

In RHA4, purposefully framing and justifying the new practice was also highly evident.In the first year of our study, we observed a full day meeting of the management teamwhere 20 senior managers critiqued and fine-tuned a communication campaigndesigned to raise awareness. The intention was to ensure that all employees, but par-ticularly those working in continuing care, knew about the significance and meaning of‘unmet need’ and the importance of adopting a team-based and client-centred approachto care of the elderly. The work was spread out to ten subcommittees that were eachcharged with further communicating how new practices should be guided by the prin-ciple of meeting ‘un-met need’. The goal was to have all health care personnel use thesame words to convince others of the value. The following exchanges took place at onemeeting of a committee.

Manager A: But what about meeting ‘un-met need’? Have we recognized the involve-ment of families in our model? How will the health team respond? What aboutadvocacy and choice?

Manager B: If we work under the case coordinated model, then those ideas will bethere.

Manager C: The logic model will provide connection between vision, mission andobjectives. Then later we can connect all those ideas.

In this exchange and throughout other committee meetings we observed a continualfocus on ‘meeting un-met need’ as a philosophy to guide the new team based approach.



Questions about specific actions to adopt the new practices were deferred until ‘after thevision is clearly developed’. Similar meetings occurred throughout our data collectionperiod (until 2005).

Proselytizing. In RHA1, managers invested significant amounts of time and energy toexplain the potential value of developing interdisciplinary teams that included nursepractitioners. They purposefully ‘talked with anyone who would listen’, constantlyrepeating the message that NPs held beneficial knowledge and skills that could improvepatient care provided by the team. For example,

[I found myself constantly trying to convince physicians and other staff.] You had togo through all the same points: What’s their [NP’s] education? What qualifies them todo the work? I had to run through all this with each and every nurse, and each andevery physician – over and over.

In RHA4 there were also extensive efforts to spread the word. For example, people inmanagement positions travelled throughout their geographic region tirelessly explainingthe message that developing these new practices would enable the delivery of moreeffective and appropriate care for the elderly.

Just last week, I went to community meetings in [three separate small towns]. Thatmeant driving about 1000 kilometers to explain this new model, answer questions andease concerns. I just have to keep repeating my message over and over. (ManagerRHA4)

Similarly, in RHA3, a manager reported,

I took it on as a personal responsibility and carried the message everywhere – fromhere to here to here . . . so that people could understand.

Overall, we saw that managers in all RHAs tried to move the macro-level theorizingassociated with the value of interdisciplinary teamwork to their own local contextsthrough discursive activities of framing and justifying the new desired practices. Thesemanagers commonly engaged in proselytizing, taking advantage of all possible oppor-tunities to tell people and hopefully convince them to support the teamwork approach.

(2) Encouraging ‘Trying It’

In RHA1 and RHA2, we observed an important shift as managers switched fromexplaining the value of the new practices, to encouraging professionals to actually trythem. We saw this shift occur later in RHA3, and only in one small site in RHA4. Welabelled this action as ‘encouraging trying it’ because we observed the persistent efforts ofmanagers to get professionals to try the new practice, without a long-term commitment.We identified two different ways that managers encouraged this: (1) co-locating profes-sionals, and (2) identifying non-financial incentives.

T. Reay et al.978


Co-locating professionals in interdisciplinary work arrangements. To encourage professionals totry working together in interdisciplinary teams, managers in RHA1 and RHA2 madechanges so that different professionals were co-located for at least part of their work time.For example in RHA1, managers decided that their best strategy was to focus on gettingan NP position approved (and filled) in a number of locations. They moved ahead withthis plan, thinking that the physical presence of an NP on a unit would help otherprofessionals experience what it would be like to work together with the NP. A managerexplained,

We need to get it rolling. Members of this committee [NP taskforce] will help to get theposition in sites throughout the RHA. Then people can try it [working as part of aninterdisciplinary team with the NP] and find out what it’s like to work with a nursepractitioner, and what it’s like to work on a team with an NP.

In RHA2, managers also focused on bringing professionals into close proximity to worktogether.

We’ve actually brought people together, so that they work in the same environment.What we’ve done is, we’ve brought the public health nurses over to the clinic to do thewell-baby visits and immunizations. We’re all in much closer proximity and we canrub shoulders with one another and communicate better. We’re much more availableto one another and that has been critical in developing a team approach to work.

Several managers told us that co-location of professionals was one of the most importantactions they took because proximity provided the opportunity for cross-professionaldiscussions and exchanges of ideas. However, they also assumed in their practice thatmerely situating offices close together was not enough.

Managers told us that they also had to show professionals how working together couldpotentially decrease individual work load and maintain (or even increase) quality of care.These actions fall into the category that we identified as non-financial incentives forpractice change.

Highlighting non-financial incentives. In all the cases we followed, managers held no controlover financial rewards. Reimbursement for professionals was established at a provinciallevel (as outlined above). Yet, we noted that in RHA1 and RHA2, and in RHA3 to someextent, managers drew particular attention to non-financial incentives that could encour-age physicians (in particular) to try working in an interdisciplinary team. These non-financial incentives were based on time-saving or improvements to quality of workingconditions, and were part of the enticement package that managers used to generatetrials. The following examples show how these arguments were made:

I try to show physicians that the role of the NP is really important. Once they can seehow NPs complement their care, how they can shorten their assessment time, and howthat will give them more time for the complicated medical decisions they need to make– they see the value, and they want more. (RHA1)



We encourage a team approach where other health professionals see patients. And so,physicians can spend more time with people that really need to see them – the oneswith complicated problems . . . We’re also hoping that it will free up physician time tospend with their families. Hopefully all of these things will influence them to partici-pate. (RHA2)

In concert with trying interdisciplinary teamwork, professionals began to modify theirpreconceptions and develop their own meanings of the new practices. Consistent withWeick’s (1995) approach to sensemaking, it was through performing the new actions anddiscussing them with others that individual meaning-making occurred. For example,prior to trying interdisciplinary teamwork, many physicians had been somewhat worriedabout the implications for their own sense of personal accomplishment and professionalresponsibility.

I worried that I was going to lose touch with my patients and what was going on intheir lives. And I had some concerns about that. You know, I wasn’t able to see [otherprofessionals’] roles. I had to actually experience it to realize that no – it’s not acomplete take-away of my responsibilities. I had to experience [the interdisciplinaryteamwork] in order to realize what the other roles are, and to understand the detailsof exactly what this means. (Physician, RHA2)

It was only later that we saw managers in RHA3 switch from proselytizing to encour-aging trials of interdisciplinary teamwork. Originally, they attached their efforts to anexternally funded initiative, thus giving up much of their ability to manage the process.Although the new practices were incorporated into a few special sites, they did not spreadto other locations. When the time-limited trials came to an end, the new practicesdisappeared. After a hiatus of about a year, new leadership took over with an explicitfocus on ‘getting people to try it’ – and we witnessed the shift in focus that we had seenearlier in RHA1 and RHA2.

In RHA4, the management team decided to connect trying the new practices with theconstruction of new ‘assisted living’ facilities. However, managers were free to moveahead with interdisciplinary teamwork if they chose to, and we observed one mid-levelmanager who did not want to wait for new buildings and found ways to encourageinterdisciplinary teamwork at one site. While this success showed that interdisciplinaryteamwork did not depend upon the construction of new buildings, the major managerialthrust relied upon new buildings which were delayed. This was noted in the RHA annualreport (2003) indicating that the initiative was ‘on hold’ because of external decisionsabout construction.

To summarize, we saw that this phase of the process (encouraging trying it) involveda critical shift in managerial focus. When managers took action in terms of co-locatingprofessionals and drawing attention to potential incentives for engaging in interdiscipli-nary teamwork, they gently nudged health professionals to experience the new practiceand then reflect on their experiences. There were intermittent frustrations, but overall weobserved that the trials, together with the opportunity for discussion and reflection,allowed professionals to make new meanings regarding the nature of their work. As this

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occurred, there was a corresponding increase in the numbers of professionals beginningto adopt the new practices.

(3) Facilitating Collective Meaning-Making

As professionals tried the new practices and engaged iteratively in making their own newmeanings, there was the potential for so much variety in how work was accomplishedthat the overall organizational commonalities could be compromised. This was animportant consideration because in each RHA, the desired approach to teamwork wasmeant to be consistent throughout the hospitals, clinics, and other facilities in the region.Managers were cognizant of this potential variation, and took steps to develop collectivemeaning about the way interdisciplinary teamwork should be conducted. We observedtwo ways they did this: (1) by creating cross-disciplinary and cross-site opportunities forgroup discussion and reflection; and (2) by introducing organizational structures such asreporting mechanisms and standards that reshaped the practices to fit with the originalmacro-level concept.

Creating occasions for collective reflection and discussion. Managers in RHA1 and RHA2 told ushow they took special steps to create space for professionals to meet and discuss the waysthey were working in interdisciplinary teams. In RHA2, although there had been timesof scepticism, physicians developed an understanding for the value of the new practicesand what they meant in terms of their own work. Managers set up opportunities for themto engage in further conversations with their colleagues and other professionals outsidetheir own clinic, and with senior managers; thus they began to further adapt thenew practices, bringing practices at different sites more into alignment. The followingquote shows how a manager told us about the value of facilitating cross-professiondiscussions.

I made sure to bring different professionals together regularly. Through these meet-ings they are telling us that co-location makes all the difference in the world. They saythat it facilitates shared planning, electronic information systems, and referral pat-terns. They say they now see that co-location is what makes the difference in terms ofbuilding trust between the providers, and supporting a change in practice. . . . It’s thesharing of thoughts in these ways that is allowing us to make co-location a requirementfor all future sites. (RHA2 manager)

Similarly, in RHA1 managers told us how they set up opportunities for talking –sometimes it was hallway conversations, other times it was during team meetings.

We could see that physicians were anxious that they would be responsible for otherprofessionals’ decisions – they didn’t understand the relationship with NPs. When theytried it, and we encouraged them to talk about it – they started to relax, realize whatit was like – and then they started telling other people.



Introducing new organizational structures. We saw that managers brought in new standards orstructures, or sometimes connected the new practices with established structures as a wayto promote similarity of practices across the RHA. For example,

We needed standards across the RHA, so we developed a few criteria based on ‘bestpractice’ – and then made those requirements. (RHA2)

It is the team approach that we were hoping to see. And I think they’re still workingthrough how they’re going to get that done. But we now have some better ideas abouthow to incorporate clinical practice guidelines, and how to let each unit develop theirown flavor while still maintaining best quality of care as an outcome. (RHA1)

In RHA1, managers engaged with professionals as part of the regular meetings. Inattending a meeting in 2005, we observed managers attempting to standardize thepractices of interdisciplinary teams through the development of an NP job description.The taskforce made significant modifications to the NP job description (and generalmodel of an NP) based on the collective experiences of localized NPs. This processcontinued over several months with the final job description reflecting the adaptationsthat had occurred through iterative cycles of trying new practices, developing newmeanings, and adapting the new practices for specific contexts. The challenge was tothen create a single job description for NPs working in relatively diverse sites. Forexample, some worked in emergency departments, others worked in paediatrics, andothers in geriatrics. After considerable discussion, managers focused on a generalizedmeaning of the role that they were able to capture in the main section of the jobdescription, with supplemental segments of the document pertinent to particular settings.This generalized job description for NPs drew on the need to fit with established HRsystems in RHA1, and it provided a framework that reduced variety in interdisciplinaryteamwork across the RHA.

We see that by facilitating collective meaning-making across professions and acrosssites, managers were able to gradually reshape the new practices to better fit with theoriginal macro-level theorization that drove the desirability of interdisciplinary team-work. This generally occurred after trying the new practices, but there was also overlapand iteration between the phases. Overall, we see that these efforts were important interms of achieving objectives to improve quality of care, and meet standards for improve-ment at the RHA level.

Indicators that the new practice of interdisciplinary teamwork has become taken-for-granted. In bothRHA1 and RHA2 we observed indications that the new practices were becomingtaken-for-granted. Interviewees told us that, in RHA1 for example, it seemed impossibleto imagine going back to the old ways without an NP as part of the interdisciplinaryteam. Newly graduated nurse practitioners told us that they moved relatively easily intoestablished health care teams; they and their colleagues knew what an NP was, and howa team including an NP should function. These more recently graduated NPs experi-enced little of the previous struggles and misunderstandings associated with the firstintroductions of the NP. Overall, data from meetings and interviews suggested that

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practices and meanings associated with the NP role had become established and the roleitself was largely taken-for-granted. But the continuing experiences of interdisciplinaryteams also helped to fine-tune the (no longer new) practices. For example, at a taskforcemeeting in 2005, the following comment was made:

Manager: As we are developing the performance evaluation tool [to determine valueof the NP position within the team], it’s really exciting that we’re getting lots of inputfrom nurse practitioners themselves. They want to be part of determining the way thatthey should be evaluated, and they are the people who really know what’s going on.It’s this kind of information that helps us to get it right.

By early 2007, success was declared and the taskforce was disbanded, ‘having accom-plished the committee’s objectives’ of overseeing the integration of NPs throughout theRHA and advocating for their full and appropriate utilization in interdisciplinary teams.

Similarly in RHA2, professionals developed strong collective meanings that supportedinterdisciplinary teamwork. Many of our interviewees suggested that the new practiceshad ‘turned into the new norm’. The following quotation provides further illustration.

When the first project ended, our physicians had the opportunity to go back to the oldways. But they didn’t. They chose to keep working in the new way, and I see that asa very important indicator that this model is sustainable.

To conclude, we observed indications that the new practice was becoming taken-for-granted at an organizational level in RHA1 and RHA2. But in RHA3, where approxi-mately 25 per cent of family physicians had adopted interdisciplinary teamwork, it wasless clear whether the new practice was becoming taken-for-granted. And in RHA4,interdisciplinary teamwork was adopted in only one small site (10 per cent of expectedlocations), showing the very localized nature of the new practice at the end of our study.

DEVELOPING A CONCEPTUAL MODEL

Based on our findings and in light of the extant literature, we developed a conceptualmodel of how new ideas are transformed into practice (see Figure 1). Our inductivemodel is grounded in the view that both macro and micro level processes are critical andinterdependent, and thus need to be connected for new practices to be successfullyinstitutionalized. By looking across our four cases, we were able to better understand howthe work of managers can facilitate this process. Thus our model shows three intertwinedbut relatively consecutive phases: (1) micro-level theorizing of new practices, (2) encour-aging ‘trying it’, and (3) facilitating collective meaning-making.

In all our cases, we saw that managers took on an important role in connecting themacro-level theorization of interdisciplinary teamwork to the micro-level of front-lineprofessionals. This process that we call micro-theorizing is similar to translation effortsidentified by Zilber (2006), where higher level meanings are continually refined andmodified as they are moved to lower levels. Although Zilber (2006) was studying nationaland organizational levels, we similarly observed efforts to translate the teamwork idea




from the organizational level to the front line so that it fit with a specific context.Managers interpreted the idea of interdisciplinary teamwork from the macro to themicro level though framing and justifying the new practices in relation to local circum-stances. They also engaged in proselytizing behaviours to convince front line profession-als that the new practices were valuable and appropriate. These activities appear to bea necessary first step to the de-habitualization of established practices and stronglyresemble the discursive work of managers in encouraging change (Rouleau and Balogun,2011).

In most of the sites we noted that following a period of micro-level theorizing,managers focused their efforts on encouraging professionals to actually try the newpractice (behaviour change). This shift in attention (from theorizing to trying it) seemedto be a critical step in facilitating interdisciplinary teamwork. As shown in Figure 1,we identified examples of two ways that managers encouraged people to try thenew practices: by co-locating professionals, and by drawing attention to non-financialincentives.

By focusing on the activity of interdisciplinary teamwork, we see that managersrecognized the resilience of habitualized behaviours (Berger and Luckmann, 1967) andattempted the critical task of de-habitualizing established behaviours associated withautonomous professional practice. By actively encouraging professionals to try the team-work approach, managers were helping them to follow through with what they agreedwas a good idea (teamwork) by performing the new activity, at least on a trial basis. Wesuggest that this focus on engaging in new behaviour achieved three important purposes.First, it interrupted the cycle of self-perpetuating autonomous professional practice in away that micro level theorizing alone could not. Second, consistent with Berger andLuckmann (1967), individuals developed their own new meaning of the new practice as

Theorizing:-Framing & Justifying-Proselytizing

Macro-View

Micro-View

INSTITUTIONALIZING NEW PRACTICES

Macro-level Theorization

Encouraging trying thenew practices & makingnew meanings:-Co-locating professionals-Highlighting non-financial incentives

Facilitating CollectiveMeaning-Making:-Creating occasions for reflection & discussion-Introducing new organizational structures

Micro-level Theorizing

Encouraging “Trying It”

Facilitating Collective Meaning-Making

New PracticesBecome Taken-for-Granted

Old PracticesAre Taken-for-Granted

PHASES →

Macro-level Theorization

De-habitualization & Re-habitualization

Figure 1. Transforming ideas into new practices

T. Reay et al.984



they tried doing it. And finally, trying the new practice may have served to re-create thechange initiative as one that was designed by professionals themselves, thus mimicking aprocess of bottom-up institutional change initiated by professionals (e.g. Reay et al.,2006; Smets et al., 2012).

After professionals tried the new practices and engaged in individual level processes ofmeaning-making, we saw that managers again shifted their attention to facilitatingcollective meaning-making. Managers were faced with a situation where professionalsenacted the new practices in somewhat different ways, consistent with established theo-ries of sensemaking (Weick, 1995). This posed problems for the overall initiative becausemanagers saw importance for a high degree of consistency across sites to meet organi-zational standards and support the normal back and forth movement of healthprofessionals from one site to another. To facilitate the development of collectivemeaning-making that underpinned the reshaping of the new practices, we observed thatmanagers created opportunities for open and engaged discussions, and introduced neworganizational structures, such as reporting mechanisms and policy statements. Collec-tive meaning-making was critical to reconnecting the new micro-level practices back intothe larger organizational context. The reshaping of practices enabled relinking with thesenior level management, enabling the development of organizational changes (e.g.restructuring) that began to establish the new practices at a more macro level. We seethat this is consistent with Berger and Luckmann’s (1967) conceptualization of habitu-alization, where repeated activities among a group of individuals become institutional-ized through ongoing interactions. What differentiates our findings is that Berger andLuckmann viewed these interactions as driven by the individuals themselves, but in ourcases, managers facilitated interactions to develop collective meanings and potentiallyinstitutionalize the new practices.

To summarize, we propose that managers attempted to transform new organizationalideas into new practices at the front line through: (1) micro-level theorizing, (2) encour-aging ‘trying it’, and (3) facilitating collective meaning-making. Although we have chosento use a linear presentation, we view the progress from one phase to another as iterative,incorporating the understanding that the transformation of ideas into practice caninvolve many sideways or even backwards steps. We do not propose that movementthrough these phases is inevitable, nor do we suggest a particular duration for any onephase. For example, in RHA3 we saw a very lengthy period of theorizing and then atransition to ‘trying it’. In RHA4, we saw continued attention on theorizing throughoutthe years of our study. We characterize the other two cases (RHA1 and RHA2) as havingmoved through all phases with early indications of institutionalizing the new practices.However, RHA1 seemed to move more quickly through the process than RHA2. Thus,our conceptualization is based on the importance of enacting each phase over time,recognizing that the time to engage in each may be highly variable.

CONCLUSIONS

We wanted to understand how ideas adopted at the organizational level are transformedinto practice at the front line. We found that managers played a critical role by micro-level theorizing, encouraging people at the front line to try the new practice and




facilitating meaning-making. Then, after new practices were tried in ways leading tolocalized modifications, managers took action to facilitate the development of collectivemeanings so that the new practices became commonly understood and more similarthroughout the organization and the health system more broadly. Our conceptual model(Figure 1) gives attention to micro and macro levels of the institutionalization process andalso shows the actions of managers in each of the different phases within the process. Weconceptualize these phases as tightly interconnected with many iterative steps involved.In addition, as our data shows, these phases do not inevitably unfold. The overall processcan be delayed or stalled at any point in time.

Our study makes three main contributions to the literature. First, by taking a micro-level perspective, we contribute to the literature on institutionalization of new practicesby developing a conceptual model that is focused on a previously understudied process– how ideas are transformed into new practices. Our study stands in contrast to the priorliterature that focused on either the macro level diffusion of new ideas (Greenwood et al.,2002; Strang and Meyer, 1993; Westphal et al., 1997), or on how new ideas are modifiedas they travel (Czarniawska and Sevon, 2005; Sahlin and Wedlin, 2008; Zilber, 2006).Instead, we give specific attention to the importance of de-habitualizing andre-habitualizing behaviours (Berger and Luckmann, 1967); that is, how ideas adopted atthe organizational level can be turned into new practices at the front line. Our studyshows that even when a new idea is accepted at the organizational level, there is still morework to do before people take on and institutionalize new practices at the front line.Building on previous research (e.g. Zilber, 2002), we highlight the critical connectionbetween meaning and practice, showing that micro-level meanings of new practices aredeveloped individually and then refined as collective meanings are created. Attention tothis component of institutionalization is critical because ultimately, it is changes inday-to-day work that are required – not just the organizational adoption (or not) of theidea of a new practice. In short, it matters what goes on inside organizations (Ansariet al., 2010; Zbaracki, 1998) and our model helps to explicate these processes.

Second, we contribute to the literature by encouraging the revival of an activity-basedview of the institutionalization process by incorporating Berger and Luckmann’s (1967)concept of (re)habitualization. As we analysed our data, we were struck with the contrastbetween the emphasis our interviewees placed on encouraging particular actions and theheavily cognitive neo-institutional accounts of institutionalization. In this heavy relianceon cognition, the social constructivist approach has left behind the focus on physicalactivity and behaviour change that underpins ‘habitualization’ (Berger and Luckmann,1967). We observed that activity was a critical part of disrupting previously habitualizedbehaviours and taken for granted meanings. Professionals in our cases had to engage ina process of re-habitualizing (Berger and Luckmann, 1967), and concurrent meaning-making (Weick, 1995; Zilber, 2002), the accomplishment of which was reliant on actuallytrying the new practice (Stensaker et al., 2008). However, in contrast to Berger andLuckmann’s (1967) portrayal of the institutionalization process in which collectivemeaning emerges over time through interaction, we found that collective meaning couldalso be facilitated by others – in our case, managers. Managers took it upon themselvesto create opportunities for reflection and discussion which encouraged the developmentof collective meanings and shared practices. Consequently, rather than activity sponta-

T. Reay et al.986




https://www.researchgate.net/publication/200552321_Implementation_Activities_and_Organizational_Sensemaking?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==





neously resulting in collective meanings as Berger and Luckmann (1967) suggest, wefound that these meanings were facilitated by people not directly involved in the activity.

Finally, our study illuminates how new practices can be institutionalized in profes-sional contexts. The process we observed is in contrast to the current literature suggestingthat successful institutionalization of new practices occurs through a bottom-up processwhere professionals design the initiative themselves as opposed to a top-down transfor-mation of organizational level ideas into new practices (Smets et al., 2012). We suggestthat the ‘trying it’ phase of our model is critical. While managers encouraged the trials,the participation of professionals in ‘trying it’ may have served to re-create a situationwhere professionals themselves determine the need for practice change. Consequently,the top-down initiatives we observed may have contained similar dynamics to cases ofsuccessful bottom-up institutional change in professional contexts. When managers areable to encourage professionals to try new practices, and thus engage in quasi-independent meaning-making, the possibility of significant and sustainable changes inthe nature of work becomes more feasible.

We developed our process model through comparative case studies of attemptedpractice change in four health care settings. Similar to all qualitative research, our studyhas inherent limitations, such as questions about the degree to which our findings aregeneralizable or transferable to other settings (Pratt, 2008, 2009). However, as Pratt(2008) illustrated, the limitations associated with in-depth research in a small number oflocations can also be a strength. When researchers are engaged in deep (rather thanbroad) approaches, the knowledge gained may be particularly valuable in similar con-texts. A significant feature of all our cases is the professionalized nature of the workforce.In particular, the ability of professionals to self-determine standards of practice meansthat they necessarily play a strong role in how new organizational ideas are transformedinto practice.

Consequently, we expect our findings to be transferable (Miles and Huberman, 1994;Silverman and Marvasti, 2008), or hold particular relevance for understanding theinstitutionalization of new practices (including and beyond interdisciplinary teamwork)in other health care settings. Moreover, because our study shows how managers in suchsettings can be important players in this transformation, we suggest that our findings willlikely hold for managers in all types of highly professionalized workplaces. When man-agers are able to encourage professionals to try new practices, and thus engage inquasi-independent meaning-making, the possibility of significant and sustainablechanges in the nature of work becomes more feasible. We encourage future research toexamine whether and how the managerial role and processes of our model hold in otherprofessionalized settings such as accounting and law, as well as in organizations whereother strong stakeholders (e.g. airline pilots or other unions) significantly control practice.We also encourage future research that covers an even longer period of time than wewere able to study. Although six years of following these transformations was lengthyfrom a researcher perspective, further observations would improve our understanding ofthe long-term stability and consequences of such managerial actions.

Our study provides an example and points to the need for multi-level researchon institutionalization, such as recent work considering the organizational and fieldlevel perspective (Love and Cebon, 2008; Purdy and Gray, 2009). By focusing on the



https://www.researchgate.net/publication/4993098_Meanings_on_Multiple_Levels_The_Influence_of_Field-Level_and_Organizational-Level_Meaning_Systems_on_Diffusion?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==

https://www.researchgate.net/publication/234021830_Fitting_Oval_Pegs_Into_Round_Holes_Tensions_in_Evaluating_and_Publishing_Qualitative_Research_in_Top-Tier_North_American_Journals?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==

https://www.researchgate.net/publication/260089104_Conflicting_Logics_Mechanisms_of_Diffusion_and_Multilevel_Dynamics_in_Emerging_Institutional_Fields?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==

https://www.researchgate.net/publication/254256348_From_Practice_to_Field_A_Multilevel_Model_of_Practice-Driven_Institutional_Change?el=1_x_8&enrichId=rgreq-e20f7c43-4f6b-46db-ba47-4c07fbcd4046&enrichSource=Y292ZXJQYWdlOzI2ODIyMjExNDtBUzoxNjM0NDExOTMwMDUwNTZAMTQxNTk3ODgyNTcyMg==

micro-level behaviour of actors, we have been able to draw attention to the role ofmanagers and professionals at the front-line in connection with the organizational level.Ours is one of the few institutional studies that take account of micro-level action in lightof macro-level changes, thus helping to inform the broader literature on the institution-alization of new practices. Overall, we wanted to understand how new practices becomeaccepted, adopted, and eventually institutionalized in the workplace. Our findingssuggest that activity at the front line matters. It is important that managers engage withprofessionals at the front line as opposed to managing from afar. More attention tomicro-level front line work will help to bring more full and nuanced understandings ofactions and meanings at multiple levels of analysis.

There are also important managerial implications arising from our study. Our findingssuggest that efforts to institutionalize new practices should be focused on creating oppor-tunities for people to try them. Managers who restrict their actions to framing orjustifying the value of new practices are unlikely to achieve desired outcomes. Byengaging with individuals at the front line, managers are better placed to take clearactions that encourage professionals to at least try new practices. Our study also showsthat managers must sustain their attention to the ongoing process of transforming ideasinto practice. It is not a one-shot affair. When micro-level actors try out a new practice,they tend to modify the practice and concurrently develop their own meanings about thevalue and significance. Managers need to support this meaning-making but it is alsocritical to take further action that helps to reshape the new practices in ways that matchwith organizational requirements or values. We see that this connection between microand macro activities is critical to understanding both the practice and theory of institu-tionalization, and we hope that our work will contribute to improving knowledge in bothrespects.

ACKNOWLEDGMENTS

The authors thank the Canadian Health Services Research Foundation (CHSRF) and the Alberta HeritageFoundation for Medical Research (AHFMR) for funding that supported this research. We also thank JMSEditor, Allen Amason, and three anonymous reviewers for their helpful and constructive feedback through-out the review process. In addition, we thank Renate Meyer and April Wright for their insightful commentson earlier versions of this article.

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Transforming New Ideas into Practice: An Activity Based Perspective on the Institutionalization of Practices