The state of decentralization of the healthcare system and nutrition programs in the Lao People's Democratic Republic: an organizational study.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle income country, has a higher malnutrition rate than other Southeast Asian countries. The decentralization of healthcare is a determinant of the effectiveness of programs to reduce malnutrition, but no study has focused on this factor in this country. This organizational study explores the state of decentralization of the healthcare system in Lao PDR that underlies the nutrition programs in the country. METHODS: A qualitative study, which is based on a neo-institutional theory conceptual framework, explored factors related to dominant structure (laws, regulations, resources) and interpretative schemes (dominant ideas and beliefs) that characterize the nutrition services provided in the Lao healthcare system. Twenty-four semistructured interviews were performed with representatives of healthcare institutions involved in nutrition programs at different government levels, external donors and civil society organizations. The interviews were completed with relevant documents. The analysis focused on the convergence of interpretative schemes of the organizations concerned and the coherence between the structure underpinning the nutrition programs and the interpretative schemes. RESULTS: Services deployed to reduce malnutrition in the Lao PDR remain largely centralized, despite factors specific to the country that led it to promote decentralization of its services. The convergence of interpretive schemes and the coherence between the observed structure and the interpretative schemes of actors at all governance levels ensure the stability of this state of decentralization, which has persisted for almost 50 years. CONCLUSION: Nutrition programs in the Laos PDR are largely under the responsibility of the central government. The transformations in the healthcare system, notably with the use of new information technologies and the fact that the provinces are populated by a growing number of professionals trained in nutrition in addition to factors that push the system to be decentralized, such as ethnic diversity, the increasing availability of human resources in provinces, and the use of communication technologies, are not strong enough to change the balance of power between governance levels. The deconcentration that characterizes decentralization is therefore likely to continue for the foreseeable future.

Implementation of Circular Economy in a Developing Economy's Mining Industry Using Institutional Theory: The Case of Namibia.

Despite the global focus on sustainability, transitioning from linear to circular production systems is slow in the mining sector of most developing economies like Namibia. However, mining plays a crucial role in supporting the livelihoods of local communities. Furthermore, existing literature indicates that the potential for regenerative production systems using the remanufacture and recycle approach remains low and limited within the mining and developing economies. Institutional theory can help reveal the reasons for the slow take-up of the regenerative circular economy models in mining. This study uses a unique dataset of 40 semi-structured interviews with key players in the mining sector of Namibia to understand the current phase of circular economy adoption and the role played by institutional pressures in the process of institutional isomorphism, when companies would display a similar level of practices within a shared institutional environment. The findings reveal: (1) 72.5% of participants believe that Namibian mines are adoption-decision phase-a beginning stage of circular economy adoption; (2) companies are reliant on heavy government participation through policy/legislation and tax incentives is recommended; (3) the ranked order-coercive, normative, and mimetic pressures-describes their significance among key actors, for the successful adoption; and (4) proactive implementation and a mindset shift towards circularity is needed to meet emerging expectations on social and environmental concerns in mining.

Impact of country governance mechanisms on carbon emissions performance of multinational entities.

This study investigates the impact of country governance mechanisms on carbon emissions performance of private sector organisations, using empirical evidence from 336 top multinational entities (MNEs) over a 15-year period. The results show that, at the aggregate level, Control of Corruption (b = -0.021, p < 0.01) and Voice & Accountability (b = -0.015, p < 0.05) are significantly and negatively associated with carbon emissions rate. While Political Stability (b = 0.007, p < 0.05) and Government Effectiveness (b = 0.018, p < 0.05) have significant positive impact on carbon emissions rate, the impact of Regulatory Quality and Rule of Law is negative but insignificant. Empirical evidence supports the conclusion that the existing institutional environment is not sufficient to deliver the net zero transition. There is a need for more coordination, strategic planning, and delivery monitoring in government institutions to achieve decarbonisation targets. The study contributes to knowledge within the context of the identified research gaps. First, the study adds to the limited literature on the impact of country governance on carbon emissions reduction, particularly with reference to scope 3 emissions. Second, with the sustainable development goals (SDGs) set to expire by 2030, the study provides empirical evidence on efforts governments of countries are making in achieving decarbonisation targets through improvement in country governance quality. Third, the study shows that the impact of the country governance on the carbon emissions performance of MNEs is contextual and varies across jurisdictions/geographical regions. Finally, the paper contributes to the debate on the actualisation of Agenda 2030, because presenting empirical evidence on the impact of country governance mechanisms on carbon emissions reduction-particularly scope 3 emissions-is an important discourse in the realisation of the SDGs.

Revolutionizing energy practices: Unleashing the power of artificial intelligence in corporate energy transition.

Corporate energy transition is crucial for long-term sustainable development. The widely discussed Artificial Intelligence (AI), as a disruptive technological innovation, is highly potential for enhancing environment performance. However, the specific impact of AI on the process of corporate energy transition and its underlying mechanisms have not been fully explored. This study focuses on A-share listed corporates in Shanghai and Shenzhen stock markets in China spanning from 2011 to 2021. Based on corporate annual report information and information from over 200,000 patent application texts, we innovatively construct indicators for corporate energy transition and AI technology application. Furthermore, we empirically investigate the impact of AI technology on corporate energy transition and its potential mechanisms through combining information asymmetry theory and institutional theory. The empirical results indicate that: 1) AI can drive corporate energy transition and the promoting effect of AI collaborative innovation on corporate energy transition should not be ignored. 2) AI can help corporates achieve energy transition through pathways such as mitigating information asymmetry, reducing financing constraints, adjusting sustainable development concepts and practices. 3) The driving effect of AI on corporate energy transition varies depending on the characteristics of different types of corporates, industries, and regions. This study provides strategic guidance and decision support for business managers and policymakers, assisting both corporates and governments in better utilizing AI technology during the social energy transition process to achieve a dual optimization of environmental and economic goals.

What drives patients' acceptance of Digital Therapeutics? Establishing a new framework to measure the interplay between rational and institutional factors.

BACKGROUND: The rising incidence of chronic diseases among the population, further exacerbated by the phenomenon of aging, is a primary concern and a serious challenge for the healthcare systems worldwide. Among the wide realm of health digital technologies, the rise of Digital Therapeutics (DTx), which are medical devices able to deliver evidence-based treatments to manage and treat diseases, opens new opportunities. However, their diffusion and usage are still fragmented among countries. As the diffusion results from the adoption of technology from a social system and individual acceptance, this study aims to design and test a theoretical model that investigates the intention to use DTx, with a particular focus on the treatment of obesity, as a widespread and burdensome chronic condition. METHODS: This research is built on 336 answers coming from a survey to test the proposed model, which consists of a combination of organizational mechanisms, derived from Institutional Theory, and rational factors, derived from the Technology Acceptance Model (TAM). The survey has been delivered to patients and former patients of Istituto Auxologico Italiano, a hospital with several locations in northern Italy, recognized as a center of excellence for the treatment of obesity. RESULTS: The analyses of the answers, performed through the Structural Equation Modelling (SEM) technique, confirmed the influence of the Perceived Usefulness on Intention To Use, and of the Perceived Ease Of Use on the Perceived Usefulness, confirming the validity of the assumptions derived from the TAM. On the other hand, institutional factors were introduced as antecedents of the Perceived Usefulness, and the Perceived Ease Of Use. Results show that the Regulative Pillar influences both the TAM constructs, the Normative Pillar (peer influence) has a positive effect only on the Perceived Usefulness, and finally, the Cultural Pillar impacts the Perceived Ease Of Use. CONCLUSION: This study allows filling the knowledge gap regarding the usage of the Institutional as a means to predict individuals' intentions. Moreover, managerial contributions are available as the results have been operationalized into practical advice to managers and healthcare professionals to foster the adoption, and thus the diffusion, of Digital Therapeutics.

The introduction of a value-based reimbursement programme-Alignment and resistance among healthcare providers.

Reimbursement programmes are used to manage care through financial incentives. However, their effects are mixed and the programmes can motivate behaviour that goes against professional values. Value-based reimbursement programmes may better align professional values with financial incentives. The aim of this study is to analyse if and how healthcare providers adapt their practices to a value-based reimbursement programme that combines bundled payment with performance-based payment. Forty-one semi-structured interviews were conducted with representatives from healthcare providers within spine surgery in Sweden. Data were analysed using thematic analysis with an abductive approach and a conceptual framework based on neo-institutional theory. Healthcare providers were positive to the idea of a value-based reimbursement programme. However, during its introduction it became evident that some aspects were easier to adapt to than others. The bundled payment provided a more comprehensive picture of the patients' needs but to an increased administrative burden. Due to the financial impact of the bundled payment, healthcare providers tried to decrease the amount of post-discharge care. The performance-based payment was appreciated. However, the lack of financial impact and transparency in how the payment was calculated caused providers to neglect it. Healthcare providers adapted their practices to, but also resisted aspects of the value-based reimbursement programme. Resistance was mainly caused by lack of understanding of how to interpret and act on new information. Providers had to face unfamiliar situations, which they did not know how to handle. Better IT-facilitation and clearer definition of related care is needed to strengthen the value-based reimbursement programme among healthcare providers. A value-based reimbursement programme seems to better align professional values with financial incentives.

Institutional theory and circular economy business models: The case of the European Union and the role of consumption policies.

The circular economy (CE) has been gaining traction in recent years as it promises a change for good, in terms of environmental, social, and economic benefits. The major changes required to implement circular economy business models (CEBMs), can prove to be especially difficult for organisations. This study provides a holistic analysis of the effect of CE institutional policies on the development of CEBMs in organisations, by exploring not only production-oriented policies, which have been the focus of previous research, but also consumption policies. Consumption policies, in the form of regulatory and information policies, are oriented towards consumers and have the potential to affect the demand for CE products, which in turn affects the development of CEBMs in organisations. The paper is framed within the institutional theory and the context of the European Union. Our results reveal that consumption policies have a positive, albeit diminishing, effect on the CEBMs. Our paper finds that regulation is the most impactful policy, having a larger impact than production policies. Our results highlight the important role of institutional policies in fostering consumers' demand for CE products and of consumption policies as tools to be employed by governments in fostering CEBMs and achieving sustainability.

On the Role of Institutional Logics in Legitimacy Evaluations: The Effects of Pricing and CSR Signals on Organizational Legitimacy.

The relationship between institutional logics and organizational legitimacy remains largely unaddressed in organizational theory and management research. We explore how individual evaluators primed with a particular institutional logic react to organizational signals sent by a firm's product/service pricing and by its engagement in corporate social responsibility (CSR) activities. In three experimental studies, we identify how the activation of a market logic or a family logic in evaluators' minds moderates the effect of pricing and CSR engagement signals on their judgments of legitimacy of a firm, as well as on their behavioral intentions. An unexpected finding from our study was that, while participants primed with the family logic reacted positively to a CSR engagement signal sent by the firm but remained indifferent to a market-based premium-pricing signal, those primed with the market logic reacted positively to both premium-pricing and CSR engagement signals, suggesting that CSR engagement forms part of their understanding of the market logic.

A very British state capitalism: Variegation, political connections and bailouts during the COVID-19 crisis.

The COVID-19 pandemic has resulted in governments playing increasingly prominent roles as active economic agents. However, state capitalism does not necessarily serve broad developmental purposes, and rather can be directed to supporting sectional and private interests. As the literature on variegated capitalism alerts us, governments and other actors regularly devise fixes in response to a systemic crisis, but the focus, scale, and scope of the interventions vary considerably, according to the constellation of interests. Rapid progress with vaccines notwithstanding, the UK government's response to COVID-19 has been associated with much controversy, not only because of an extraordinarily high death rate, but also because of allegations of cronyism around the granting of government contracts and bailouts. We focus on the latter, investigating more closely who got bailed out. We find that badly affected sectors (e.g. hospitality, transportation) and larger employers were more likely to get bailouts. However, the latter also favored the politically influential and those who had run up debt profligately. Although, as with state capitalism, crony capitalism is most often associated with emerging markets, we conclude that the two have coalesced into a peculiarly British variety, but one that has some common features with other major liberal markets. This might suggest that the eco-systemic dominance of the latter is coming to an end, or, at the least, that this model is drifting towards one that assumes many of the features commonly associated with developing nations.

Different while being similar: The dual institutional process and differential organizational status.

Connecting the neoinstitutional theory with Bourdieu's field theory, we develop a framework on the dual institutional process of integration and differentiation in a field. While the neoinstitutional theory has focused on similar organizational structures, we shift the research focus to offer an institutional explanation of differential organizational status. Drawing insights from Bourdieu's theory and key concepts, we highlight that the very institutional mechanisms causing isomorphism-regulative forces, normative pressures, and cognitive processes-also generate systematic status differentiation among organizations via their different levels of capital, homologous structures, and various habitus in a field. Our extended framework has theoretical significance in advancing the neoinstitutional theory, the research of status in organizational and economic sociology, and the Bourdieusian perspective. By theorizing status differentiation among organizations, it also adds an important dimension to enrich our understanding of multilevel status and social hierarchies.

Exploring the effects of sudden institutional coercive pressure on digital transformation in colleges from teachers' perspective.

While past technology acceptance studies focus on organization readiness, little is known about the acceptance behavior under sudden institutional coercive pressure. Against COVID-19 and distance teaching, this study explores the relationship between digital transformation readiness, adoption intention, digital transformation success, and sudden institutional coercive pressure based on the readiness research model and institutional theory. Surveying 233 college teachers who participated in distance teaching under COVID-19 in Taiwan for model and hypothesis validation using the partial least square structural equation modeling (PLS-SEM) approach. This result shows that (1) Teacher, social/public, and content readiness are crucial to distance teaching. Individuals, organizational resources, and external stakeholders influence distance teaching success and adoption; and (2) Sudden institutional coercive pressure has a negative moderated effect on teachers' readiness and adoption intention. When teachers are unprepared to implement distance teaching, this unanticipated epidemic and sudden institutional coercive pressure will accelerate and enhance their intention. The study provides government, educational policymakers, and teachers with a better understanding of distance teaching during the COVID-19 pandemic.

Stuck between medals and participation: an institutional theory perspective on why sport federations struggle to reach Sport-for-All goals.

BACKGROUND: Sport-for-All emphasizes that every individual has the right to participate in sport. Despite all efforts to deliver Sport-for-All during the past decades, studies indicate that sport participation rates have been stagnating, whereas social inequalities in sport continue to exist. By applying an institutional theory lens, this study sheds light on how the dual mission of sport federations, i.e., providing Sport-for-All and high performance sport, affects the Sport-for-All projects of Flemish sport federations (e.g., amount of projects and target groups). In particular, Sport-for-All projects have to reduce barriers to engage in the sport system and be supported by a sport federation. Furthermore, this study seeks to better understand the impact of the underlying institutional logic on the institutional pressure and legitimacy of the sport federations. METHOD: This study implemented a cross-sectional field study in sport federations. In particular, the sport federations selected for our study are the 47 Flemish sport federations. Both qualitative (i.e., document analysis) and quantitative research methods (i.e., a new questionnaire was developed based on institutional theory) were applied in the study. RESULTS: Results indicated that sport federations are important partners in support of Sport-for-All projects, but also suggested that there is a discrepancy between the projects of the high performance-oriented and the Sport-for-All-oriented federations. Specifically, the high performance-oriented federations were targeting youth participants, whereas Sport-for-all-oriented federations aimed to reach disadvantaged groups. Furthermore, the results indicated that high performance-oriented federations endured more institutional pressure than Sport-for-All-oriented federations. CONCLUSION: The results of our study indicated that the Sport-for-All projects of performance-oriented federations are often more superficial compared to Sport-for-All oriented federations, and that the latter federations play an important role in attaining public health targets. Moreover, policymakers should consider how they can optimize the role of the performance-oriented federations in the Sport-for-All delivery (e.g., they could function as a bridge to guide participants who prefer a less competitive setting towards Sport-for-All oriented federations).

Organizational logics in time of crises: How physicians narrate the healthcare response to the Covid-19 pandemic in Swedish hospitals.

BACKGROUND: The COVID-19 pandemic has challenged healthcare organizations and puts focus on risk management in many ways. Both medical staff and leaders at various levels have been forced to find solutions to problems they had not previously encountered. This study aimed to explore how physicians in Sweden narrated the changes in organizational logic in response to the Covid-19 pandemic using neo-institutional theory and discursive psychology. In specific, we aimed to explore how physicians articulated their understanding of if and, in that case, how the organizational logic has changed during this crisis response. METHODS: The empirical material stems from interviews with 29 physicians in Sweden in the summer and autumn of 2020. They were asked to reflect on the organizational response to the pandemic focusing on leadership, support, working conditions, and patient care. RESULTS: The analysis revealed that the organizational logic in Swedish healthcare changed and that the physicians came in troubled positions as leaders. With management, workload, and risk repertoires, the physicians expressed that the organizational logic, to a large extent, was changed based on local contextual circumstances in the 21 self-governing regions. The organizational logic was being altered based upon how the two powerbases (physicians and managers) were interacting over time. CONCLUSIONS: Given that healthcare probably will deal with future unforeseen crises, it seems essential that healthcare leaders discuss what can be a sustainable organizational logic. There should be more explicit regulatory elements about who is responsible for what in similar situations. The normative elements have probably been stretched during the ongoing crisis, given that physicians have gained practical experience and that there is now also, at least some evidence-based knowledge about this particular pandemic. But the question is what knowledge they need in their education when it comes to dealing with new unknown risks.

Overcoming institutionalised barriers to digital health systems: an autoethnographic case study of the judicialization of a digital health tool.

BACKGROUND: The deployment of digital health systems may be impeded by barriers that are, or are linked to underlying enduring institutions. Attempting to challenge the barriers without addressing the underpinning institution may be ineffective. This study reflects on ways actors may surmount institutionalised barriers to the uptake of digital tools in health systems. METHODS: I applied Institutional theory concepts to an autoethnographic case study of efforts to introduce a digital tool to provide citizens with medicines information. RESULTS: The tool's uptake was impeded because of state regulators' institutionalised interpretation of pharmaceutical advertising laws, which rendered the tool illegal. I, along with allies beyond the health sector, successfully challenged the regulators' institutionalised interpretation of pharmaceutical advertising laws through various actions. These actions included: framing the tool as legal and constitutional, litigation, and redefining these concepts: 'advertising', 'health institution', and the role of regulatory bodies vis a vis innovation. CONCLUSION: After identifying a barrier as being institutionalised or linked to an institution, actors might challenge such barriers by engaging in institutional work; i.e. deliberate efforts to challenge the relevant institution (e.g. a law, norm or shared belief). Institutional work may require the actions of multiple actors within and beyond the health sector, including judicial actors. Such cross-sectoral alliances are efficacious because they provide institutional workers with a broader range of strategies, framings, concepts and forums with which to challenge institutionalised barriers. However, actors beyond the health system (e.g. the judiciary) must be inquisitive about the potential implications of the digital health interventions they champion. This case justifies recent calls for more deliberate explorations within global health scholarships and practice, of synergies between law and health.

Reviving health promotion in South Australia: The role of ideas, actors and institutional forces.

Globally health promotion has remained marginalized while biomedical health systems have maintained and even increased their dominance. During 2019-2021 we drew on the local and historical knowledge of actors from multiple sectors through semi-structured interviews and focus groups, to assess the implications of the withdrawal of the state from health promotion in a suburban region of South Australia. Institutional theory enabled in-depth analysis of the ideas, actors, and institutional forces at play in the institutional field, and how these elements come together to maintain the dominance of medicine. We found that the ideas, actors and institutional forces supporting health promotion in the study region have weakened and fragmented. This has happened as biomedicine has increased its dominance in the region's health system, mirroring international trends. The results point to a withdrawal of state and federal governments from health promotion, which has led to severe gaps in leadership and governance, and locally, to a decline in capacity and resources. The state health department reallocated resources to focus on individual behavioural change rather than more structural factors affecting health. While some activities aimed at the social determinants of health or community development strategies remained, these had minimal institutional support. The establishment of a state government wellbeing agency in 2020 prompted an exploration to determine whether the agency and the international wellbeing movement presents an opportunity for a revival of more comprehensive health promotion.

Health promotion has a rich history in South Australia. However, since government withdrew funding and institutional support, health promotion has become increasingly fragmented, unco-ordinated and targeted towards individual behaviour change activities. Analysis of the role of ideas, actors, and institutional forces, such as government policies, found that biomedical approaches to health and health care increasingly dominate the health system and health policy environment in the state and Australia wide. The establishment of a state government wellbeing agency in 2020 prompted optimism from participants that the government may once again take a leadership role in reviving health promotion and prevention strategies.

The European university alliances-an examination of organizational potentials and perils.

The European Union (EU) has repeatedly underlined the importance of higher education, research and innovation as drivers in the further development of Europe-economically, socially and culturally. One of the latest policy initiatives by the European Commission (EC) intended to promote this agenda is the European Universities Initiative (EUI) where alliances between universities across national borders are to identify new approaches for boosting European scientific cooperation. It might be argued that this development represents an attempt to find an organizational solution to the European policy ambitions in higher education, research and innovation. This article presents a framework for analysing European university alliances. Based on interviews with persons occupying key leadership and management roles in ten alliances, the article analyses the potential gains and perils alliances might face along four dimensions: their internal coordination, their ways of resolving conflicts, the commitment of member universities and the cultural characteristics of the alliances.

A Social Media Organizational Productivity Model: Insights From Public Health Professionals.

BACKGROUND: Many previous studies have explored socialization-oriented social media (SM), but their reach has been limited to the context of information exchange for common personal interests. This study focuses on work-oriented SM, which can enhance organizational networking and productivity levels in the context of public hospitals. OBJECTIVE: This study aims to provide a theoretical framework to explain how the use of SM can enhance the skills of health professionals and levels of organizational productivity in uncertain environments. METHODS: A total of 2 distinct forms of data collection techniques were combined: focus groups and semistructured interviews. Both were conducted with doctors and nurses in Saudi public sector hospitals. RESULTS: The findings reveal that the use of SM can create professional socialization at the level of the institution, and this can enhance skills, knowledge, decision making, and the overall level of organizational productivity. The increasing use of SM creates collaboration between health experts (particularly endocrinologists and pulmonologists in this case) who arrange video calls to share best practices in terms of medication, diet, and health care plans for patients with multiple diseases. Many of these patients are particularly vulnerable, given the wider context of the current global pandemic. CONCLUSIONS: This study culminates in the Social Media Organizational Productivity model, which provides insights into how SM has increased the accessibility of health professionals through the use of technology. Access to such professionals creates a patient-centric approach and a culture of shared communication for dealing with high-risk patients during the current global pandemic.

Understanding the reactions of government and gaming concessionaires on COVID-19 through the neo-institutional theory - The case of Macao.

This paper looks at how Macao, the world's most densely populated city, deals with the COVID-19 disease, with a focus on government interventions and responses of the gaming concessionaires who operate integrated resorts. Macao was selected as the case not only because of the background of the authors, but also because Macao has been cited in many media coverage as a "good practice" example when it comes to fighting against this COVID-19 pandemic situation. Since there are already ample of articles on the background, development timeline, and overall commentary, this paper adopts a mixed approach by combining supplementary secondary data on the COVID-19 timeline in Macao (focusing on government interventions that can affect the tourism and hospitality industry) and primary qualitative in-depth interviews with senior management personnel (holding positions of Director or above) from major integrated resorts in Macao to get insights on industry strategic responses and expectation on future. A total of seven interviews were conducted with senior management members of five integrated resorts in May 2020. Four areas of responses were identified. They are 1. Survival; 2. The New Business Norm; 3. Business Rebound Strategies and 4. Corporate Social Responsibility (CSR). The findings indicate a seemingly utopian scenario among the major integrated resorts and gaming concessionaires in Macao towards their compliance and autonomous actions. The mechanism of this utopian-like scenario is explained by adopting the neo-institutional theory.

Indirect Compellence and Institutional Change: U.S. Extraterritorial Law Enforcement and the Erosion of Swiss Banking Secrecy.

Based on an in-depth, qualitative case study about a conflict between governmental authorities from the United States and Switzerland over the regulation of Swiss banks, we introduce indirect compellence as a novel triadic and indirect mechanism through which coercion leads to institutional change. Hostage-taking being a prototypical example, indirect compellence is typified by a coercive actor who takes a third party hostage to gain influence over a targeted actor. In our case, it meant that U.S. authorities (coercers) compelled Swiss policy makers (targets) to erode the famed Swiss banking secrecy rules by threatening the targets to otherwise enforce U.S. law extraterritorially against Swiss banks and bankers (hostages). Our constructivist and target-centered perspective explains this type of coercive pressure in detail, and it also suggests that targeted policy makers judge and respond to it contingent on their political ideologies. Our study contributes to research on power and influence in institutional environments and to research on global business regulation and transnational governance. Most generally, it also expands scholarly understanding of triadic relationships. In contrast to Simmelian perspectives' focus on triads in which the third party is in a powerful brokerage position and frequently benefits as a tertius gaudens, our study suggests that the third party can also become a rather powerless tertius miserabilis who suffers rather than benefits from others' conflict.

A multilevel neo-institutional analysis of infection prevention and control in English hospitals: coerced safety culture change?

Despite committed policy, regulative and professional efforts on healthcare safety, little is known about how such macro-interventions permeate organisations and shape culture over time. Informed by neo-institutional theory, we examined how inter-organisational influences shaped safety practices and inter-subjective meanings following efforts for coerced culture change. We traced macro-influences from 2000 to 2015 in infection prevention and control (IPC). Safety perceptions and meanings were inductively analysed from 130 in-depth qualitative interviews with senior- and middle-level managers from 30 English hospitals. A total of 869 institutional interventions were identified; 69% had a regulative component. In this context of forced implementation of safety practices, staff experienced inherent tensions concerning the scope of safety, their ability to be open and prioritisation of external mandates over local need. These tensions stemmed from conflicts among three co-existing institutional logics prevalent in the NHS. In response to requests for change, staff flexibly drew from a repertoire of cognitive, material and symbolic resources within and outside their organisations. They crafted 'strategies of action', guided by a situated assessment of first-hand practice experiences complementing collective evaluations of interventions such as 'pragmatic', 'sensible' and also 'legitimate'. Macro-institutional forces exerted influence either directly on individuals or indirectly by enriching the organisational cultural repertoire.