A realist evaluation: how institutional entrepreneurs build adaptive not-for-profit healthcare organisations

Abstract

This thesis is a report of a theory-driven approach designed to evaluate the role of ‘institutional entrepreneurs’ in developing adaptive not-for-profit healthcare organisations.Thesis aim and objectives:The aim of this thesis was to seek the program theories that describe how, why and under what circumstances institutional entrepreneurs might build adaptive not-for-profit healthcare organisations; to examine the strategies they use, under which circumstances they are used, the projected outcomes of those strategies, and the underlying mechanisms driving adaptive change.Methods:This thesis is a realist evaluation, which involved two parts: (1) a rapid realist review to develop initial program theories, and (2) a realist evaluation of a case study to test and refine those theories. Part 1 was a rapid realist review of the relevant literature supplemented by six rounds of Delphi discussions with an Expert Reference Group (n=8) over a period of approximately 10 months. This was followed by Part 2, a realist evaluation case study of not-for-profit disability service providers in Queensland preparing for a large-scale mandated reform— the National Disability Insurance Scheme (NDIS). Data comprised of two rounds of realist, semi-structured interviews (n=39) and documentation review over a period of approximately 12 months.Findings:Eight program theories describing strategy-context-mechanism-outcome (SCMO) configurations were rigorously developed, tested and refined over the course of the study drawing on rich data. My contribution to the theory of institutional entrepreneurship and discourse of adaptive capacity is based on taking a forward-looking perspective. I provide strong evidence to demonstrate how the strategic work of institutional entrepreneurs before change can build adaptive organisations, thereby ensuring that organisations are ready to respond to disturbances in the field. The study’s final findings are presented under the themes of 1) Emergence, 2) Execution, and 3) Engagement, to show how such strategic work ensures that not-for-profits exhibit appropriate adaptive characteristics, including openness to change, learning, social networks, innovation, and collective leadership. Institutional entrepreneurs’ structural and content legitimacy are important, and can foster greater support and trust from staff towards new institutional logics and the legitimacy of change itself. Skilful rhetoric can overcome conditions of coercive pressure, institutionalised practices, and ongoing changes in the field by influencing individuals’ perceptions of adaptive change. The extent to which adaptive capacity penetrates into the culture of the organisation depends on the network of groups and individuals involved in its promotion.Conclusions:Addressing a need for greater adaptability in not-for-profit healthcare organisations, this thesis highlights the important role of institutional entrepreneurship to this area of inquiry. Practical implications can be drawn from the theoretical propositions uncovered in this thesis, regarding the use of strategies by institutional entrepreneurs wishing to prepare their organisations for ongoing change in the not-for-profit healthcare sector. The realist approach to inquiry has offered more useful focus areas for developing adaptive capacity, in that institutional entrepreneurs can make informed decisions based on the findings about what is likely to “work” in their unique situation. Organisational structure, historical factors, and the motivations and interactions of staff are factors that need to be taken into consideration in adaptive capacity building efforts.