Organization Science Volume 22 Issue 4 2011 (Doi 10.1287/orsc.1100.0574) Battilana, Julie - The Enabling Role of Social Position in Diverging From The Institutional Status Quo - Evidence From The UK

Organization Science
Vol. 22, No. 4, JulyAugust 2011, pp. 817834

issn 1047-7039 eissn 1526-5455 11 2204 0817
doi 10.1287/orsc.1100.0574
2011 INFORMS
The Enabling Role of Social Position in Diverging from

the Institutional Status Quo: Evidence from the
UK National Health Service
Julie Battilana
Organizational Behavior Unit, Harvard Business School, Boston, Massachusetts 02163, jbattilana@hbs.edu
his study examines the relationship between social position, both within the field and within the organization, and the
likelihood of individual actors initiating organizational changes that diverge from the institutional status quo. I explore
this relationship using data from 93 change projects conducted by clinical managers at the National Health Service in the
United Kingdom. The results show social position, both within the field and within the organization, influences actors
likelihood to initiate two types of organizational change that diverge from the institutional status quo, namely, (1) changes
that diverge from the institutionalized template of role division among organizations and (2) changes that diverge from the
institutionalized template of role division among professional groups in a field. The findings indicate that these two types
of divergent organizational change are likely to be undertaken by individual actors with different profiles in terms of social
position within the field and the organization.
Key words: divergent organizational change; social position; health-care reform

History: Published online in Articles in Advance September 30, 2010.
Introduction
in the 1980s some law firms implemented changes in

their human resources policies that diverged from the
institutionalized up or out system, according to which
lawyers moved up to the position of partner or out of the
firm after six or so years. The causes of such organizational changes, hereafter referred to as divergent organizational changes, are particularly intriguing because they
require actors to distance themselves from the institutional environment in which they are embedded so as to
break with the institutional status quo.
External shocks, such as social upheaval, technological disruption, competitive discontinuity, and regulatory changes, have been shown to play a key role in
enabling divergent organizational change (Thornton and
Ocasio 1999; Fligstein 1997, 2001; Greenwood et al.
2002; Child et al. 2007). All the actors affected by
such external shocks do not, however, initiate change
that diverges from the institutional status quo, which
suggests that other factors participate in the occurrence
of divergent organizational change. Research has highlighted the enabling role of an actors position in a field
(e.g., Hirsch 1986, Leblebici et al. 1991, Greenwood and
Suddaby 2006), which is a recognized area of institutional life (Bourdieu 1977, DiMaggio and Powell 1983).
Low-status actors, who are said to be at the periphery
of a field (Shils 1975), have been shown to be more
likely to initiate change that diverges from the institutional status quo. Being less privileged by the prevailing
institutions, actors who are at the periphery are more
likely to be willing to initiate divergent change. Because
Research on the causes of organizational change has

highlighted the role of internal and external factors in
explaining actors likelihood to initiate organizational
change (Pettigrew 1987). Scholarly work that examines
the internal causes of organizational change has found
that the characteristics of the individual actor, and those
of the organization, influence the likelihood that an actor
will initiate organizational change (see Van de Ven and
Poole 1995, Armenakis and Bedeian 1999, Greenwood
and Hinings 2006 for reviews). In turn, research on the
external causes of organizational change has emphasized
the role of an organizations environment in influencing actors likelihood to initiate organizational change
(e.g., Pfeffer and Salancik 1978, Huber 1984, Meyer
et al. 1990).
In the latter area of research, many studies have shown
that organizations embedded in the same environment
and subjected to the same institutional pressures tend to
adopt the same practices (for a review, see Heugens and
Lander 2009). In doing so, these studies have contributed
to explaining the causes of organizational changes that
are convergent with existing institutions, which are
defined as patterns of acting and organizing that have
become so taken for granted that actors perceive them
as natural (Douglas 1986). But organizational changes
do not always converge with existing institutions; they
sometimes diverge from them (Greenwood and Hinings
1996, DAunno et al. 2000, Amis et al. 2004). For
example, Sherer and Lee (2002) have documented how
817
Battilana: The Enabling Role of Social Position in Diverging from the Institutional Status Quo
818
of their peripheral position, these actors are, however,

likely not to have the power to effect divergent change,
which may deter them from initiating such a change
(Bandura 1986). Actors who are at the periphery of institutions in a field may thus be willing but not able to
initiate divergent organizational change (Greenwood and
Hinings 1996, Kellogg 2011).
In this paper, I argue that to address this issue, one
needs to understand the influence of individual actors
social position more fully by examining not only the
influence of their position in the field in which their
organization is embedded but also the influence of their
position within their organization. Indeed, their position
within the hierarchy of their organization may grant individual actors with the necessary authority and access
to resources that will enable them to initiate divergent
organizational change (Tushman and Romanelli 1985).
An important and still largely unanswered question that
must be addressed to identify the locus of divergent
organizational change is, thus, where are the individual
actors who are more likely to initiate divergent organizational change locatedboth in their organization and
in the field in which their organization is embedded?
I explore this question in the context of the UK
National Health Service (NHS), a state-funded healthcare system made up of more than 600 organizations.
I develop a model of how individual actors social position, both within the field of the NHS and within their
organization, influences their likelihood to initiate two
types of divergent organizational change: (1) changes
that diverge from the institutionalized template of role
division among organizations and (2) changes that
diverge from the institutionalized template of role division among professional groups in the NHS. I propose
that these two types of divergent organizational change
are likely to be initiated by individual actors with different profiles in terms of social position, both within the
field and within their organization.
I test these arguments using data from 93 change
projects conducted between 2003 and 2004 by 93 clinical managers in 80 different organizations within the
NHS. The results show that social position, both within
the field and within the organization, influences the likelihood that individual actors will initiate changes that
diverge to a greater extent from the institutional status quo and influences the type of divergent organizational change they are likely to undertake. These findings
indicate that different types of divergent organizational
change are likely to be undertaken by individual actors
with different profiles in terms of social position both
within the field and the organization.
The Field of the UK National

Health Service
In 2004, the NHS, the public, state-funded health-care
system established by the United Kingdom in 1948, had
Organization Science 22(4), pp. 817834, 2011 INFORMS
a budget of approximately 60 billion and employed

more than a million people. All UK residents have
access to NHS services, which are free at the point of
delivery. The NHS is a field (Bourdieu 1977, DiMaggio
and Powell 1983) within which organizations, professionals, patients, and governing bodies involved in
the common purpose of commissioning and providing
health-care services in the United Kingdom interact with
each other (Scott 1994).
Key Actors in the Field of the NHS
The two main categories of collective actors to which
individual actors belong in the NHS are professional
groups and organizations. The professional groups to
which those who deliver services belongphysicians
(including consultants who work in hospitals and general practitioners, or GPs, who work in general practices), nurses, allied health professionals,1 pharmacists,
health assistants, managers, and support staff (such as
porters and cleaners)are the most salient social groups
in the NHS (Ferlie et al. 2005). Health-care professionals, whether physicians, nurses, or allied health professionals, can fill a purely clinical position but might also
have both clinical and managerial responsibilities or only
managerial responsibilities. Those who fall into these
last two categories are said to be clinical managers.
According to the 2004 NHS Hospital and Community Health Service nonmedical workforce census
(Information Centre for Health and Social Care 2005),
the field of the NHS in 2003 and 2004 encompassed
more than 600 organizations that fell into three broad
categories: administrative organizations (7%), primary
care service provider organizations (49%), and secondary
care service provider organizations (44%). Administrative organizations are responsible for running the NHS at
the regional and/or national level. All NHS professionals
who provide primary care services, that is, services provided to patients at the time that they first report a health
problem, are managed by primary care trusts (PCTs),
local health organizations that serve large populations of
250,000 or more. General practices were required to join
PCTs when they were created in 1998. PCTs provide primary care services and commission secondary care services from hospitals. The NHS hospitals that provide secondary care services, that is, acute and specialist services
required to treat conditions that normally cannot be dealt
with by primary care providers, are managed by NHS
Trusts that closely monitor the quality of health care and
efficiency of budgets. Figure 1 identifies the key organizational and professional actors in the field of the NHS.
The Institutionalized Template for Organizing in the
NHS: The Model of Medical Professionalism
Consistent with other health-care systems throughout the
Western world (e.g., Scott et al. 2000, Kitchener 2002,
Reay and Hinings 2005), the relationships between the
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Figure 1
Key Organizational and Professional Actors of the NHS
National and regional administrative organizations
Primary care providers
Secondary care providers
Organizations
Primary care trusts (PCTs)
Organizations
Hospitals
Mental health services
Ambulance services
Professionals
Physicians (General practitioners (GPs))
Nurses
Allied health professionals (AHPs)
Managers
Staff
Professionals
Physicians (Consultants)
Nurses
Allied health professionals (AHPs)
Managers
Staff
Provision of all local health and care services
different categories of actors in the NHS have been governed by the model of medical professionalism for more
than five decades (Giaimo 2002). This template for organizing prescribes specific role divisions among professionals on the one hand and organizations on the other
hand. The model of role division among professional
groups is predicated on physician dominance over all
other categories of health-care professionals. Physicians
continue to be the key decision makers, controlling not
only delivery of services but also, in collaboration with
successive governments, the organization of the NHS
(for a review, see Harrison et al. 1992, pp. 3033). They
are powerful both collectively at the national level and
individually at the local level (Harrison et al. 1992),
with their power deriving from both the social legitimacy of their mission and their exclusive ability to apply
expert knowledge to particular cases (Freidson 1986;
Abbott 1988, pp. 99100). Physicians command deference from the general public as well as from most
other groups of health-care professionals. Nurses, for
example, are expected to act as physicians assistants,
and allied health professionals, termed medical auxiliaries when the NHS was created, are expected to act
on physicians instructions (Jones 1991). Managers not
only refrain from contradicting physicians but often act
in the capacity of diplomats to smooth internal conflicts in organizations and facilitate the physicians work
(Giaimo 2002).
The model of role division among organizations prescribed by medical professionalism places hospitals and
administrative organizations at the heart of the healthcare system (Peckham and Exworthy 2003). Hospitals often enjoy a monopoly position as providers of
secondary care services in their health communities
(Le Grand 1999), providing most of the health-care services and ultimately receiving most of the resources.
PCTs are supposed to serve as gatekeepers to the secondary care sector, but primary and secondary care organizations tend to operate in isolation (Peckham and
Exworthy 2003). PCTs are newer organizations that still
depend on hospitals for many aspects of care provision and on administrative organizations for budget allocation. The emphasis in patient care on treating acute
episodes of disease in the hospital setting rather than
providing follow-up and preventive care in the home
or community setting, which is under the responsibility
of primary care organizations, corresponds to an acute
episodic health system. Table 1 presents the model of
medical professionalism.
Setting the Stage for Change
Different governments have attempted to infuse the NHS
with new models for organizing that challenged the institutionalized model of medical professionalism. The set
of reforms implemented by Margaret Thatchers Conservative governments aimed to impose a new model of
quasi-market that prescribed that health-care services be
manager-driven rather than profession-led and that the
balance of power shift from the secondary to the primary care sector (Pettigrew et al. 1992, Klein 1998). In
turn, Tony Blairs Labour governments tried to infuse
the NHS with a new model of market managerialism
that promoted collaboration across professions and sectors (Le Grand 2002, Peckham and Exworthy 2003).
The objective of the public authorities was to effect a
shift from an acute episodic health-care system to a system that would provide continuing care by integrating
services and increasing cooperation among professional
groups.
820
Table 1
Model of Medical Professionalism
Role division among professionals

Professionals role
Rules of interaction among

professionals
Role division among organizations
Organizations role
Rules of interaction among

organizations
Physicians act as key decision makers in the clinical and

administrative domains
Nurses act as physicians assistants
Allied health professionals act as medical auxiliaries
Managers (administrators) act as diplomats facilitating the
work of physicians
Physicians hold authority over all other NHS professionals in
the clinical and in the administrative domains
Hospitals act as both commissioners and providers of
secondary care services
Administrative organizations are responsible for planning
and budget allocation
General practices act as gatekeepers to the secondary
care sector
Hospitals hold authority over most other NHS organizations
Although there persists a distinct dominance order that

finds physicians (Harrison et al. 1992, Ferlie et al. 2005)
and hospitals (Peckham and Exworthy 2003) operating
at the apex, suggesting that the NHS remains a relatively institutionalized field, the attempts that began in
the mid-1980s to challenge the model of medical professionalism have introduced heterogeneity to the NHS.
This heterogeneity has set the stage for change in the
NHS (Sewell 1992, Whittington 1992, Clemens and
Cook 1999, Lounsbury 2007). The practices respectively
associated with the models of quasi-market and market
managerialism emerged as alternatives to the practices
associated with the dominant model of medical professionalism. These alternative models, although they have
not yet been institutionalized, have thus introduced some
variance in practices in the field, thereby sowing the
seeds of change.
Social Position and Divergent

Organizational Change
In this study, I focus on two dimensions of individual
actors social position: their position within the field of
the NHS (i.e., center versus periphery), which is largely
determined by the status of the organization and professional group to which they belong (Shils 1975); and
their position within their organization, which is largely
dependent on their position in the organizational hierarchy. The social position of a nurse in charge of a ward
in an NHS hospital, for example, is determined by her
position both within the field of the NHS and within her
organization. Her position within the field of the NHS is
largely dependent on the status of both the organization
(i.e., hospital) and the professional group (i.e., professional group of nurses) to which she belongs, and her
position within her organization is largely dependent on

her position in the hospital hierarchy.
Below, I examine how social position both within the
field and within the organization influences individual
actors likelihood to initiate organizational changes that
diverge to a greater extent from the institutional status
quo. More specifically, I examine how individual actors
positions in the field and in their organization independently and jointly influence the likelihood that they
will initiate the types of divergent organizational change
identified earlierspecifically, changes that diverge to a
greater extent from the institutionalized model of role
division among organizations and changes that diverge
to a greater extent from the institutionalized model of
role division among professionals in the NHS.
Position in the Field
Fields are political arenas (Bourdieu 1977, Brint and
Karabel 1991). Because they imply differential access to
and control over key resources and decision processes
(Shils 1975, Bourdieu 1988, Hargrave and Van de Ven
2006), the institutionalized models of organizations and
professionals role division are a source of power for
the members of organizations and professional groups
who benefit from positive privileges but not for those
who incur negative privileges (Weber 1978, p. 305).
Status, the unearned ascription of actors social rank
(Washington and Zajac 2005), is an effective claim to
social esteem in terms of positive or negative privileges
(Weber 1978, p. 305). The institutionalized models of
organizations and professionals role division will thus
determine the status of the organizations and professional groups to which individual actors belong, which
in turn will influence the likelihood that they will diverge
from these models (Battilana 2006).
Organization Status. Research has shown that lowstatus organizations are more likely to introduce new practices that diverge from the existing institutions and highstatus organizations are more likely to mobilize resources
to maintain the status quo (e.g., Tushman and Anderson
1986, Leblebici et al. 1991, Kraatz and Zajac 1996,
Haveman and Rao 1997, DAunno et al. 2000). In most of
these studies, divergent organizational changes introduced
in low-status organizations diverged from the institutionalized model of role division among organizations. Although
organizations were the unit of analysis in the latter stream
of research, it is apparent that individual members of lowstatus organizations initiated these changes.
Within a given field, actors who belong to low-status
organizations are in a challenger position (Fligstein
1997, Hensmans 2003) relative to actors who belong to
high-status organizations. Maguire et al. (2004) found
that individual actors who belonged to organizations less
advantaged by the institutionalized model of role division among organizations were more likely to initiate
changes that diverged from that model. In the NHS,
individual actors who belong to PCTs, which are lowerstatus organizations compared with hospitals and administrative organizations, are in a challenger position compared with individual actors who belong to hospitals
or administrative organizations (Peckham and Exworthy
2003). Because PCTs, being less privileged by the institutionalized model of organizations role division, have
less to lose from social deviance, members of PCTs are
more likely to be willing to transform to a greater extent
the existing model of role division among organizations.
The pattern of value commitments (Greenwood and
Hinings 1996, p. 1036) in PCTsthat is, the extent to
which members of PCTs are committed to the prevailing
institutionsis also likely to facilitate the initiation of
changes that diverge to a greater extent from the institutionalized model of role division among organizations.
Other organization members are indeed likely to be less
committed than are actors who belong to higher-status
organizations to the institutionalized model of role division among organizations.
To initiate a change that diverges to a greater extent
from the institutionalized model of role division among
organizations, members of lower-status organizations
must believe that such change is possible within the field
in which they are embedded (Turner and Brown 1978,
Tajfel 1981, Tajfel and Turner 1986). In the NHS, within
which at least two alternative organizing models successively infused by public authorities prescribe models
of role division among organizations that differ from
the institutionalized model prescribed by medical professionalism, individual actors who belong to PCTs are
likely to believe that change is possible and therefore are
more likely to take action.
Hypothesis 1A (H1A). Within the NHS, individual
actors who belong to PCTs (i.e., lower-status organizations) are more likely than other individual actors
821
to initiate changes that diverge to a greater extent

organizations.
Professional Group Status. Actors who belong to
higher-status professional groups benefit from the prevailing model of role division among professionals,
which reinforces their dominance over actors who
belong to lower-status professional groups. In the NHS,
as in most other health-care systems, doctors are
accorded high status compared with other groups of
health-care professionals (Starr 1982, Harrison et al.
1992). Doctors are likely to defend their traditional privileges and autonomy, whereas nondoctors, who belong
to lower-status professional groups less favored by the
institutionalized model of role division among professionals, are less likely to be content with the status quo
(Starr 1982, Abbott 1988). Nondoctors, being in a challenger position (Fligstein 1997, Hensmans 2003) and
having less to lose from social deviance, are more likely
to be willing to transform to a greater extent the existing
model of role division among professionals.
To initiate a change that diverges to a greater extent from the institutionalized model of role division
among professionals, members of lower-status professional groups must believe that such change is possible
within the field in which they are embedded (Turner
and Brown 1978, Tajfel 1981, Tajfel and Turner 1986).
In the NHS, within which at least two alternative organizing models successively infused by public authorities
prescribe models of role division among professionals
that differ from the institutionalized model prescribed by
medical professionalism, nondoctors are likely to believe
that change is possible and therefore are more likely to
take action.
Hypothesis 1B (H1B). Within the NHS, individual
actors who are not doctors (i.e., lower-status professionals) are more likely than doctors to initiate changes
that diverge to a greater extent from the institutionalized
model of role division among professionals.
Position in the Organization
Initiating change is challenging, and initiating divergent organizational change is even more so because
it requires that organization members be convinced to
adopt practices that not only are new to them but also
to diverge from the institutional status quo in the field
(Battilana et al. 2009). Because actors low in the organizational hierarchy lack the necessary authority and
access to resources, it often falls to those higher up to
initiate divergent organizational change (Tushman and
Romanelli 1985). Top managers have been shown to
play a key role in initiating such change (e.g., Keck and
Tushman 1993, Miles 1997). Executives, for example,
were instrumental during the 1970s and 1980s in liberal arts colleges adoption of professional programs that
822
diverged from taken-for-granted practices (Kraatz and

Moore 2002).
As they get higher in the hierarchy of their organization, individual actors access to resources, and their
concomitant ability to initiate more divergent organizational change, increases. They can also leverage the
authority associated with higher hierarchical positions
to impose changes that diverge to a greater extent from
the norms for the field. Individual actors higher in their
organizational hierarchy are also more likely to have a
subjective sense of power; that is, they are more likely
to have a subjective experience of control over their
own and others resources together with a belief that
they are capable of influencing others and exerting control over their environment. Such a sense of power is
likely to increase the likelihood that they will take action
(Galinsky et al. 2003).
Although they have the ability to implement organizational change, top managers, evidence shows, are
not uniformly open-minded about it or about divergent
organizational change in particular (Miller and Friesen
1980, Hambrick et al. 1993). Although they are more
capable of initiating divergent organizational change, top
managers are not necessarily more likely to initiate it.
They might instead be inclined to preserve the institutional status quo to maintain their power and ensure their
continuing control within the organization (Pfeffer and
Salancik 1978, Pfeffer 1981). Within the NHS, however,
top managers, who like all NHS employees are civil servants, are supposed to manage their organizations following the guidelines of and meeting the quality requirements for care and the financial targets decided upon by
the government (Harrison and Wood 1999, Peckham and
Exworthy 2003). Their effectiveness as top managers is
thus partly assessed on the basis of their ability to align
their organizations with the health-care policy developed
by the government (Department of Health 2004).
In such a system, top managers are supposed to be the
local champions of health-care reform implementation.
In the late 1990s, the Labour government of Tony Blair
started implementing a reform aimed to increase collaboration both across organizations and professions (Klein
1998). To facilitate such collaborations, the government
launched a new program that aimed to empower nondoctors, thereby breaking with the institutionalized model of
role division among professionals (Department of Health
2000). It also aimed to develop a more integrated and
less centralized care system, thereby breaking with the
institutionalized model of role division among organizations. Because the top managers role in the NHS is to
make sure that their organization will hit the targets set
by the government (Department of Health 2000), they
thus have not only the necessary resources, authority,
and sense of power but also greater incentive to initiate
changes that diverge to a greater extent from the institutionalized models of role division among organizations
and professionals prescribed by medical professionalism.

actors higher in the hierarchy of their organization
are more likely than other individual actors to initiate
changes that diverge to a greater extent from the institutionalized model of role division among organizations.
actors higher in the hierarchy of their organization
changes that diverge to a greater extent from the institutionalized model of role division among professionals.
Joint Effect of Position in the Field and
in the Organization
Whereas thus far I have discussed their possible independent contributions to the initiation of divergent organizational change, position in the field and position in the
organizational hierarchy might also have a joint effect.
Actors who belong to lower-status organizations or professional groups, although likely to be willing to initiate changes that diverge to a greater extent from the
institutionalized models of role division among, respectively, organizations and professional groups in the NHS,
might lack access to the resources needed to initiate
such changes (Greenwood and Hinings 1996). Greater
authority, a sense of power, and increased access to
resources will enhance the perceived self-efficacy of
those who rise higher in the organizational hierarchy
(Bandura 1986). Being more confident in their ability
to implement a divergent organizational change when
they get higher in the hierarchy of their organization,
individual actors belonging to lower-status organizations
or professional groups who rise higher in their organizational hierarchy will be even more likely to initiate changes that diverge to a greater extent from the
institutionalized models of role division among organizations and professionals (Martorana et al. 2005). The
foregoing effect is likely to be stronger when individual
actors believe that divergent change is possible, which
increases the likelihood that they will take action (Turner
and Brown 1978, Tajfel 1981, Tajfel and Turner 1986).
This is likely the case for managers within the NHS,
given the existence of the competing models of professionals and organizations role division prescribed by
the models of quasi-market and market managerialism.
Accordingly, I expect that their position in the organizational hierarchy will positively moderate the relationship between individual actors position in the field and
the likelihood that they will initiate changes that diverge
to a greater extent from the institutionalized models
of role division among, respectively, organizations and
professionals.
actors who belong to PCTs (i.e., lower-status organizations) and are higher in the hierarchy of their organization are more likely than other individual actors
to initiate changes that diverge to a greater extent

organizations.
actors who are not doctors (i.e., lower-status professionals) and are higher in the hierarchy of their organization
changes that diverge to a greater extent from the institutionalized model of role division among professionals.
Method
Participants
The participants in the present study were 93 NHS
clinical managers (i.e., actors with both clinical and
managerial responsibilities) who had attended an executive education program entitled Clinical Strategists Programme, a two-week residential learning experience
conducted by a European business school. The first week
focused on improving participants effectiveness within
their immediate sphere of influence and leadership ability within clinical bureaucracies by developing individuals skills and awareness. Principles and practices of
effective organizational change were also featured in the
first weeks curriculum. The second week focused on
developing participants strategic change capabilities at
the levels of the organization and the community health
system. When applying for the program, applicants were
asked to provide a description of a change project they
would be required to begin to implement within their
organization after attending the second week of the program. Project implementation was a requirement of the
program. Participants were asked to refine these change
project descriptions to reflect any modifications after
three months of implementation.
The program, available to all clinical strategists within
the NHS, was advertised both online and in NHS
brochures. Participation was voluntary. All who applied
were selected. Although participation in the present
study was also voluntary, all 95 attendees agreed to
participate. The final sample of 93 observations, corresponding to 93 change projects, reflects the omission of
two participants for whom data were incomplete. Participants ranged in age from 34 to 56 years (average
age was 43) and included 71 women (76%) and 22 men
(24%). All had clinical backgrounds (24% were physicians; 28%, allied health professionals; and 48%, nurses)
as well as managerial responsibilities, with levels of
responsibility varying from mid- to top-level management. The participants also represented a variety of NHS
organizations (44% worked within PCTs; 45%, in hospitals or other secondary care organizations; and 11%,
in NHS administrative units).
Although program attendees undeniably had an interest in change, a number of factors alleviate empirical concerns related to potential sample selection bias.
823
First, in principle, such a bias ought to work against,

not in favor of, supporting the hypotheses. If managers
had attended this program with divergent organizational
change initiation in mind, there should be less, not more,
variation on the dependent variable (that is, the likelihood of initiating divergent organizational change). Second, and related, there is in fact significant variation on
the dependent variable, and the majority of the managers initiated non-divergent change projects. Third, that
there was no mention of divergent organizational change
in either the title of the executive program or its presentation alleviates the concern that participants might
have self-selected into the program based on their interest in such change. Finally, and indirectly, the sample
used in this study by and large appears to be representative of the NHS, which should further mitigate sample
selection concerns. The distributions reported above for
my sample76% women, 24% physicians, 48% nurses,
and 28% allied health professionalscompare remarkably well with the breakdown of the NHS workforce.
In 2003 and 2004, women represented approximately
74% of the NHS workforce; 21% of the NHS healthcare professionals were physicians, 54% were nurses,
and 25% were allied health professionals (Department
of Health 2006).
Data Collection
Data collection focused on the characteristics of the participants and their change projects. Data on the former were obtained from their curriculum vitae; data on
the latter were collected at two points in the design
and implementation of the change projects. I had access
to the descriptions of participants intended change
projects submitted prior to attending the program (at
the time they applied) as well as to the refined change
project descriptions that they had to write after three
months of implementation. Both sets of descriptions
were quite similar. Participants were assured that their
change project descriptions would remain confidential.
With the refined project descriptions in hand, I conducted one-on-one (1015 minutes) telephone interviews
with all participants as well as with members of their
organizations. These interviews enabled me to ascertain whether the participants had in fact initiated implementation of their change projects, which all had, and
whether the change being implemented corresponded to
the one described in their change project descriptions,
which all did. Although all of the participants I interviewed claimed that they had developed the idea for
their change project, their answers, of course, might have
been biased. For this reason, I acknowledge that some
amongst them, although they were the primary drivers of
the change, might not have been the ones who originated
the idea for the change. Nonetheless, I was able to confirm through the interviews I conducted with members
of their organizations that all of the participants were in
824
charge of initiating the implementation of their change

projects.
Dependent Variables
The primary dependent variable in this study is the
degree to which participants change projects diverged
from the institutionalized model of medical professionalism on two dimensions: the institutionalized division
of organizational roles, in which hospitals have traditionally dominated; and the institutionalized division of
professional roles, in which physicians have traditionally
dominated. Following Cliff et al. (2006), I developed a
questionnaire intended to create a rank-ordered categorical measure of the change projects degree of divergence
on each of these two dimensions, thereby constructing
two dependent variables.
Four items in the questionnaire (scale 1) captured the
degree to which change projects diverged from the institutionalized model of role division among professionals: (1) To what extent does the project aim to increase
nurses/allied health professionals/managers decisionmaking power in the clinical domain? (2) To what extent
does the project aim to increase nurses/allied health
professionals/managers decision-making power in the
administrative domain? (3) To what extent does the
project aim to decrease doctors decision-making power
in the clinical domain? (4) To what extent does the
project aim to decrease doctors decision-making power
in the administrative domain? Six items in the questionnaire (scale 2) assessed the degree to which change
projects diverged from the institutionalized model of role
division among organizations: (1) To what extent does
the project aim to increase the influence of the primary
care sector in the clinical domain? (2) To what extent
does the project aim to increase the influence of the primary care sector in the administrative domain? (3) To
what extent does the project aim to decrease the influence of the secondary care sector in the clinical domain?
(4) To what extent does the project aim to decrease the
influence of the secondary care sector in the administrative domain? (5) To what extent does the project
aim to improve cooperation across organizations (especially across primary, secondary, and social care organizations)? (6) To what extent does the project aim to
promote continuous care through integration of services?
Each of the 10 items in the questionnaire was assessed
using a three-point rank ordered scale that ranged from
1 (no extent) to 2 (some extent) to 3 (great extent).
I developed instructions for coding the change projects
using this 10-item questionnaire and, together with two
independent coders blind to the studys hypotheses,
coded the change project descriptions written by the participants after three months of project implementation.
These descriptions averaged three pages in length and
followed the same template: presentation of the project
goals, resources required to implement the project, people involved, key success factors, and measurement of
the outcomes. Interrater reliability, as assessed by the
kappa correlation coefficient, was 0.90, suggesting a
high degree of agreement among the three raters (Landis
and Koch 1977, Fleiss 1981). To resolve coding discrepancies, we noted passages in the change project descriptions deemed relevant to the codes and discussed them
until we reached consensus (Larsson 1993).
I ran a confirmatory factor analysis on the results of
the coding to assess the validity of scales 1 and 2. For
scale 1, which measured the degree of divergence of
the change projects from the institutionalized model of
role division among professionals, the confirmatory factor analysis had a goodness-of-fit index (GFI) of 0.98,
suggesting that a single factor represented this scale very
well. This scale also exhibited an acceptable reliability
value (Cronbachs alpha, 0.79). For scale 2, which measured the degree of divergence of the change projects
organizations, the GFI was 0.80, representing a lower fit
compared with scale 1.2 However, Cronbachs alpha for
the six-item scale was quite high (0.91), increasing my
confidence in using all six variables for scale 2. The low
level of correlation (0.106) between scales 1 and 2 suggests that they should be treated as two distinct dependent variables. All change projects were assigned a score
on each of the two scales ranging from 1 (no extent) to
3 (great extent) and corresponding to the average of the
items included in each scale.
Among the 93 change projects that I studied, a project
aimed at transferring stroke rehabilitation services such
as language retraining from a hospital-based unit to a
PCT (i.e., from the secondary to the primary care sector)
is an example of a project that diverges from the institutionalized model of role division among organizations
to a great extent. Prior to the change, people experiencing strokes were stabilized and rehabilitated in the
acute ward in the hospital, thus incurring long stays and
tying up resources more appropriate for the acute treatment phase. As a result of this organization, there were
insufficient beds to admit all stroke patients on the acute
ward because many beds were being used for patients
who were undergoing post-acute rehabilitation. The service transfer involved physical relocation of post-acute
patients to a unit operated by the PCT. The objective was
to maintain the acute unit in the hospital and develop a
specialist rehabilitation service in the primary care sector. Patients would be transferred to the rehabilitation
unit operated by the PCT once they were medically stable and ready for rehabilitation. This would ensure that
the acute unit would only deal with patients that were
really acute patients and that these patients would then
receive appropriate rehabilitation services for as long as
necessary in the PCT. This transfer of resources and
responsibility for the delivery of rehabilitation services
825
from the secondary to the primary care sector greatly

diverged from the institutionalized model of role division among organizations.
A project aimed at developing a day hospital for the
frail elderly that would involve both primary and secondary care service providers is an example of a project
in my sample that diverges from the institutionalized
model of role division among organizations to some
extent. The creation of this day hospital aimed to facilitate continued care, reduce hospital stay, and decrease
readmission for the elderly patients. This day hospital
was meant to serve individuals too ill to be cared for
at home but not sufficiently ill to justify full admission
to the hospital. Patients who checked into the hospitaloperated day unit for a few hours received services
from both primary and secondary care professionals.
Although primary care service providers were engaged
in the provision of services formerly provided only
by secondary care service providers, which involved
increased collaboration between primary and secondary
care service providers, the project diverged from the
institutionalized model of role division among organizations only to some extent because the new service was
still operated by the hospital.
A project aimed at transferring a ward that specialized
in the treatment of the elderly from a PCT to a hospital is an example of a project in my sample that does
not diverge from the institutionalized model of organizations role division. Prior to the change, both the PCT
and hospital provided services for the elderly, the bulk
of patients receiving care in the hospital setting. Transferring responsibility for all elderly care services to the
hospital reinforced the centralization of health-care services around the hospital. Far from diverging from the
institutionalized model of role division among organizations, it thus extended the institutionalized delivery
model, thereby reinforcing the hospitals dominance over
the PCT.
Projects aimed at developing nurse-led preadmission
clinics or nurse-led discharge, which transferred both
clinical tasks and decision-making authority from physicians to nurses, are examples of change projects in my
sample that diverge from the institutionalized model of
role division among professionals to a great extent. Traditionally, preadmission clinics were run by physicians
only, and discharge decisions were also made by physicians only. The implementation of nurse-led preadmission clinics involved nurses taking over responsibility
from specialist physicians to conduct the preoperative
assessment of patients. The implementation of nurse-led
discharge, on the other hand, involved nurses taking over
responsibility from specialist physicians for making the
final decision to discharge the patients after coordinating with the physicians and all the relevant services in
the hospital. In these projects, nurses expanded scope
of practice involved more responsibility, accountability, and risk for their clinical decisions. In contrast, the
physicians ceded control over some aspects of decision

making, thus freeing them to focus on more complex
patients and tasks.
A project aimed at delegating ultrasound examinations
from physicians to nurses, without expanding nurses
authority to participate in subsequent decisions regarding patients treatment, is an example of a project in
my sample that diverges from the institutionalized model
of role division among professionals to some extent.
Although this project aimed at enabling nurses to perform medical examinations they usually did not perform,
it diverged from the institutionalized model of role division among professionals only to some extent because
nurses gained no decision-making power in either the
clinical or administrative domain. Finally, a project
aimed at hiring an administrative assistant to implement
and manage a computerized appointment booking system in a general practice is an example of a project that
does not diverge from the institutionalized model of role
division among professionals. The addition of this assistant to the workforce did not change either the division
of labor or the balance of power between health-care
professionals within the general practice.
Although most of the divergent change projects in my
sample rated high on only one of the two dimensions,
a few (6%) rated high on both, having scores strictly
superior to 2 on both dimensions. An example of such
a project is the redesign of stroke services in a health
community that involved transferring the rehabilitation
unit from the secondary to the primary care sector and
transferring administrative and clinical decision-making
power for the unit from a doctor to a physiotherapist.
(Note that the results were robust to the exclusion of
these observations.)
Independent Variables
Organization Status. As the analysis of the field of the
NHS revealed, of the three types of organizations that
make up the NHS, PCTs were considered to be lowerstatus organizations compared with hospitals and administrative units (Peckham and Exworthy 2003). There
was no clear status hierarchy between the hospitals and
administrative organizations that collaboratively ran the
NHS (Peckham and Exworthy 2003). Accordingly, I
measured organization status with a dummy variable
coded 1 for PCTs (low-status organizations) and 0 for
hospitals and administrative organizations (high-status
organizations).
Professional Group Status. As the analysis of the field
of the NHS revealed, two professional group statuses
were represented: physicians, who were of higher status, and other health-care professionals (i.e., nurses and
allied health professionals), who were of lower status
(Harrison et al. 1992, Ferlie et al. 2005). Accordingly,
professional groups status was measured with a dummy
826
variable coded 1 for nondoctors (low-status professionals) and 0 for doctors (high-status professionals).
Hierarchical Position. I measured actors hierarchical
position by means of a rank-ordered categorical variable.
Positions ranged from middle to top-level managers,
ranked low to high as follows: 1 = deputy head/assistant
director, 2 = head of service, 3 = nonexecutive director,
and 4 = executive director with a seat on the organizations board. As a government-run set of organizations,
the NHS has standardized definitions and pay scales
for all positions, which ensured that participants roles,
responsibilities, and hierarchical positions were uniform
across organizational sites (Department of Health 2004).
Because the individuals in my sample occupied positions ranging from middle managers to top managers,
and none occupied lower positions in the organizational
hierarchy, I centered the hierarchical position variable
around its mean, thereby using the mean rather than
zero as a benchmark (Aiken and West 1991, Kam and
Franzese 2007).
Control Variables
Because clinical managers in my sample might have initiated divergent organizational changes for reasons other
than their social position within the field and the organization, in particular as a consequence of the extent
and diversity of their managerial experience, I controlled
for the impact of three career-specific variables: tenure
in management positions, tenure in the current formal
position, and level of interorganizational mobility.
Tenure in Management Positions. Tenure in management positions was measured straightforwardly as the
number of years spent in management positions. Management experience is likely to make an actor more
comfortable initiating change, especially divergent organizational change that breaks with practices widely
accepted and used not only within a given organization
but throughout a field (Huber et al. 1993). Actors with
longer tenure in management positions might be more
confident of their ability to initiate organizational change
that diverges to a greater extent from the institutional
status quo and therefore be more likely to do so.
Tenure in Current Position. Tenure in current position
was measured, again straightforwardly, as the number of
years spent in the current position. Actors who would
persuade other organizational members to abandon practices widely accepted and used not only in their organization but throughout the field must have legitimacy
in the eyes of those other organizational members. They
also need in-depth knowledge of their organization to
overcome the obstacles likely to be encountered during
the implementation of divergent organizational change.
Actors with longer tenure in their current position usually command greater legitimacy in the eyes of both
subordinates and superiors and tend to be highly knowledgeable about specificities of their organizations (Huber
et al. 1993). Longer tenure in their current position is

thus likely to be positively related to actors ability to
initiate organizational change that diverges to a greater
extent from the institutional status quo and therefore to
the likelihood that they will do so.
Interorganizational Mobility. I measured interorganizational mobility as the number of different NHS organizations in which actors had worked in the course of their
careers. Research suggests that degree of interorganizational mobility might be an important predictor of who
initiates divergent organizational change (Kraatz and
Moore 2002, Boxenbaum and Battilana 2005). Actors
with higher levels of interorganizational mobility, having
been exposed to greater numbers of different organizational contexts, are less likely to take for granted the
functioning of their current organization and more likely
to be aware of existing opportunities for action in their
field (Sewell 1992, Emirbayer and Mische 1998, Seo and
Creed 2002). In addition, actors with higher levels of
interorganizational mobility are likely to have more ties
to others in other organizations. These ties might function as conduits of knowledge about divergent organizational change initiatives happening in other organizations
and afford individual actors access to more resources,
thereby facilitating their own initiation of organizational
change that diverges to a greater extent from the institutional status quo.
Data Analysis
My dependent variables are categorical and rank
ordered, so I used ordered logit estimations in all models. But because a nontrivial number of my observations
(24 of 93) were clustered in the same organizations3
and hence might not be independent within groups,
baseline-ordered logit estimates might be biased. I therefore adjusted these estimations by clustering data with
repeated observations of organizations to obtain robust
variance estimates that adjust for within-cluster correlation (Williams 2000). I report heteroskedasticityadjusted (i.e., robust) standard errors for all models.
Results
I report below results associated with the two dependent
variables, the degree of divergence from the institutionalized model of role division among organizations and
the degree of divergence from the institutionalized model
of role division among professionals. Table 2 reports
means, standard deviations, and correlations. There are
in my data set no critically collinear variables, that is,
none greater than 0.8 in absolute value (Kennedy 2003).
Diverging from the Institutionalized Model of
Role Division Among Organizations
Table 3 reports results from three ordered logit regressions predicting actors likelihood to initiate a change
827
Table 2
Summary Statistics and Bivariate Correlations
Variables
Mean
[1] Degree of divergence from the

institutionalized model of
organizations role division
[2] Degree of divergence from the
institutionalized model of
professionals role division
[3] Low-status organization
[4] Low-status professional group
[5] Hierarchical position
[6] Tenure in management positions
[7] Tenure in current position
[8] Interorganizational mobility
Min
Max
[1]
10387 00520
10000
20833
10000
10449 00509
10000
20500
00106 10000
00441
00763
00000
110624
20677
40796
S.D.
[2]
00499 00000 10000 00313 00025

00427 00000 10000 00009 00169
10000 20022 00978 00020 00125
40917 20000 260000 00009 00237
20102 00000 110000 00142 00101
20577 10000 140000 00152 00046
[3]
[4]
[5]
[6]
[7]
[8]
10000
00117 10000
00046 00344 10000
00171 00542 00215 10000
00143 00037 00064 00032 10000
00014 00104 00331 00055 00137 10000
Note. N = 93.
that diverges to a greater extent from the institutionalized

model of role division among organizations. In column 1
are results from a model with only the control variables (tenure in management positions, tenure in current
position, and interorganizational mobility). Column 2
presents results from a model with control variables and
the main effect variables that correspond to the status of
the organization to which actors belong (PCTs, i.e., lowstatus organization) and their position in the hierarchy
of their organization (hierarchical position). In column 3
are the results from a model with control variables and
all the above-cited main effect variables plus the interaction term (organization status hierarchical position).
The contribution of one or more variables is assessed
with the likelihood ratio (LR) test, which compares the
Table 3
Ordered Logit Coefficients Predicting Likelihood of

Actors to Initiate a Change that Diverges to a Greater
Extent from the Institutionalized Model of
Organizations Role Division
Tenure in management
positions
Tenure in current
position
Interorganizational
mobility
Low-status organization
(1)
(2)
(3)
00007
4000365
00070
4000755
00134
4000655
00020
4000405
00046
4000765
00168
4000645
10155
4004475
00259
4001905
00019
4000405
00042
4000745
00169
4000635
10156
4004445
00301
4001805
Hierarchical position
Low-status organization
Log pseudolikelihood
Wald chi-squared
LR testa
00134
4004535
170080
6042
166002
17032
9057
165097
18011
9067
Note. N = 93; robust standard errors are in parentheses.

a
LR test is based on comparison with model (1).
Significant at 10%, significant at 5%, significant at 1%. Statistical significance is based on one-tailed tests for all independent
variables and interaction terms.
goodness of fit of a pair of nested models distinguished

by one or a set of variables (Bishop et al. 1975).
The results supported H1A, which states that individual actors who belong to PCTs are more likely than
other individual actors to initiate changes that diverge to
a greater extent from the institutionalized model of role
division among organizations (see column 2). Hypothesis 2A, which states that individual actors higher in
the hierarchy of their organization are more likely than
other individual actors to initiate changes that diverge
role division among organizations, was not supported.
Although the relationship between actors hierarchical
position and the likelihood that they will initiate changes
that diverge to a greater extent from the institutionalized
model of role division among organizations was significant, it was in the opposite direction to the one hypothesized (see column 2). Hypothesis 3A, which states that
individual actors who belong to PCTs and are higher
in the hierarchy of their organization are more likely
than other actors to initiate changes that diverge to a
division among organizations, was not supported either
(see column 3).
As for control variables, there was, as expected, a positive and significant relationship between interorganizational mobility and the likelihood that actors will initiate
change that diverges to a greater extent from the institutionalized model of role division among organizations.
Neither tenure in management positions nor tenure in
current position was significantly related to the likelihood that actors will initiate organizational change that
diverges to a greater extent from the institutionalized
model of role division among organizations.
Diverging from the Institutionalized Model of
Role Division Among Professionals
The columns in Table 4 correspond to the same models presented in Table 3, save that the dependent variable is the degree of divergence of change projects from
828
Table 4
Ordered Logit Coefficients Predicting Likelihood of

Actors to Initiate a Change that Diverges to a Greater
Extent from the Institutionalized Model of
Professionals Role Division
(1)
Tenure in management
positions
Tenure in current
position
Interorganizational
mobility
00083
4000325
00064
4000715
00043
4000625
Low-status professional
group
(2)
(3)
00079
4000395
00092
4000755
00026
4000765
00071
4000405
00118
4000845
00005
4000815
00739
4005505
00530
4002345
20083
4100665
20291
4101715
10871
4102235
Low-status professional
group
Log pseudolikelihood
Wald chi-squared
LR testa
145093
10008
143001
12073
5084
141056
19021
8074
Note. N = 93; robust standard errors are in parentheses.

a
LR test is based on comparison with model (1).
Significant at 10%, significant at 5%, significant at 1%. Statistical significance is based on one-tailed tests for all independent
variables and interaction terms.
the institutionalized model of role division among professionals and that the first independent variable corresponds to the status of the professional group to which
actors belong (nondoctors, i.e., low-status professionals).
Hypothesis 1B, which states that individual actors who
are not doctors are more likely than doctors to initiate
changes that diverge to a greater extent from the institutionalized model of role division among professionals,
was supported (see column 2). The results also supported H2B, which states that individual actors higher in
the hierarchy of their organization are more likely than
other individual actors to initiate changes that diverge to
division among professionals (see column 2).
Although the interaction effect of the status of the professional group and hierarchical position of the individual actors on the likelihood that the latter will break to
a greater extent with the institutionalized model of role
division among professionals was statistically significant
(see column 3), the sign of the coefficient indicated that
the effect was counter to the one hypothesized in H3B.
Indeed, this latter hypothesis states that individual actors
who are not doctors and are higher in the hierarchy of
their organization are more likely than other individual
actors to initiate changes that diverge to a greater extent
professionals. In fact, there was a negative relationship
between the likelihood that individual actors will break
with the institutionalized model of role division among
professionals and the interaction term between the status of the professional group to which actors belong and
their hierarchical position.
As for control variables, tenure in management positions had the expected positive and significant impact on
the likelihood that individual actors will initiate changes
that diverge to a greater extent from the institutionalized model of role division among professionals. Neither tenure in the current position nor interorganizational
mobility was significantly related to the likelihood that
actors will initiate organizational change that diverges to
division among professionals.
Robustness Checks and Supplementary Analyses
In supplemental regression models (not reported here), I
included as additional control variables gender, age, educational background, and organizational budget. These
variables (whether added separately or together) were
not significant in any model and did not affect the
sign or significance of any variables of interest. Separately, to alleviate concerns related to potential selfreport bias (i.e., participants potential tendency to
describe their change projects as being more divergent
than they actually were), I also checked for the influence of one dispositional characteristic, overconfidence
of the individual (using self-report versus others data
from 360 leadership surveys participants had to fill out
before they attended the executive program). Results
remained robust even when controlling for this dispositional characteristic.
I also examined (1) the relationship between the status of the organization to which actors belonged and the
likelihood that they would initiate changes that diverged
role division among professionals, and (2) the relationship between the status of the professional group to
which actors belonged and the likelihood that they would
initiate changes that diverged to a greater extent from
the institutionalized model of role division among organizations. Neither of these relationships was significant,
which strengthens the finding that different positional
characteristics influence the likelihood that actors will
initiate one or the other of the two types of divergent
organizational change.
Because the interaction term between the low-status
professional group and the hierarchical position variables was significant only at the 10% level, to crosscheck the validity of this finding, I also estimated the
regression with fewer variables. More specifically, I
reran model 3 (see Table 4) without nonsignificant control variables. In this regression, all the remaining variables kept their sign and were statistically significant.
It is important to note that the model fit increased, as
expected, and the interaction term was now significant
at the 5% level, thus bolstering my confidence in the
reported results. In addition, to establish the robustness

of the results to the measurement of the dependent variables, I reran regressions on alternative measures of the
dependent variables. The sign and significance of these
results were the same as those obtained with the above
ordered logit estimations.
Finally, one might be concerned that hierarchical position is not entirely beyond an individuals control and
hence not strictly exogenous. This is potentially problematic because if common unobserved factors affect
both hierarchical position and the divergence of the
change project, the results might be inconsistent as the
position in the organizational hierarchy will be correlated with the error term of the regression models. To
address this problem, I estimated the models using a
two-stage least squares instrumental variables approach
(see Johnston and DiNardo 1997 for a review). These
estimations yielded qualitatively identical results, showing that potential endogeneity of hierarchical position is
neither biasing nor driving the reported findings.
Discussion and Conclusion

Social Position and Divergent Organizational Change
This study demonstrated that social position, both within
the field and within the organization, influences the likelihood that individual actors will initiate changes that
diverge to a greater extent from the institutional status quo and the type of divergent organizational change
they are likely to undertake. As expected, actors disadvantaged by the institutionalized model of organizations or professionals role division, that is, actors who
were at the periphery (Shils 1975) of these institutionalized models, were more likely to initiate change that
diverged to a greater extent from the institutionalized
model of, respectively, organizations or professionals
role division.
These results are consistent with resource dependence
theory predictions (Pfeffer and Salancik 1978, Pfeffer
1981) as well with results of institutional studies conducted at the organizational level of analysis that have
shown that organizations disadvantaged by existing institutions are more likely to initiate divergent organizational change (e.g., Leblebici et al. 1991, Kraatz and
Zajac 1996, DAunno et al. 2000, Maguire et al. 2004).
Furthermore, these results confirm there to be at least
two different types of divergent organizational change in
the field of the NHS: that which diverges from the institutionalized model of role division among organizations
and that which diverges from the institutionalized model
of role division among professionals. As expected, actors
might, depending on their position in the field, initiate
one type of divergent organizational change but not the
other.
Furthermore, it is clear that their position in the hierarchy of their organization also influences the likelihood
829
that actors will initiate changes that diverge to a greater

extent from the institutional status quo. The results show
the influence of hierarchical position to vary depending
on the type of divergent organizational change considered. As expected, the higher they were in the hierarchy
of their organization, the more likely participants were
to initiate changes that diverged to a greater extent from
the institutionalized model of role division among professionals but, contrary to what I hypothesized, the less
likely they were to initiate changes that diverged to a
division among organizations.
This radically different relationship between actors
hierarchical position and likelihood to initiate the two
types of divergent organizational change might reflect
the fact that one type (change in role division among
professionals) relates to change that can be managed
within the boundaries of the organization without involving outside actors, whereas the other (change in role
division among organizations) relates to change that
involves organizational members as well as outside
actors belonging to other organizations. Top managers
in the NHS might be willing to initiate divergent organizational change as long as it does not threaten their own
continuing control over their organization (Pfeffer and
Salancik 1978, Pfeffer 1981). Because organizational
changes that diverge from the institutionalized model of
role division among professionals can be implemented
within the boundaries of the organization without involving any outsiders, they are less likely to threaten top
managers control over their organization. In contrast,
because organizational changes that diverge from the
institutionalized model of role division among organizations involve not only their organization but also
organizations with which their organization interacts, top
managers might perceive such changes as threatening
their own continuing control over their organization. As
a result, top managers might be less likely than middle managers, who will have less to lose individually, to
initiate such changes.
Position in the hierarchy of the organization, again as
expected, also moderated the relationship between the
status of the professional group to which actors belonged
and the likelihood that they would initiate changes that
diverged to a greater extent from the institutionalized
model of role division among professionals. Findings
related to the interaction term between the professional
group to which actors belonged and their position in
the hierarchy of their organization, however, suggest that
contrary to what I hypothesized, actors who had made
it to the top of the hierarchy of their organization and
who belonged to lower-status professional groups were
relatively less likely to initiate changes that diverged to
division among professionals. These results are consistent with studies of women (e.g., Kanter 1977a, b) and
830
ethnic minorities (e.g., Smith 2005) in the workplace,

which suggest that members of these groups who make
it to the top of the hierarchy of their organization may
become relatively less likely to assist in-group members.
For example, Smith (2005), studying the conditions that
enable black, urban, poor job seekers to mobilize their
network of relations for job-finding assistance, observed
that job contacts within this community often express
great reluctance to assist their job-seeking ties. The findings of the present study are similar to those reported
above in that they suggest that actors who belong to lowstatus professional groups, but who are currently high in
the organizational hierarchy, are more reluctant to initiate changes that diverge from the institutionalized model
of role division among professionals.
There are several possible explanations for such
behavior. It might be that having made it to the top,
managers belonging to low-status social groups adopt
a highly individualistic approach: having achieved their
personal objective, they feel it is no longer necessary to
fight. They might also perceive others who still belong to
low-status social groups to be a potential threat. Another
possibility is that as they rise higher in the organizational
hierarchy, actors might identify more with their organization and less with their social group. Finally, it might
be that actors seeking to be regarded as legitimate members of the group of top managers attempt to forget, and
have others forget, their initial low-status social group
membership. This type of behavior is a way for them to
demonstrate loyalty to the group of top managers and
distance themselves from their former group members
(Dittes and Kelley 1956).
Contributions
This study contributes both to the literature on organizational change and to the institutional theory literature. It first contributes to the organizational change
literature by better identifying the locus of organizational change that diverges from the institutional status
quo. It shows that individual actors social position, both
within their organization and within the field in which
their organization is embedded, influences the likelihood
that they will initiate organizational change that diverges
from the institutional status quo. More specifically, the
results show that the widely held belief that divergent
organizational change is initiated by low-status actors,
who are said to be at the periphery of fields (Shils
1975), might be misleading. Actors at the periphery of
the institutionalized model of organizations role division might be more likely to diverge from this model
but not from the institutionalized model of professionals role division. The center versus periphery imagery
should thus be used carefully because actors might be
at the periphery of certain institutions and at the center
of others within the same field. The findings also suggest that actors position at the center versus the periphery of the institutionalized model of organizations or
professionals role division is not the only positional

characteristic that influences the likelihood that they will
initiate divergent organizational change; their position
in the organizational hierarchy also exerts an important
direct influence and moderates the influence of actors
position in the field.
Second, the results presented here show there to be
in the NHS at least two types of divergent organizational change characterized by different predictors with
respect to actors positional characteristics. The findings
thus reveal that variation in whether individual actors
at the center or on the periphery of a field and higher
or lower in the hierarchy of their organization are more
likely to initiate divergent organizational change can be
explained by the existence of different types of such
change. This suggests that the change literature should
distinguish between different types of divergent organizational change depending on the institutions with which
they break. These different types of divergent organizational changes may not only have different predictors
with respect to actors positional characteristics, but they
may also unfold differently.
This study also contributes to the institutional theory
literature by complementing the work of researchers who
have already identified field-level and organizationallevel conditions that enable actors to diverge from existing institutions (Dacin et al. 2002, Strang and Sine
2002). As explained earlier, the causes of divergent organizational change are particularly intriguing because that
kind of change requires actors, whose beliefs and actions
are shaped by existing institutions, to break with the
institutional status quo. This seeming paradox, which
is referred to as the paradox of embedded agency
(Holm 1995, Seo and Creed 2002), alludes to the tension
between human agency and institutional determinism.
This study helps to resolve this paradox by highlighting the role of individual actors social position both
within the field and the organization in enabling them to
break with the institutional status quo (Battilana 2006).
In doing so, it also contributes to bridging the individual level of analysis with the organizational and field
levels, thereby answering the numerous calls for crosslevel research in institutional theory (e.g., Ocasio 2002,
Palmer and Biggart 2002, Strang and Sine 2002, Chreim
et al. 2007). Although the individual level of analysis was accounted for in early institutional studies, it
has received scant attention over the last two decades
(Greenwood and Hinings 1996, Hirsch and Lounsbury
1997, Reay et al. 2006, Powell and Colyvas 2008).
Such neglect is surprising because before being objectivated (i.e., experienced as an objective reality) by
human beings, institutions are produced by them (Berger
and Luckmann 1967, p. 60). Overall, this study contributes to the continuing awareness of the role of human
agents in the emergence of practices that break with
existing institutions.
Limitations and Directions for Future Research

This study has a number of limitations that suggest
directions for future research. First, the analysis must
be considered exploratory given the small nonprobability sample of managers in the NHS. I cannot fully discount the possibility of sampling bias because the study
group consisted of self-selected individuals who applied
and were all selected for advanced leadership training.
Because the analysis was limited to a sample of change
projects initiated by clinical managers in the NHS, one
also cannot be assured that its results are generalizable
to other settings. Addressing this concern will require
comparisons across contexts to better account for the
potential interactive effects of actors social position and
contextual factors on actors likelihood to initiate different types of divergent organizational change. In particular, the relationship between hierarchical position and
individual actors likelihood to initiate organizational
change that diverges to a greater extent from the institutional status quo may vary depending on field characteristics. It might be that in emerging fields, as opposed
to more mature fields like the NHS, top managers will
be more likely to initiate any type of divergent organizational change, including change that diverges from
the institutionalized model of organizations role division, because divergent organizational change will be
perceived to be less risky by them than by top managers
in more mature fields, who might be more reluctant to
change the status quo from which they benefit (Pfeffer
and Salancik 1978, Pfeffer 1981).
The relationship between hierarchical position and
individual actors likelihood to initiate divergent organizational changes may also vary across mature fields. In
the NHS, as explained above, top managers have incentives to initiate changes that diverge from the institutional status quo. It might be that in the absence of
any incentive system pushing them to initiate divergent
organizational change, top managers in mature fields are
more likely to preserve the status quo and thereby less
likely to initiate any type of divergent organizational
change (Pfeffer and Salancik 1978, Pfeffer 1981). Comparative studies across contexts will enable us to have
a more fine-grained understanding of the influence of
actors position in the field and in the hierarchy of their
organization on their likelihood to initiate different types
of divergent organizational change.
Depending on the context, it might also make sense
to distinguish between not just two social statuses, that
is, low and high, but between three: low, middle, and
high (Phillips and Zuckerman 2001). In the context of
the NHS, there is a clear dichotomy between nondoctors,
who are the lower-status professionals, and doctors, who
are the higher-status professionals (Harrison et al. 1992,
Ferlie et al. 2005), as well as between PCTs, which are
the lower-status organizations, and other organizations
(hospitals and administrative organizations), which are
831
the higher-status organizations (Peckham and Exworthy

2003). It would be interesting to see, in contexts in
which one can distinguish between low-, middle-, and
high-status social actors, how findings related to the
influence of social position on the likelihood of actors to
initiate different types of divergent organizational change
might vary.
In addition to studies in other field contexts, there is
a need for studies that will provide a more fine-grained
account of the influence of the organizational context in
which actors evolve. I controlled in this study for the
possible influence of organizational size and organizational status on actors likelihood to initiate divergent
organizational change. These two variables have been
identified as crucial organizational factors in enabling
divergent organizational change (Leblebici et al. 1991,
Kraatz and Zajac 1996, Rao et al. 2000, Garud et al.
2002, Greenwood and Suddaby 2006). Future research
should explore the influence of other organizational
characteristics, such as the extent to which the organization has a positive climate for innovation implementation
(Klein et al. 2001).
Moreover, the impact of other positional characteristics might also be a fruitful area of exploration. In this
study, I have focused on professional group membership
and organizational membership when examining actors
position in the field, but actors may belong to other
social groups. For example, the social class to which
they belong has been shown to influence actors behavior (Bourdieu 1984). In the UK in particular, the class
system is an important aspect of modern British history
(Cannadine 1998, Dacin et al. 2010). Future research
should thus explore the influence of actors position not
only in professional groups and organizations but also
in other social groups. Similarly, other positional characteristics such as actors position in informal organizational networks and in multiple fields also deserve more
attention.
Future research should explore as well other individual factors that might enable different types of
divergent organizational change, for example, individual psychological factors. Leaders might have unobserved attributes that predispose them to initiating divergent organizational change. A number of psychological
traits, including the extent to which individuals have a
positive self-concept, their level of risk tolerance, and
their dispositional resistance to change, have been shown
to influence their attitude toward organizational change
(Armenakis et al. 1993, Judge et al. 1999, Oreg 2003).
Future research needs to examine the extent to which
these traits as well as others influence actors likelihood
to initiate divergent organizational change.
This study has shown that different types of divergent organizational change are likely to be undertaken by
individual actors with different social position profiles.
This finding helps to change how we think about the
832
implementation of major restructuring, such as healthcare sector reforms. It indeed suggests that instead of
viewing such reforms as monolithic blocks, one should
identify the different types of divergent change that they
entail so as to then identify the actors who will be more
likely to champion them. Further examination of the
dynamics of these changes is crucial because it will help
us better understand how actors can break with the institutional status quo and thereby contribute to changing
their institutional environment.
Acknowledgments
The author thanks Tina Dacin and three anonymous reviewers
for their valuable comments on earlier versions of this paper.
The author also thanks Thomas DAunno and Metin Sengul
for their continuous feedback. Finally, the author acknowledges
the helpful comments received from Jeffrey Alexander, Michel
Anteby, Rodolphe Durand, Amy Edmondson, Robin Ely,
Mattia Gilmartin, Ranjay Gulati, Herminia Ibarra, Katherine
Kellogg, Christopher Marquis, Anne-Claire Pache, Leslie
Perlow, Jeffrey Polzer, Jean-Claude Thoenig, Patricia Thornton, Michael Tushman, participants in the Harvard Business
School workshop on organizations, participants in the MIT
Harvard economic sociology seminar, and participants in the
Subtheme 15 on institutional change and the transformation of
public organizations. For excellent assistance, the author thanks
Tal Levy, Melissa Ouellet, and Julie Mirocha.
Endnotes
1
Allied health professionals include art therapists, chiropodists

and podiatrists, dietitians, drama therapists, music therapists,
occupational therapists, orthoptists, paramedics, prosthetists
and orthotists, physiotherapists, diagnostic radiographers,
speech and language therapists, and therapeutic radiographers.
2
Further investigation revealed this to be due mainly to the
variables corresponding to the last two items in scale 2 (i.e.,
To what extent does the project aim to improve cooperation
across organizations? and To what extent does the project
aim to promote continuous care through integration of services?) having a strong but relatively weaker relationship with
the factor than the other four variables.
3
In the sample, 69 organizations are represented once, 9 organizations twice, and 2 organizations three times.
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Julie Battilana is an assistant professor of business administration in the Organizational Behavior Unit at Harvard Business School. She holds a joint Ph.D. in organizational behavior from INSEAD and in management and economics from
Ecole Normale Suprieure de Cachan. Her research examines
the process by which organizations or individuals initiate and
implement changes that diverge from taken-for-granted practices in a field of activity, that is, the process of institutional
entrepreneurship.

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Organization Science

Vol. 22, No. 4, JulyAugust 2011, pp. 817834

The Enabling Role of Social Position in Diverging from

Key words: divergent organizational change; social position; health-care reform

in the 1980s some law firms implemented changes in

Research on the causes of organizational change has

of their peripheral position, these actors are, however,

The Field of the UK National

Organization Science 22(4), pp. 817834, 2011 INFORMS

a budget of approximately 60 billion and employed

Organization Science 22(4), pp. 817834, 2011 INFORMS

Key Organizational and Professional Actors of the NHS

National and regional administrative organizations

Primary care providers

Secondary care providers

Provision of all local health and care services

Organization Science 22(4), pp. 817834, 2011 INFORMS

Model of Medical Professionalism

Role division among professionals

Rules of interaction among

Rules of interaction among

Physicians act as key decision makers in the clinical and

Although there persists a distinct dominance order that

Social Position and Divergent

position within her organization is largely dependent on

to initiate changes that diverge to a greater extent

diverged from taken-for-granted practices (Kraatz and

Organization Science 22(4), pp. 817834, 2011 INFORMS

Hypothesis 2A (H2A). Within the NHS, individual

to initiate changes that diverge to a greater extent

First, in principle, such a bias ought to work against,

charge of initiating the implementation of their change

Organization Science 22(4), pp. 817834, 2011 INFORMS

Organization Science 22(4), pp. 817834, 2011 INFORMS

from the secondary to the primary care sector greatly

physicians ceded control over some aspects of decision

Organization Science 22(4), pp. 817834, 2011 INFORMS

et al. 1993). Longer tenure in their current position is

Organization Science 22(4), pp. 817834, 2011 INFORMS

Summary Statistics and Bivariate Correlations

[1] Degree of divergence from the

00499 00000 10000 00313 00025

that diverges to a greater extent from the institutionalized

Ordered Logit Coefficients Predicting Likelihood of

Note. N = 93; robust standard errors are in parentheses.

goodness of fit of a pair of nested models distinguished

Organization Science 22(4), pp. 817834, 2011 INFORMS

Ordered Logit Coefficients Predicting Likelihood of

Note. N = 93; robust standard errors are in parentheses.

reported results. In addition, to establish the robustness

Discussion and Conclusion

that actors will initiate changes that diverge to a greater

ethnic minorities (e.g., Smith 2005) in the workplace,

Organization Science 22(4), pp. 817834, 2011 INFORMS

professionals role division is not the only positional

Limitations and Directions for Future Research

the higher-status organizations (Peckham and Exworthy

Allied health professionals include art therapists, chiropodists

Organization Science 22(4), pp. 817834, 2011 INFORMS

Battilana, J., B. Leca, B. E. Boxenbaum. 2009. How actors change

Ferlie, E., L. Fitzgerald, M. Wood, C. Hawkins. 2005. The nonspread

Organization Science 22(4), pp. 817834, 2011 INFORMS

Seo, M. G., W. E. D. Creed. 2002. Institutional contradictions, praxis,