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Management of laboratories : examining symbolic and substantive outcomes Pickard, Lynette Elizabeth 1982

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MANAGEMENT OF LABORATORIES: EXAMINING SYMBOLIC AND SUBSTANTIVE OUTCOMES by LYNETTE ELIZABETH PICKARD National Diploma in Occupational Therapy, Pretoria College of Occupational Therapy, South Africa, 1967 B.Sc. (Occupational Therapy), University of Western Ontario, 1975 M.A. (Adult Education) University of British Columbia, 1979 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Interdisciplinary Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1982 Lynette Elizabeth Pickard, 1982 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements fo r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6 (3/81) ABSTRACT Pfeffer (1981) contends that the role of the manager i s chiefly symbolic. The purpose of this study was to investigate his claims that the manager's effect i s primarily on symbolic outcomes and less on substantive outcomes; that external power holders have a small effect on symbolic outcomes; and that substantive and symbolic aspects of organizational activity are loosely linked. Two hospital laboratories in Western Canada (similar along many dimensions) were chosen for inclusion in the study. Through observation, interviewing and examination of records, the researcher obtained information on relationships between the actions of managers and other power holders and substantive and symbolic outcomes. Pfeffer's theory was used to form the classification system for categorizing findings. In addition to a deductive approach, the researcher attempted to discover patterns from the data. Steps were taken to check potential sources of invalidity. Study findings indicated that external power holders have a small effect on symbolic outcomes. Pfeffer's claim that management has a greater impact on beliefs, attitudes and feelings than on tangible outcomes was not supported. Reasons for this may be that managerial effect on symbolic outcomes i s contingent on managerial motivation, type of symbolic action, level of management, type of organization and time in the organizational l i f e cycle. There was l i t t l e evidence to support Pfeffer's claim that substantive and symbolic aspects of organizational activity are imperfectly linked. The explanation of this appears to be that factors affecting the strength of coupling differ with the type of symbolic action employed and with the existence (or absence) of efforts to make the use of power unobtrusive. Concepts which emerged from data captured ideas not contained i n P f e f f e r ' s w r i t i n g s . For example, managers and external power holders may have an i n t e n t i o n a l and unintentional influence on b e l i e f s and a t t i t u d e s ; and proximity to/distance from the organization influences the extent to which external power holders a f f e c t symbolic outcomes. Increased understanding of the variables a f f e c t i n g the r e l a t i o n s h i p between symbolic and substantive outcomes and the magnitude of the manager's impact on substantive versus symbolic outcomes, may be u t i l i z e d by future researchers. i v TABLE OF CONTENTS ABSTRACT . i i LIST OF TABLES vi LIST OF FIGURES v i i ACKNOWLEDGEMENTS v i i i Chapter I. SCOPE OF STUDY AND LITERATURE REVIEW 1 Background of Problem 1 Statement of Problem 4 Definition of Terms 4 Literature Review 6 Statements and Alternate Statements 18 Summary 23 II. METHOD 25 Research Setting 27 Similarities and Differences Between Research Settings. . . 32 Importance of Differences in Settings in Terms of Investigating Pfeffer's Statements 35 Investigation of Research Statements: A General Outline. . . 37 Pilo t Study 40 Sampling 40 Measuring Instruments 44 Data Analysis 48 Validity of Findings 48 V III. ANALYSIS OF FINDINGS 52 Introduction 52 Statement 1 52 Statement 2 70 Statement 3 84 Statement 3a 87 Statement 4 89 Statement 4a 95 Summary of Findings 98 IV. CONCLUSIONS ' 100 The Manager's Impact on Substantive Outcomes 100 The Manager's Impact on Symbolic Outcomes 102 The Influences of External Power Holders on Symbolic Outcomes 108 The Linkage Between Symbolic and Substantive Outcomes. . . 109 Significance of Findings 116 Future Research. 118 REFERENCES 123 APPENDIX A APPENDIX B v i LIST OF TABLES I. Similarities and Differences Between Two Pathology Laboratories 33 II. Substantive Outcomes of Laboratories and Powerful Forces and Individuals Influencing Laboratory Operation 45 III. Interviews, Observations and Document Analysis Associated with Each Statement 47 IV. Findings Related to Statement 1 i n Terms of Substantive Outcomes 54 V. Manager's Influence on Tangible Outcomes and Beliefs Related to Those Outcomes 72 VI. Influence of External Powers on Beliefs of Laboratory Personnel 88 VII. Relationships Between Tangible Aspects of Outcome and Beliefs About Outcome 9 0 VIII. Factors Influencing Strength of Coupling Between Substantive and Symbolic Outcomes With Various Types of Symbolic Action. . 115 v i i LIST OF FIGURES 1. The Relationship Between Substantive and Symbolic Outcomes and Management Versus External Control 3 2. Conditions Producing the Use of Power in Organizational Decision Making 8 3. Sources of Structurally Determined Power and Strategies to Enhance That Power 12 4. Environmental and Hospital Forces Influencing Laboratory Activities and Outcomes. 28 5. Projected Relationships Between Variables 41 6. Pfeffer's Claims and Study Findings Regarding These Statements 101 7. Factors Influencing Substantive Outcomes 103 8. Substantive Versus Symbolic Impact By Level of Management. . . . 107 9. External Powers Affecting Hospital Laboratories Categorized According to Intentionality of Influence and Proximity to Laboratories 110 10. Linkage Between Substantive and Symbolic Outcomes With and Without Managerial Legitimations 111 v i i i ACKNOWLEDGEMENTS Many people assi s t e d with t h i s study and I wish to thank them a l l . The d i r e c t o r , manager and s t a f f of two laboratories i n Western Canada were p a r t i c i p a n t s i n the study. Their willingness to be interviewed and to have me spend time i n t h e i r l a b o r a t o r i e s , made the study pos s i b l e . Dr. Anne Crichton's knowledge of the health system was extremely h e l p f u l i n terms of s e l e c t i o n of study s i t e and i n t e r p r e t a t i o n of c e r t a i n f i n d i n g s . Dr. Peter Frost's expertise i n q u a l i t a t i v e methodology was invaluable i n the study. His i n t e r e s t , enthusiasm, s e n s i t i v i t y and humour helped make the endeavour enjoyable. Dr. Vance M i t c h e l l guided me through the various stages of thesis w r i t i n g with warmth and under-standing and always had time to t a l k to me. Sid Jongbloed was loving and supportive and amazingly accepting of time devoted to t h i s task. 1 CHAPTER I SCOPE OF STUDY AND LITERATURE REVIEW Background of Problem Causes of organizational variation in function, process and form are conceptualized very differently by various organizational theorists. Some view variation as caused largely by organizational members (e.g. decision makers and the dominant e l i t e ) . According to others, forces outside the organization generate variation. Organizational variation has his t o r i c a l l y been attributed to organizational members — to leaders in particular (Gouldner, 1959; March & Simon, 1958). And this remains the dominant view (e.g. Katz & Kahn, 1978). The manager's perceptions of changes in the environment lead to decisions to adjust organizational structure and processes to this altered environment. i. Theorists who emphasize the importance of external forces in organizational variation include population ecologists Hannan and Freeman (1977) and Aldrich (1979), who view the nature and distribution of resources in the organization's environment as the central factor in organizational change. Given available resources, the environment selects optimal combinations of organizations. A population of organizations survives because i t effectively acquires resources in competition with other organizations. Theorists who attribute organizational variation to the manager emphasize managerial a b i l i t y to buffer the organization from environmental disturbances. Population ecologists, on the other hand, stress the numerous 2 internal and external pressures towards inertia (such as legal and f i s c a l barriers to market entry, and sunk costs represented by plant and equipment) which constrain adaptation options (Hannan S Freeman, 1977). In Pfeffer and Salancik's (1978) resource dependence model, both external forces and people are conceptualized as important sources of organizational variation. Organization-environment coupling in this model i s seen as loose, in contrast with the population ecology model in which i t i s viewed as strong. The way in which powerful organizational members interpret the environment affects organizational actions. But unnoticed parts of the environment may also affect organizational outcomes — an indication that people are not in complete control of organizational outcomes. Approaches to organizational theory have traditionally emphasized observable, measureable behaviours and facts. Recently, however, a cognitive perspective on organizations has emerged which, in contrast to the traditional approach, assumes that reality is largely socially constructed and emphasizes the importance of language and symbols. Pfeffer (1981) has articulated a model which combines traditional and cognitive approaches and attempts to resolve the dualism between external constraints on activities and the influence of individuals in the organization. He views organizations as systems of patterned activity and the task of management as explaining and rationalizing these a c t i v i t i e s . Substantive organizational actions like the allocation of budgets to various subunits can be predicted from power-dependence relationships. A subunit which copes with c r i t i c a l problems or supplies resources on which the organization depends, is likely to have a lot of power and thus to be allocated large sums of money in comparison with less powerful subunits. Managers in this model have a limited impact on tangible organizational outcomes; their effect is chiefly on symbolic outcomes. The manager 3 rationalizes and legitimates organizational activities to members and people outside organizational boundaries, thereby ensuring the participation and commitment of members and support from the environment. Pfeffer has drawn heavily on the writings of Edelman (1977) which state that every instance of policy formulation involves both a symbolic effect and a rational reflection of interest in resources. A manpower program may, for example, confer tangible benefits and also symbolize that action is being taken regarding unemployment. Edelman stresses the importance of examining how some groups get the tangible things they want from an organization and what those actions mean to the rest of the people in the organization. Dahl and Lindblom (1976) also distinguish between beliefs and tangible outcomes. They note that policy change tends to be incremental in nature. Those with power are often biased against reform and maintain a set of beliefs and values which operate to their benefit and against major change (Bachrach and Baratz, 1970). Figure 1 shows relationships (proposed by Pfeffer) between symbolic and substantive action and control by management and the environment. FIGURE 1 THE RELATIONSHIP BETWEEN SUBSTANTIVE AND SYMBOLIC OUTCOMES AND MANAGEMENT VERSUS EXTERNAL CONTROL Substantive outcomes (allocations or decisions with physical referents) Symbolic outcomes (attitudes, sentiments, values, perceptions) External control based on power, dependence Large effect predicted by resource dependence, natural selection, and operant conditioning approaches. Small effect Management control derived from language and symbolic action Small effeet.because of environmental constraints and social system size and complexity Large effect predicted by theories of attitude formation change and the social construction of reality SOURCE: Pfeffer (1981). 4 The organization of this dissertation is as follows: In the remainder of Chapter I, terms used in the dissertation are defined, empirical studies i n this area are described, and Pfeffer's ideas regarding management are outlined. Statements (about the effects of managers and external powers) which are to be investigated are identified. Chapter II outlines the design of the study, the research setting, methods of data collection and analysis and steps taken to increase the validity of findings. Findings of the study are described in Chapter III. Conclusions, implications for future research and the significance of findings are presented in Chapter IV. Statement of the Problem Pfeffer proposes two levels of analysis; one concerned with predicting actions which have observable outcomes; the other with predicting how organizational activities are legitimated and perceived. The two levels are loosely linked. His claims have not been investigated. The purpose of this study is to investigate organizations empirically and to describe them in a manner which allows the researcher to examine Pfeffer's central ideas about actions, perceptions and outcomes. These claims provide the framework for the inquiry. Concepts (not addressed by Pfeffer) which emerge inductively w i l l be used to suggest amendments to his ideas. Definition of Terms Power "is the capability of one social actor to overcome resistance i n achieving a desired objective" (Pfeffer, 1981a, p. 2). In Pfeffer's terms i t refers to a "structural phenomenon, created by the division of labour or departmentation that characterize the specific organization being investigated" (Pfeffer, 1981a). Certain individual characteristics affect the exercise of power. 5 Manager in this study refers to people at senior organizational levels. The operational definition w i l l depend on the organization studied. According to Pfeffer (1977), empirical studies on leadership have mostly dealt with f i r s t line supervisors. If the leader has any impact, i t is likely to be at higher organizational levels where there is greater discretion in decision making. Substantive organizational actions are "allocations or decisions with objective, physical referents" (Pfeffer, 1981). Operational definition of substantive organizational actions w i l l depend on the organization studied. Substantive outcomes "refer to tangible, measureable results such as salary allocations, capital or budget allocations" (Pfeffer, 1981). The nature of the research organization w i l l dictate how substantive outcomes are defined. Symbolic outcomes are "assessed by sentiments of affect, by satisfaction, by values and by beliefs" (Pfeffer, 1981). The nature of the organization studied w i l l determine the operational definition of symbolic outcomes. Tight coupling occurs when two separate systems have many variables in common or when the common variables are more closely linked than are other variables that influence the system. For example, i f the goal of an organization is to teach people to drive cars and the organization has the power to do this, then the tangible outcomes (e.g. number of people who learn to drive) and beliefs about the number of people who learn to drive are likely to correspond very closely. Loose coupling "occurs either when two separate systems have few variables in common or when the common variables are weak compared to the other variables that influence the system" (Weick, 1979, p. 111). For example, i f an agency bears symbolic responsibility for dealing with poverty but has l i t t l e power to get people jobs, then tangible organizational achievements and the manager's statements about these accomplishments are likely to correspond very l i t t l e . 6 Conditions of power and dependence. Conditions for the use of power are scarcity, interdependence, heterogeneous goals and beliefs about technology. The importance of the resource and the distribution of power determine whether power is used. Power w i l l be used only when the resource/decision is perceived as c r i t i c a l and when power and control are dispersed. Power is determined by a subunit's structural position and ability to cope with c r i t i c a l problems as well as by personal characteristics that f a c i l i t a t e using power resources. Literature Review Theories regarding the relative influence of leaders and external constraints on organizational ac t i v i t i e s vary greatly. While population ecologists maintain that numerous external forces constrain managerial activity, the dominant view remains that leaders have considerable impact on organizational ac t i v i t i e s and outcomes. Empirical studies in this area have been scarce. Three studies have sought to determine variance in organizational outcomes attributable, to the manager. Only 15 percent of variance in outcomes was attributable to managers in studies by Lieberson and O'Connor (1972) and Salancik and Pfeffer (1977). They concluded that the manager has l i t t l e effect on organizational outcomes and that managerial influence is drastically limited by organizational and environmental constraints. Weiner and Mahoney (1981), noting deficiencies in the designs of the above studies, used a multivariate analysis thus avoiding considering each independent variable sequentially. They examined specific environmental and organizational measures instead of attributing variance in organizational performance to changes in year, industry and company. Stewardship (the same measure of leadership used by Lieberson and O'Connor) was found to account for 7 40 percent of the variance in p r o f i t a b i l i t y and stock prices over and above environmental, organizational or leadership strategies (defined as observable patterns of corporate action). Theories and empirical studies have examined the influence of leaders on tangible, measurable outcomes. Organizational reality i s , however, inherently social in nature (Berger and Luckman, 1976). Feelings about decisions and actions can be affected quite independently of tangible actions and outcomes. Factors such as work hours and promotions have physical referents but perceptions about these factors are subject to social influences. Analysis of Management at Two Levels According to Pfeffer (1981), the analysis of management should occur at two levels. At the level of tangible actions and outcomes, decisions are mostly the result of power-dependence relationships and external constraints. At the symbolic level, p o l i t i c a l language and symbolic action are used to legitimate organizational decisions. Each of these levels is described in some detail below. Substantive level Substantive results in Pfeffer's model are determined by the distribution of power in a situation. Conditions for the use of power are interdependence, scarcity and heterogeneous goals and beliefs about technology. Power w i l l be used only when the resource or decision is perceived as important and when power and control are dispersed (i.e. not centralized). Conditions producing the use of power in organizational decision making are presented schematically i n Figure 2. What are sources of power in an organization? Functionally determined sources of power for individuals and subunits are substitutability, uncertainty, coping capacity, resource dependence and a b i l i t y to affect the decision process. 8 FIGURE 2 CONDITIONS PRODUCING THE USE OF POWER IN ORGANIZATIONAL DECISION MAKING I n t e r d e p e n d e n c e Heterogeneous g o a l s S c a r i t y , C o n f l i c t P o l i t i c s Heterogeneous b e l i e f s about t e c h n o l o g y Importance of r e s o u r c e / d e c i s i o n D i s t r i b u t i o n of power SOURCE: P f e f f e r (1981a) 9 The amount of power an individual possesses i s derived from the importance of his/her performance in the organization. Power differences arise from the division of labour (or task specialization). When various people perform different parts of the whole task i t is almost inevitable that these tasks w i l l not be equally c r i t i c a l to task completion and organizational survival. Units responsible for most important tasks have the most power. In this way power can be seen to be structurally determined. Power also derives from people's a b i l i t i e s to perform their tasks and increase their power bases by convincing others of the necessity of their contributions. Power derives from the a b i l i t y to supply or withhold resources on which the organization i s dependent. Ability to cope with uncertainty can be defined as a c r i t i c a l resource. If the uncertainty being dealt with i s central to the organization's act i v i t i e s and i f the subunit coping with uncertainty i s non-substitutable, then that subunit w i l l have power. Being irreplaceable is an additional source of power.. Irreplaceability i s a dynamic concept; and strategies such as use of specialized language and centralization of expertise may be employed by subunits and individuals attempting to enhance their power within the organization. Power may also derive from influence over decision processes. Decisions are largely determined by the premises underlying decisions. Actors who control decision premises are powerful, as are those who control which alternatives are considered and information about alternatives. Consensus and technological certainty can enhance the power of the subunit. Consensus fa c i l i t a t e s cohesion; and the a b i l i t y of members to argue that results are certain, increases the likelihood of resource allocation to such a subunit. One's position in the formal and informal communication networks 10 determines the power one w i l l have from information control. The power of the subunit in which the actor is located i s another determinant of individual power. P o l i t i c a l strategies can enhance the power of an individual within the constraints described above. Most strategies are aimed at making the use of power less obtrusive, at legitimating the decision that i s to be made on the basis of power to organizational members or at increasing support of the position advocated by a certain actor. Strategies aimed at attaining one or more of these goals are outlined below. In decision situations, decision makers are confronted with choosing among multiple alternatives and multiple c r i t e r i a . It is not legitimate to argue for the validity of a certain actor on the basis of an actor's power. Choices must be legitimated by selectively emphasizing c r i t e r i a that favour the position which that actor advocates. Using an expert can allow the use of power to affect decisions in a less visible way. Experts can also legitimate decisions reached. Controlling the agenda and thereby preventing the decision issue from arising in the f i r s t place, is a very unobtrusive way of exercising power. Tactics through which additional power is mustered are coalition formation and cooptation. Coalition formation involves mobilising support on the part of those who agree with the organizational member involved. Subunits may build relationships with external groups as a way of increasing their power within the organization. Less powerful organizational members can attain their goals by forming alliances with others, particularly those with greater power. Cooptation i s concerned with trying to change the views of powerful actors so that they favour the interests of the subunit. Those who are coopted to participate in decision making are confronted with pressures to 11 conform, informational social influences and expectations that increase commitment to the organization (Pfeffer, 1981a). In legitimating decision making processes and mobilising support for the subunit's position on important issues, the use of language, ceremonies, rituals and symbols is important. Pfeffer (1981) refers to these activities as the symbolic level of management. To summarize, within structural constraints there are differences in the a b i l i t i e s of individuals to advocate their s k i l l s in dealing with problems, to shape the way the situation is defined and in willingness to use their s k i l l s to impact the p o l i t i c a l process. Power is thus determined by the subunit's structural position and a b i l i t y to cope with c r i t i c a l problems as well as by personal characteristics which f a c i l i t a t e using power resources (Pfeffer, 1981a). These concepts are schematically represented in Figure 3. Symbolic level It is important to distinguish between decisions like promotions and resource allocation and beliefs about these decisions. O'Reilly and Caldwell (1979) found, experimentally, that job perceptions and emotional reactions to the job were more strongly influenced by social information than by the nature of the task i t s e l f . Perceptions of pay equity have also been found to be socially anchored (Adams, 1965; Goodman & Friedman, 1971). The task design literature (Salancik & Pfeffer, 1978) indicates that perceptions about the legitimacy of a decision and justification for decisions can stem from the social environment. The social environment has a large influence on the dimensions of a decision an individual focuses on, how these dimensions are weighted and i t also provides cues about how others have evaluated the decision on various dimensions. Those exercising power within organizations employ social processes FIGURE 3 SOURCES OF STRUCTURALLY DETERMINED POWER AND STRATEGIES TO ENHANCE THAT POWER St r u c t u r a l l y Determined Power Power derives from d i v i s i o n of labour. Individuals/units doing most important tasks have most power. Sources of s t r u c t u r a l l y determined power are i r r e p l a c e a b i l i t y coping capacity a b i l i t y to aff e c t the decision process resource dependence a b i l i t y to cope with uncertainty P o l i t i c a l Strategies to Enhance  S t r u c t u r a l l y Determined Power making power less obtrusive e.g. c o n t r o l l i n g "the agenda le g i t i m a t i n g decisions to be made on the basis of power e.g. using experts to legitimate the d e c i s i o n mustering a d d i t i o n a l power/support for the p o s i t i o n of an.actor e.g. co-optation and c o a l i t i o n formation use of language ceremonies r i t u a l s symbols important SOURCE: Peters (1978) 13 similar to those identified above to justify decisions that have been made on the basis of power (pfeffer, 1981a). Weick (1979) notes that the task of the manager is largely management of myths, symbols and images. And Pondy (1978) views symbolic activity as a major component of the exercise of power. Managers label and define decisions and actions and also develop a social consensus around these labels and definitions. Legitimations are aimed at ensuring commitment to the organization on the part of organizational participants and support from the larger social context. One of the ways of obtaining external support is by presenting an organizational paradigm in a way that is consonant with existing social expectations, as well as by identifying the organization with socially accepted individuals, instructions and methods of operation (Pfeffer, 1981). Pfeffer (1981) illustrates the symbolic role of management in a description of a school in a particular university in which salaries were low in comparison with other schools in that organization. Low salaries could be interpreted as questionable competence on the part of current leaders of the school. A social definition of the situation developed that the school possessed an intellectual environment conducive to research and creative thought and that faculty members chose to remain in this organization with fewer extrinsic rewards because of i t s i n t r i n s i c a l l y rewarding atmosphere. This might have been a conscious misinterpretation of cause and effect relationships. The real cause of lack of turnover might have been the geographic area. By managing a social definition of the situation, commitment to the organization was managed. With this situational definition the power of those currently in administrative positions was maintained. Power (derived from strategies and resource-based considerations) is used in defining social r e a l i t i e s and in justifying activities in ways that are 14 consistent with the position of those in power. Language is a key tool of social influence and is crucial in developing justifications and rationaliza-tions for a c t i v i t i e s . P o l i t i c a l language is used to justify organizational decisions, thereby making the exercise of power more effective and less overt. Ideologies regarding the value of rational planning may be used to justify decision outcomes, while obscuring the use of power which underlies the decision making process. P o l i t i c a l language and symbolic action can be effective for a number of reasons. First, preferences of individuals or groups in the organization may be uncertain or undefined. March (1978) argues that preferences do not guide action, but emerge as a consequence of action. This point is also made by Weick (1979) in his discussion of retrospective rationality. People may, then, discover preferences through what they obtain from organizational decisions. One may not be able to identify how much of a resource one desires or how one w i l l react to the hiring of a colleague, u n t i l these decisions have been made and the outcomes are evident. If preferences are unstable, people w i l l have d i f f i c u l t y in assessing whether p o l i t i c a l outcomes of a decision process are satisfactory. Satisfaction with decisions is far more easily evaluated when preferences are formed before the decision outcome. When people are unclear about what they ' want, they may have d i f f i c u l t y discriminating symbolic language from substantive outcomes (Pfeffer, 1981a). Second, informational social influence is more powerful in uncertain circumstances (Festinger, 1954). The surroundings, act i v i t i e s and interaction patterns of an organization are unfamiliar to newcomers. The organization is also usually a physically separate entity, an important factor in the socialization process (Dornbusch, 1955). New entrants to the organization are likely to be anxious and uncertain about what is required of them and 15 consequently susceptible to believing social stories and p o l i t i c a l language. Third, even i f preferences are well formed, p o l i t i c a l language may be enough to satisfy some people i f evaluation of the decision i s d i f f i c u l t . Hospitals tend to avoid publishing mortality or morbidity figures and educational organizations the release of student achievement data. Restricted access to information is supported through the development of myths which justify the practice. For example, public school o f f i c i a l s claim that the release of achievement data w i l l tend to direct instructors to teach for proficiency on tests, rather than produce citizens who are broadly trained. Fourth, people may find i t d i f f i c u l t to evaluate those organizational outcomes which have may attributes. Uncertainty about the value of outcomes may also stem from a definition of professionalism which maintains that clients are not qualified to evaluate decisions. Those designated to identify acceptable decision c r i t e r i a become the experts who define for others what they should believe. Even in the absence of professionalization, assessment of what one receives many be hindered by the multi-attribute nature of organizational decisions. Finally, i f people are unable to assess organizational outcomes or specify exactly what they want, a symbolic response may be a l l that they desire (e.g. some reassurance that their concerns are being taken seriously) (Pfeffer, 1981a). A l l these factors combined indicate that p o l i t i c a l language may have real consequences in terms of quieting opposition, mobilizing support, diverting or satisfying demands. The effects of symbolic action are evident in participatory decision making. Involvement in decision making, even i f symbolic, can increase commitment to decisions reached. Groups which are dissatisfied with the organization may be placated by symbolic actions. For example, the existence of an administrative structure to deal with complaints may quiet students. P o l i t i c a l language and symbolic actions may be used in 16 implementing change. For example, since one measure of the importance of a goal is the time spent on i t , the symbolic administrative action of spending time on an activity that i s defined to be important, conveys to others the importance of the focus of that time (Peters, 1978). Four types of symbolic action are important in the meaning creation process. These are ceremonies, settings, language and the use of symbols. Examples are given below. Ceremonies. Replacing someone in an executive position provides an opportunity to manage meaning creation and could indicate intention to change organizational operations. It may involve rituals to emphasize the importance of the position. Meetings may be ceremonial in character and provide reassurance that the interests of a particular group are being seriously considered. The annual meeting of stockholders is a ceremony and creates an i l l u s i o n of control. Stockholders have the opportunity to ask questions, vote for directors and review financial reports. The symbolic value of the meeting lies in i t s reassurance of the owners of the corporation that they have an important role in the corporation. Symbols. Organizational restructuring can be seen as a symbolic process. It may provide symbolic reassurance that action is being taken and may change the symbolic meanings given to various aspects of the organizational operation. The creation of new subunits, for example, allows new aspects of the organization to be emphasized. Settings. The effect of ceremonies, language and symbols depends on the physical setting in which these activities take place. The size, location and physical space in which p o l i t i c a l activity occurs influences meanings given to that activity. Settings influence how organizational members perceive the 17 organization and their role in i t . Location and amount of office space provide an index of hierarchical position. Language. Whether organizational outcomes are successful or not depends largely on definitions and classifications. Shared language i s one of the ways in which shared beliefs, paradigms and cultures are created. Language is used to legitimate and develop support for decisions that are reached on the basis of power. Questionnaires assess individual preferences while at the same creating those preferences. Asking employees their opinions provides them with symbolic assurance of changes in the future and that their opinions are important. Pfeffer (1981a) and Culbert and McDonough (1980) have different ideas regarding the nature of legitimations. While i t is not the intent of this study to examine the nature of legitimations, these are discussed with the view to assisting the researcher identify legitimations. Pfeffer (1981) refers to the literature on attribution theory which states that people seek explanations which are both accurate and provide a feeling of control over events. He hypothesizes that explanations w i l l be constrained to be legitimate in that context, with a preference for explanations which provide a feeling of control over events. Culbert and McDonough (1980) state that "people proceed with a job orientation that spontaneously spins out interpretations and meanings that serve the unique way they need reality constructed in order to be a success." They argue that managers w i l l attempt to show organizational participants that (i) their (the managers') mission i s essential to the health of the organization, ( i i ) the role they have defined for themselves is an effective way of contributing to the mission, and ( i i i ) their daily actions and the accomplishments of organizational mission are linked. 18 Statements and Alternate Statements Pfeffer (1981a) claims that substantive actions and outcomes are determined by the distribution of power in a situation. The manager justifies decisions that have been made on the basis of power, thereby influencing beliefs about these decisions. Four of his key statements regarding the effects of the manager and power-dependence relationships are presented below, along with some alternate ideas. Statement 1 (SI). The manager has l i t t l e , although some discretionary impact  on instrumental action. There i s , according to Pfeffer, a tendency to attribute actions and outcomes to factors inside the organization. He asserts that understanding of the organizational social context is c r i t i c a l . The social system in which the manager is embedded (departments, unions, the government, etc.) constrains managerial behaviour. The manager accounts for very l i t t l e variation in organizational outcomes compared to external factors (Pfeffer, 1977). The manager is able to react to contingencies, f a c i l i t a t e the adjustment of the organization in i t s context and alter the context of the organization to some extent (Pfeffer & Salancik, 1978). Many factors affecting organizational performance are not under the leader's control; and leaders typically have unilateral control over very few-resources. Leaders' positions vary in terms of the strength and position of the organization. Also, organizations have f a i r l y enduring strengths and weaknesses (Pfeffer, 1977). Pfeffer contends that the manager's impact on tangible outcomes is small. Where, then, does he see the manager as having some influence? Statement 2 (S2). Management's action operates largely on expressive or  symbolic outcomes. (Pfeffer, 1981, p. 6) 19 Social reality is partly an outcome of the process of social construction. One important administrative activity is the development of shared paradigms. By labelling, defining and explaining organizational act i v i t i e s , the manager makes these events meaningful and develops a social consensus around them. Through the use of language, ceremonies, symbols and settings, decisions that are largely outcomes of power and influence are rationalized. The purpose of the rationalization and legitimation of organizational activities i s to ensure support from the organizational environment and continued commitment to the organization by organizational members. A way of obtaining external support for an organization is to make the goals and outcomes of the organization appear valuable to the larger social system. Pfeffer argues that the manager has l i t t l e effect on substantive outcomes. Influencing symbolic outcomes is the domain of the manager. What, then, are his views regarding the effects of power and dependence on symbolic outcomes? Statement 3 (S3). Conditions of power and dependence have a small effect on  symbolic outcomes (such as attitudes, values, perceptions). Pfeffer provides l i t t l e rationale for this hypothesis, but does state that conditions of power and dependence are decoupled from symbolic outcomes (Pfeffer, 1981b). Although variables related to a particular set of power-dependence relationships and their effects might be highly related to beliefs about these conditions and their effects, close relationships between power conditions and beliefs would not be the norm. Knowledge of which units provide c r i t i c a l resources, are irreplaceable or able to affect decision processes could not be used to predict whose beliefs would be influenced and in what way. For example, knowing that the emergency unit of a hospital provides an essential service, does not provide one with 20 information regarding whom the manager of the emergency unit w i l l attempt to influence nor the nature of this influence. (Similarly, i t could be argued that the knowledge of the distribution of power i s insufficient to predict substantive outcomes, as Pfeffer claims i t is.) Conditions do not affect outcomes; people do. The distribution of power allows those with power to affect substantive and symbolic outcomes. The strategies employed by people are c r i t i c a l in each case. Alternate Statement 3 (S3a). Conditions of power and dependence have a  potentially powerful effect on symbolic outcomes in that they allow those with  power to influence symbolic outcomes. When and how this occurs depends on the  motivations of those with power. Pfeffer (1981a) views power as both structurally determined and affected by the strategies undertaken by organizational members to increase their power. Many of these strategies are concerned with influencing beliefs and attitudes of others. What comes to be seen as uncertainty or as a c r i t i c i a l resource is largely a matter of social definition'. For example, because i t i s seldom possible to determine scarcity objectively, the group or person owning the resource can increase their power and the value of the resource by talking and behaving as i f the resource were scarce. Those with powers may affect decision premises; they may control both the alternatives considered and information about alternatives. In so doing they affect the beliefs of others. By selectively stressing certain c r i t e r i a for evaluating alternatives, the perceptions and beliefs of those exposed to this information are influenced. People co-opted to support a particular position are subjected to informational social influence which often changes their attitudes and perceptions. The motivations of those with power w i l l determine the nature of beliefs which they influence. It i s not contended that a l l power-dependence relationships are 21 associated with affecting attitudes and beliefs. Rather, power conditions create an environment which allows certain individuals to influence beliefs of others. Thus, conditions of power and attempts to influence symbolic outcomes wi l l be closely linked more often than hypothesized by Pfeffer. Pfeffer (1981) argues that language and symbolic action are used to influence the beliefs and attitudes of organizational participants. The distribution of power determines substantive results. How, then, are the symbolic and instrumental aspects of organizational activity linked? According to Pfeffer (1981) they are imperfectly related. Statement 4 (S4). The symbolic and instrumental aspects of organizational  activity are clearly linked; but i t i s clear that the coupling between them i s  loose. Decisions may well precede the formation of explanations, just as behaviour often precedes the development of an attitude consistent with that behaviour. The explanation for a decision and the decision i t s e l f may be very loosely linked. If inconsistencies between the content of the explanations and the content of the decision are made more visible, then those legitimating organizational a c t i v i t i e s may invest more energy in explaining decisions (Pfeffer, 1981a). Thus when external demands are absent, outcomes and attitudes w i l l l i k e l y correspond very l i t t l e . But external forces may prompt greater effort into legitimating organizational activities and perceptions of these a c t i v i t i e s (Pfeffer, 1981). The only factor identified by Pfeffer (1981a) as influencing the strength of coupling between symbolic and substantive outcomes is the presence or absence of external demands. He views the amount and conditions of linkage between substantive and symbolic outcomes as an important research issue. Three factors which possibly influence how strongly symbolic and instrumental outcomes are linked are described i n Alternative Statement 4. 22 Alternate Statement 4 (S4a). The symbolic and instrumental aspects of  organizational activities are linked. How strongly or loosely they are linked w i l l be influenced by (a) managerial motives for redefining the situation, (b)  characteristics of the outcomes, and (c) characteristics of recipients of  outcomes. (a) Managerial motives for redefining the situation Incongruities between the goals of an organization and i t s actual power may prompt emphasis on symbolic outcomes which are loosely coupled with substantive outcomes. A welfare agency, for example, has no legal power to get people jobs, yet bears the major public symbolic responsibility for coping with poverty (Edelman, 1977). Congruence between goals and power to achieve these goals i s lik e l y to be associated with tighter coupling between substantive and symbolic goals. In an organization whose achievements are at odds with i t s ostensible purpose, the difference between aims and outcomes may result in managers seeing themselves as vulnerable. For example, public disaffection with huge profits of o i l companies may lead to o i l companies emphasizing the importance of spending money on research and exploration (Frost, 1981). In an organization with a controversial objective, those in power are like l y to be motivated to explain the situation i n ways which di f f e r from substantive outcomes. Coupling between substantive and symbolic outcomes is likely to be loose. With an uncontroversial objective, tighter coupling i s more li k e l y . When there i s a need to focus attention on a symptom, thereby diverting attention from the root cause (e.g., inefficiency) substantive and symbolic outcomes are li k e l y to be loosely linked, (b) Characteristics of outcomes When organizational outcomes are not directly observable by people in or outside the organization there is greater potential for people with power to 23 redefine outcomes and hence a greater likelihood of loose coupling between substantive and symbolic outcomes. When outcomes are clearly observable to a l l organizational participants, there is a greater likelihood of tight coupling. (c) Characteristics of recipients of outcomes When preferences of people in (or outside) the organization are undefined/ambiguous, this allows those defining the situation to make their definition of the situation more readily acceptable. Coupling between substantive and symbolic outcomes is likely to be loose. When preferences are unambiguous, this w i l l be less easy. In situations where groups in contact with the organization are unable to define the value of an outcome, have undefined preferences or desire symbolic action only, loose coupling between substantive and symbolic outcomes is lik e l y . Symbols and perceptions which are institutionalized become the basis on which decisions are made. This is tight coupling. Summary This chapter reviewed empirical studies and theories on the relative influence of the manager and external constraints on organizational a c t i v i t i e s . The dominant view is that managers exert considerable control over organizational outcomes; and observable activities have been emphasized. An overview was presented of Pfeffer's theory regarding management in organizations. He states that substantive outcomes are determined by the distribution of power in a situation. A combination of five factors determines whether p o l i t i c a l activity w i l l be the method by which choices are made. Power is determined by the subunit's structural position as well as by personal characteristics which f a c i l i t a t e using power resources. 24 The task of management is to provide explanations and legitimations for organizational a c t i v i t i e s . The symbolic actions of management can be effective because those in contact with the organization may have undefined preferences, organizations may avoid assessment, individuals or groups may be unable to evaluate the value of outcomes they are receiving and may desire nothing more than symbolic outcomes. Symbolic action can have consequences for mobilizing support and satisfying demands. The general forms of symbolic action are language, ceremonies, the use of symbols, and settings. The objectives of the study were stated as investigating organizations empirically, with the intent of looking for evidence which would allow the researcher to assess whether the manager's effect is primarily on symbolic outcomes and is less on substantive outcomes; whether the distribution of power in an organization has a small effect on symbolic outcomes; and whether symbolic and substantive aspects of organizational activity are loosely coupled. 25 CHAPTER II METHOD This chapter outlines the study design, methods of data collection, data analysis and steps taken to increase the validity of findings. Differences between two research sites are analyzed in terms of their potential impact on the investigation of Pfeffer's statements. The steps involved in examining each statement are presented and sampling procedures and measuring instruments are described. The chapter concludes with a discussion of data analysis procedures. This study focused on gaining understanding of the impact of power relationships and managerial actions on tangible outcomes and beliefs. The meaning people give to events and the manager's a b i l i t y to influence beliefs and meanings were important aspects of the study. Study questions did not lend themselves to experimental or even less rigorous quantitative designs. How the words and actions of the manager and others with power are related to symbolic and substantive outcomes can best be understood within a naturalistic design, which prescribes the gathering of data on a large number of aspects of the organization in an attempt to understand phenomena and the situation as a whole. Key statements in Pfeffer's (1981) theory were used as a scheme for data collection and analysis. Data were descriptive and content analysis was used to examine patterns which emerged. Why did the researcher choose the above design, method of data collection and analysis? As mentioned earlier, there has been l i t t l e empirical 26 investigation into the influence of the manager on organizational outcomes. The three studies conducted in this area have examined existing data on organizational outcomes over a period of time and determined how much variance could be attributed to the manager. None examined the social nature of managerial influence nor involved a closeness to the phenomena under study. An examination of Pfeffer's theory of managerial action, with i t s emphasis on the impact of the manager's actions on beliefs, attitudes and feelings, represents a new area of investigation. The application of descriptive techniques, non-traditional in organizational behaviour, are expected to provide the basis for i n i t i a l study of Pfeffer's ideas. Understanding the texture and the kinds of relationships which exist between symbolic and substantive outcomes, should precede s t a t i s t i c a l testing of hypotheses. It was considered premature at this point to gather large quantities of data on relationships between selected variables. Future studies might well do this. Interviews, systematic observation, and examination of records were used to study the same phenomenon. Interviews capitalize on language, a powerful form of communication. Structured, open-ended questions allow the interviewer to focus on specific issues and interviewees freedom to express thoughts and feelings about those issues. Changes in the interviewer are a potential source of invalidity (Bouchard, 1976). Systematic observation focuses on behaviour rather than verbal cues and u t i l i z e s categories from theory as units for observation. Reactions of organizational members to the presence of the manager, may, for example, be observed. Sources of invalidity include simplification of the problem by the observer, enhancing some factors while ignoring others and hesitancy to give extreme ratings (Weick, forthcoming). The advantage of examining records is that they are not contaminated by reactivity. 27 Research Setting Power i s central to Pfeffer's theory. The a b i l i t y of the researcher (in the research setting for a short period of time) to detect which powerful actors affect which outcomes, depends largely on the prominence of the operation of power in that organization. Two pathology laboratories in teaching hospitals in Western Canada were chosen as research settings for this study. Power relationships constitute an important part of the functioning of these units. Is i t l i k e l y that the health care setting influenced answers obtained to study questions? Power relationships in health care settings are affected by the issue of professionalism. Pathologists remunerated on a fee for service basis may, for example, not view themselves as hospital employees. It i s contended, however, that such contextual issues do not impinge on study questions. Whether the manager has a greater effect on symbolic than substantive outcomes; and whether beliefs are loosely or tightly linked with tangible outcomes are not l i k e l y to be greatly affected by the setting. The laboratory i s a component of the hospital, which in turn, i s part of a larger environment. Factors from within the hospital and in the larger environment which impinge on laboratories in teaching hospitals in Western Canada are portrayed in Figure 4. Forces in the larger environment are the Regional Hospital District, the Provincial Ministry of Health, the university in that area providing training for medical students, the Canadian Council on Hospital Accreditation, the Canadian Society of Laboratory Technologists, the Royal College of Physicians and Surgeons and unions for technical and c l e r i c a l staff. Forces within the hospital which influence laboratory functioning are the type of hospital and hospital administrators. The impact of each of these factors i s briefly outlined below. 28 FIGURE 4 ENVIRONMENTAL AND HOSPITAL FORCES INFLUENCING LABORATORY ACTIVITIES AND OUTCOMES Royal College of Physicians & Surgeons Regional Hospital D i s t r i c t Canadian Council on Hospital A c c r e d i t a t i o n Canadian Society of Laboratory Technologists P r o v i n c i a l Medical Association P r o v i n c i a l M i n i s t r y of Health i t y Unions for technical & c l e r i c a l s t a f f HOSPITAL Type of Hospital Hospital Administrators LABORATORY 29 Larger Environment Minis t r y of Health Total operating costs of hospitals are funded by Hospital Programs ( P r o v i n c i a l M i n i s t r y of Health). The amount allocated to any one h o s p i t a l f o r a p a r t i c u l a r year i s the outcome of bargaining between h o s p i t a l administrators and Ministry of Health o f f i c i a l s . Each department head submits a budget to the h o s p i t a l administrator and can attempt to influence formally and informally the amount a l l o c a t e d to his/her department. The Min i s t r y of Health provides 75 percent of the funding for diagnostic equipment and 33.33 percent of the funds for non-diagnostic equipment. Department heads submit requests for equipment to h o s p i t a l administrators who, in turn, submit a l i s t of h o s p i t a l p r i o r i t i e s to the Minis t r y of Health and the Regional Hospital D i s t r i c t . O f f i c i a l s i n these organizations review equipment requests from many hospital s and then make decisions regarding a l l o c a t i o n s . Regional Hospital D i s t r i c t The Regional Hospital D i s t r i c t pays 25 percent of the cost of diagnostic equipment and 66.66 percent of the cost of equipment such as wheelchairs and operating tables. The a l l o c a t i o n process was described above. Decisions of Regional Hospital D i s t r i c t o f f i c i a l s are constrained i n that th e i r a l l o c a t i o n of funds requires the approval of the Mi n i s t r y of Health. University The u n i v e r s i t y o f f e r i n g a medical t r a i n i n g program i n that area i s another force a f f e c t i n g teaching h o s p i t a l s and laboratories i n these h o s p i t a l s . Medical students gain p r a c t i c a l experience i n h o s p i t a l s e t t i n g s . The u n i v e r s i t y has an a f f i l i a t i o n agreement with those hospi t a l s conducting teaching programs f o r medical students and residents. The agreement 30 stipulates that where a teaching program is offered by a hospital department and/or division, the chairman of the division i s to be appointed and/or reappointed by a formal agreement between the hospital and university. In addition to this, chairmen of the c l i n i c a l departments at teaching hospitals are to hold f u l l time academic appointments in the faculty of medicine, with some component of their salaries coming from the academic budget of the university. And whenever new members of staff are to be appointed to departments involved in teaching, the head of the university department involved is to be consulted ( A f f i l i a t i o n Document Between Hospital A and the university, 1980; A f f i l i a t i o n Document Between Hospital B and the university, 1977). Unions Technologists belong to a provincial union and c l e r i c a l hospital employees to a national union. The collective agreement between each union and the Provincial Health Labour Relations Association sets forth the conditions of employment relating to remuneration, hours o i work, benefits and general working conditions. The Canadian Council on Hospital Accreditation The Canadian Council on Hospital Accreditation is authorized to conduct accreditation programs in Canadian hospitals. Participation in the program i s voluntary; however, hospitals cannot operate teaching programs without accreditation. The Council conducts accreditation programs and establishes standards for hospital operation. A hospital may be accredited for a period of one, two or three years. A one year certificate of accreditation w i l l l i k e l y be issued i f major changes are required. Standards have been identified for laboratory medicine i n the areas of organization and staffing, f a c i l i t i e s , channels of communication, quality 31 control systems, tissue examination, necropsy service, blood transfusion service and c l i n i c a l reports (Canadian Council of Hospital Accreditation, 1977). The Provincial Medical Assocatiotion An Accreditation committee of the provincial medical association examines laboratory operations every two years. Much emphasis is placed on quality control. The Royal College of Physicians and Surgeons The Royal College of Physicians and Surgeons accredits the pathology resident training program. Resident training in a hospital may be limited i f the training program i s assessed as inadequate along certain dimensions. The Canadian Society of Laboratory Technologists The Canadian Society of Laboratory Technologists accredits the technologist training program and defines what students are to be taught. Hospital Forces Policies and decisions of two groups of people in the hospital have a considerable impact on laboratory actions and outcomes. Type of Hospital Provision of reliable and accurate test results in ways that are convenient to the physician and patient and which are, in addition, economical, are central goals of laboratory operation. The type of hospital (in particular, i t s teaching status) contributes to demand for tests. The presence of residents and medical students in a hospital results in an increased volume of laboratory tests ordered. Laboratory tests can be seen as a quantitative response to uncertainty. Those in training are likely to experience increased amounts of uncertainty (Martz and Ptakowski, 1978). 32 Hospital Administrators The hospital administrator's responsibilities include the allocation of capital and operational funds to departments. Laboratory operation i s influenced by the degree to which the administrator centralizes control, the lines of communication he/she establishes and how he/she regards the role of the director of the laboratory. Similarities and Differences Between Research Settings In order to draw inferences from patterns that emerged, data were needed on a minimum of two managers in each of two settings. So that differences in findings could not be attributed to i n i t i a l differences between managers or settings, similarity of managers and settings along certain dimensions was desirable. The unit of analysis in this study was the individual; the manager being the focal individual. The content of analysis was the subunit (the laboratory). Managerial and subunit factors were hence considered more important than organizational characteristics such as age and size. Two laboratories in Western Canada were chosen for inclusion in this study. They are similar along many dimensions but dif f e r on some. Similarities and differences are listed in Table I. The administrative structure of the two laboratories i s similar. Division heads are responsible to the director for professional activities such as research and teaching and to the manager for administrative concerns such as equipment and supplies. (See Appendix B) The laboratory director and division heads in Hospital A have joint appointments with the university. The director spends less than 50 per cent of his time at the hospital; division heads spend 90 per cent of their time there. The laboratory and division heads at Hospital B are less closely associated with the university. However, the laboratories do not differ greatly in terms of the amount of time directors spend on administrative 33 TABLE I SIMILARITIES AND DIFFERENCES BETWEEN TWO PATHOLOGY LABORATORIES Variable Laboratory A Laboratory B Difference a f f e c t s i n -v e s t i g a t i o n of statement Size (no. of employees i n laboratory Period of time lab has been i n existence Type of h o s p i t a l Technical system of laboratories Power Environment Admin, structure of unit Unit grouping Recent h i s t o r y of unit Pay of p r o f e s s i o n a l s t a f f Length of time manager has been i n that p o s i t i o n Background of Manager Sex of Manager 240 30+ years Teaching 150 30+ years Teaching Work procedures standardized and s i m i l a r across l a b o r a t o r i e s . Power i n d i v i d u a l s or units i n and outside the organization are s i m i l a r across l a b o r a t o r i e s , with one exception. | The h o s p i t a l and external environ-ments are s i m i l a r across l a b o r a t o r i e s . I Very s i m i l a r across l a b o r a t o r i e s . D i v i s i o n s dispersed Power of d i v i s i o n s d i f f e r e d . Role of| manager to a l l o -cate resources according to need Salaried s t a f f Computer science and systems ana l y s i s . Male Div i s i o n s located on 3 f l o o r s , d i r e c t l y above one another. A r e l a t i v e l y stable u n i t . No major changes or upheavals i n the l a s t years. Pay based on a percentage of fees for service. Technical: has worked i n labora-tory for 20 years. Female Statement 1 Statement 3 Statement 1 34 concerns, since the director at Hospital B spends most of his time on pathology related tasks. The background of the laboratory manager in Hospital A is in computer science and systems analysis. Historically this laboratory operated in such a way that divisions which made the greatest demands were allocated the most resources. The present manager has been responsible for rationalizing resource allocation. He has considerable power in that the director relies on him for information about division needs and bases decisions on this information. The laboratory manager in Hospital B has a technical background. She has worked in the laboratory for 20 years and been the manager for the last seven years. The operation of this laboratory has been relatively stable over the last 10 years. The director of the laboratory at Hospital A is also head of the department of pathology at the university. His sources of power are several. As head of pathology he has considerable control over the appointment of division heads in laboratories in a l l teaching hospitals, in that a l l appointments require his approval. He exerts control over the way in which specialties in microbiology, haematology, etc. develop in each hospital in this way. He is well respected in the f i e l d and his brother was a deputy minister at one time. Thus, what constitutes an external power for Hospital B i s both an external and internal power for Hospital A. Professional staff (the director and division heads) at Hospital A are salaried members of staff. Hospital o f f i c i a l s have established rates of pay for assistant pathologists, associate pathologists and pathologists. Part of a division head's salary may come from the university; the amount depending on the degree of his/her involvement there. At Hospital B, hospital administrators assess and measure (with laboratory professional staff) the volume of work done by the laboratory in 35 terms of fees for service. The total fee for service is based on a percentage of fees laid out by the Provincial Medical Association schedule of fees. The percentage of fees is adjusted periodically to insure that total fees in a 12 month period do not exceed a certain amount. The total figure is comprised of the fees paid by the hospital to the professional staff and the amount paid by the regional member hospital laboratories• which use Hospital B's laboratory services (Agreement Between Hospital B and Laboratory Director and Associates, 1981). The laboratory director and manager in each hospital are the focus of this study. The term "management" applies to these individuals. Importance of Differences in Settings i n  Terms of Investigating Pfeffer's Statements S1 asserts that the manager has a small impact on instrumental action. Investigation of this statement included examining the effect of external powers on instrumental outcomes. Method of payment is a variable with the potential of affecting the manager's a b i l i t y to influence substantive outcomes. The pay of pathologists in Hospital B is based, in part, on number i of tests performed, which may serve as a motivator for creating conditions which promote increased ut i l i z a t i o n (e.g. allowing the laboratory to be f u l l y operational 24 hours a day). Pathologists i n Hospital A are on salaries and unlikely to be similarly motivated. The head of the department of pathology at the university serves as an external power for Hospital B and as both an external power and laboratory director i n Hospital A. Ambiguity about whether the director or head of pathology had influenced outcomes was expected. According to S2, management's action operates largely with and on symbolic outcomes. Which variables are likely to affect such action? Unit size can influence the amount of time the manager is required to spend on 36 supervision and hence time l e f t for other tasks. None of these managers is responsible for direct supervision. Division heads do some technical supervision but standardization of work reduces the need for direct supervision. Unit size is thus unlikely to influence the effect the manager has on symbolic outcomes. Laboratories A and B differ in terms of unit grouping. When divisions are dispersed, as in Laboratory A, r i v a l r i e s often develop making i t d i f f i c u l t for the manager to create consensus about organizational a c t i v i t i e s . But investigating S2, involved examination of the impact of the manager on symbolic outcomes, not the existence of consensus. Differences in unit grouping were not expected to hinder examination of this statement. One manager has a background in management and the other a technical background. The former is very aware of p o l i t i c a l variables and may have greater motivation than the latter to influence symbolic outcomes. One manager is male and the other, female. Pfeffer maintains, however, that the manager's actions w i l l have their largest effect on symbolic outcomes in spite of such individual differences. S3 focuses on the effects of conditions of power and dependence on symbolic outcomes. As outlined above, the head of the department of pathology plays a dual role in Laboratory A. Possible ambiguity regarding which role had influenced outcomes in this laboratory was anticipated. S4 claims that symbolic outcomes and the instrumental aspect o1 organizational activity are l i k e l y to be closely linked. According to S4a, the strength of the linkage w i l l depend on managerial motives for redefinition, the characteristics of outcomes and on the characteristics of recipients of outcomes. Since characteristics of outcomes (e.g. equipment) and characteristics of recipients of outcomes are very similar in both laboratories, investigation of S4 and S4a was not affected by variables listed i n Table I. 37 In summary, differences between laboratories were expected to affect investigation of statements in certain ways. Method of payment of professional personnel could influence examination of S1 ; and the fact that laboratory relationships with the head of pathology d i f f e r , might affect investigation of S1 and S3. Investigation of Research Statements:  A General Outline Research statements were not investigated separately. For example, the interview with the manager focused on issues related to several statements. The section below presents a general picture of what was involved in examining each statement. SI: The manager has l i t t l e effect on substantive outcomes. Exploring this statement involved several steps which are listed below and elaborated. (i) identifying substantive outcomes. ( i i ) determining whether the manager's actions directly affect substantive outcomes and how large this impact is in relation to other factors influencing outcomes. (i) Because managerial impact on various substantive outcomes may differ, as many substantive outcomes as possible were examined. Determining (retrospectively) the causation of factors that influenced existent substantive outcomes can be problematic. Archival data were thus used where possible; for example, division heads' written requests for equipment. ( i i ) Determining the extent to which the manager directly affects substantive outcomes included: (a) interviewing the manager regarding his/her impact on substantive outcomes (cognizant of the fact that a manager would likely attribute outcomes to his/her actions). 38 (b) identifying conditions of power and dependence at the organizational and subunit levels; identifying which of these could have influenced substantive outcomes; interviewing people and examining relevant documents in order to assess the magnitude of the impact of the external power versus that of the manager on substantive outcomes. S2. Management's action operates largely with and on symbolic outcomes. Examining this statement involved the following: (i) interviewing the director, associate director and manager and observing as wide a range of their actions as possible. ( i i ) observing and conducting interviews with organizational participants regarding the meanings they ascribed to managerial behaviour. Each of the above steps is examined in some detail below, (i) Managerial actions. Pfeffer (1981a) states that managerial control derives from symbolic action. Symbolic action refers to actions/ utterances in which the intended meaning differs from the obvious or l i t e r a l meaning. An act may be both symbolic and substantive in nature. The overt meaning of a manager's actions was determined (in part) by asking him/her about intended meanings of actions and words. Since i t was recognized that this would not always yield valid information, some questions were indirect. Descriptive and contrast questions were used (Spradley, 1980). ( i i ) Meaning assigned to managerial actions. According to Pfeffer, the manager uses language, symbols, rituals and ceremonies to achieve the following goals: (a) to give organizational actions and events meaning, (b) to legitimate decisions that were resolved through the use of power, (c) to mobilize support, and (d) to quieten the dissatisfied. The meaning assigned to managerial actions was ascertained by asking contrast questions, such as "Do you see any differences ...?" Sets of contrasts may reveal kinds of differences that reveal symbolic meaning. ( i i i ) Is management's effect primarily with respect to symbolic outcomes? 39 Whether the manager's effect is primarily on symbolic outcomes can be answered only in conjunction with the issue of the extent of the manager's effect on substantive outcomes (S1). 53. Conditions of power and dependence have a small effect on symbolic  outcomes (such as attitudes, values and perceptions). S3a. Conditions of power and dependence have a potentially powerful effect on  symbolic outcomes i n that they allow those" with power to influence symbolic  outcomes at the organizational, subunit and individual levels. When and how  this occurs depends on the motivations of those with power. Examining these statements included the following: (i) identifying conditions of power and dependence. This involved identifying conditions of resource scarcity, interdependence, disagreement regarding goals, important resources and dispersion of power. ( i i ) identifying the extent to which conditions of power and dependence affected symbolic outcomes. This involved talking to powerful external actors, managers and organizational participants and identifying types of symbolic outcomes which might benefit powerful external actors or organizations. ( i i i ) the extent to which powerful individuals succeeded in influencing the beliefs of organizational members was ascertained by talking to these members. 54. The symbolic and instrumental aspects of organizational activity are  clearly linked; but at the same time i t i s lik e l y that the coupling between  them i s loose. S4a. The symbolic and instrumental aspects of organizational activities are  linked. How strongly or loosely they are linked w i l l be influenced by (a)  managerial motives for redefining the situation, (b) characteristics of  outcomes, and (c) characteristics of recipients of outcomes. Substantive and symbolic aspects of organizational activity which are loosely coupled have few variables in common. A substantive outcome was selected and variables in that outcome identified .through observation, interviewing and examination of records. Beliefs and feelings related to that outcome were identified and the degree of similarity/overlap between variables of substantive and symbolic outcomes was assessed. 40 This process was repeated with a number of substantive outcomes. Patterns of relationships between pairs of substantive and symbolic outcomes were examined in order to determine whether loose coupling i s more l i k e l y when one or more of the following conditions i s present: incongruities exist between organizational goals and power. organizational achievements are at odds with i t s purpose the organization has a controversial objective, organizational outcomes are not directly observable. preferences of people (in or outside the organization) are undefined/ambiguous. Projected relationships between variables in a l l statements are presented diagramatically in Figure 5. Pi l o t Study A p i l o t study was conducted in the laboratory of a teaching hospital; the purpose of which was to determine and correct any failings discovered in study design and methods. Some of the standardized open-ended interview questions i n i t i a l l y included in the interview schedule were found to be inappropriate and were altered. Sampling The investigator spent 25 days (between February 1 and March 12, 1982) in Laboratory A and 18 days (between March 15 and April 15, 1982) in Laboratory B. Size explains the discrepancy in time spent in each; Laboratory A has considerably (240 vs 150) more staff than Laboratory B and a greater number of interviews was required there. The researcher did not enter both laboratories with the same assumptions and expectations. From her experience in Laboratory A, she had some sense of the strengths and shortcomings of Pfeffer's ideas and then explored these in greater depth in Laboratory B. Since the nature of. 41 FIGURE 5 PROJECTED RELATIONSHIPS BETWEEN VARIABLES Actions of management I x Powerful i n d i v i d u a l s i n or outside h o s p i t a l S2 Actions of management have l i t t l e e f f e c t on substantive outcomes S4 Loose coupling e.g. Important factors i n promotions, acquiring c a p i t a l equipment etc. and b e l i e f s about these factors correspond very l i t t l e SI S3a x X X Symbolic Outcomes (Attitudes Feelings B e l i e f s ) x X x/ \ X X X \ \ \ X Substantive actions and outcomes ^ (laboratory t e s t s acquiring c a p i t a l equipment, h i r i n g f i r i n g , promotions, budget a l l o c a t i o n s ) S3 Conditions of power and dependence do not a f f e c t symbolic outcomes S4a Strength of coupling depends on the motivations of manager, c h a r a c t e r i s t i c s of \ outcomes and j c h a r a c t e r i s t i c s of f r e c i p i e n t s of outcomes actions a f f e c t outcomes .—>-actions do not a f f e c t outcomes —xx xx xx—y linkage ( r e l a t i o n s h i p ) between symbolic and substantive outcomes 42 this research i s both inductive and deductive, this process i s appropriate and desirable. A l l those interviewed were informed that the intent of the study was to identify the extent to which laboratory activities are influenced by people in the laboratory and to what extent by people in other parts of the hospital or outside the hospital. Several consecutive days were spent in each of the five divisions in each laboratory. In an attempt to reduce obtrusiveness, the investigator spent 5-10 hours observing division activities and interacting with division members before conducting interviews. After individuals had discerned the purpose of her study and had talked to her, they appeared to feel comfortable with her presence and continued with work routines and interactions. Field notes were taken at coffee breaks, lunch times and other intervals during the day. Each interview lasted 40-90 minutes. Many interviewees assented to be tape recorded. Notes were taken during the interviews of those who did not, and expanded immediately following the interview. Time sampling of tapes was performed to assess the consistency of investigator behaviour in interviews, over time. The investigator noted that people in positions of power were far more open when the tape recorder was switched off than when i t was on. This led to the decision not to attempt to tape interviews with those in positions of power (e.g. laboratory managers and hospital administrators). Study participants at lower levels in the organization may also have been reluctant to be completely honest while being taped. But since the question asked of these individuals posed less risk of exposure, i t was thought that the hesitancy they might experience would be minimal. Sources of information were interviews, observations and documents. Each source i s described below. 43 Interviews Interviews were conducted with the following people in each organization. (Questions asked are listed in the Appendix). (i) the laboratory director and manager. ( i i ) the assistant director and assistant manager in Laboratory A (positions which do not exist in Laboratory B). ( i i i ) division heads (5 in Laboratory A; 4 in Laboratory B). (iv) a s t r a t i f i e d sample of medical staff (10 percent selected randomly from each division, i . e . 4 individuals in Laboratory A and 1 in Laboratory B) . (v) head technologists (9 in Laboratory A, 5 in Laboratory B). (vi) a st r a t i f i e d sample of technologists (25 percent selected randomly from each division; i.e. 15 in Hospital A and 8 in Hospital B). (vii) the hospital administrator responsible for resource allocation. ( v i i i ) person responsible for labour relations. (ix) the head of the department of pathology at the university. Research reports have documented the influence of physician demand on the number of tests performed (Freeborn, Baer, et a l , 1972). Interviewing of physicians in relation to this issue was thus considered redundant. Observations Observations were conducted of the following: (i) the general activity in each of the divisions of both laboratories. ( i i ) the actions, language, dress, office furniture and office layout of the laboratory direct and manager. Documents Agreements between technical and c l e r i c a l employees and their respective unions were studied. Reports of research on laboratory costs and u t i l i z a t i o n conducted by the director and others in Laboratory A were examined. Documents 44 (written by division heads and laboratory managers) requesting capital equipment and additional staff were reviewed, as were annual reports of the department of pathology at the university. Measuring Instruments Observations and questions focused on relationships between the actions of managers and other powerful individuals and substantive and symbolic outcomes. Substantive outcomes and powerful individuals (identified in conjunction with the managers of laboratories and others knowledgeable in this field) are itemized in Table II. Powerful individuals are those with some control over resources or decisions of importance to laboratory operation. The study was limited to examination of substantive outcomes within the laboratory. Tangible outcomes outside the laboratory which laboratory personnel could have affected (e.g., hiring of the director of nursing) were not examined, since this would have required investigation of numerous additional influences. This section outlines those observations and interview questions which could be specified in advance. Factors such as beliefs and attitudes were unknown prior to entry in the organizations. Advanced formulation of a l l questions and observations was thus not feasible. Interviews The existence of some unknown factors such as the nature of beliefs and feelings about managerial actions, necessitated the use of two approaches to conducting open-ended interviews. Standardized open-ended questions were constructed in advance, phrased precisely as they were asked in the interview. This approach i s intended to minimize interviewer effects and enhances the c r e d i b i l i t y of data collected. An interview guide of issues to be explored during the interview was prepared. The guide kept the interaction 45 TABLE II SUBSTANTIVE OUTCOMES OF LABORATORIES AND POWERFUL FORCES AND INDIVIDUALS INFLUENCING LABORATORY OPERATION Substantive Outcomes Funding f or equipment Operating budget Laboratory costs and u t i l i z a t i o n Research Teaching Quality Control A c c r e d i t a t i o n H i r i n g of p r o f e s s i o n a l personnel Promotion of pro f e s s i o n a l personnel F i r i n g of pr o f e s s i o n a l personnel Payment of pro f e s s i o n a l personnel H i r i n g of te c h n i c a l and c l e r i c a l personnel Promotion of t e c h n i c a l and c l e r i c a l personnel F i r i n g of te c h n i c a l and c l e r i c a l personnel Powerful Individuals and Forces Physicians ordering laboratory tests Hospital administrators M i n i s t r y of Health o f f i c i a l s Head of department of pathology at u n i v e r s i t y Canadian Council on Hospital A c c r e d i t a t i o n Canadian Society of Laboratory Technologists Royal College of Physicians and Surgeons Unions for t e c h n i c a l and c l e r i c a l s t a f f P r o v i n c i a l Medical Association 46 i focused, but allowed for the emergence of individual perspectives and experiences (Patton, 1980). Standardized open-ended interview questions asked of selected individuals in each setting are itemized in the Appendix. Questions asked of a particular person may pertain to several statements. Table III l i s t s the people interviewed and statements to which interview questions relate. Interviews which were long were staggered over a period of two or three days. Observation Observation was used primarily in investigating Statement 2 and focused on ways in which the behaviour of the manager operated on beliefs, feelings and attitudes. The dress, speech, actions, office layout and office design of directors and managers convey nonverbal messages to others even when not expl i c i t l y planned to do so. Open desk placement i s , for example, likely to convey friendliness (Morrow & McElroy, 1981); but one cannot assume that i t w i l l have this effect. The only way of finding out what particular actions mean to people i s to ask them. The researcher noted which people have the most contact with the director and manager. Subtle comments on the behaviour of the director and manager were made to these people in an attempt to discover what the actions of those in charge of the laboratory meant to them. According to Pfeffer (1981a), the manager uses language, symbols, rituals and ceremonies to legitimate decisions made on the basis of power, to give meaning to organizational activities, to mobilize support and to quieten the dissatisfied. Observations to be made could not be precisely specified in advance. The researcher was heedful of managerial attempts to legitimate, mobilize support, etc. However, since managers and directors spent l i t t l e time in the laboratory, the research was afforded l i t t l e opportunity to observe their interactions with laboratory personnel. 47 TABLE I I I INTERVIEWS, OBSERVATIONS AND DOCUMENT ANALYSIS ASSOCIATED WITH EACH STATEMENT Interviewing the d i r e c t o r Interviewing the manager Interviewing medical s t a f f Interviewing d i v i s i o n heads Interviewing head technologists Interviewing technologists Interviewing h o s p i t a l administrators Interviewing head of pathology at the un i v e r s i t y Observing.manager 1s actions Observing d i r e c t o r ' s actions Observing a c t i v i t y i n laboratory Document analysis SI involved / / / / / / S2 involved / / / / / / / / / / / / S3 involved / / / / / S4 involved / / / / / / 48 Data Analysis Since the study was concerned with investigating relationships between substantive and symbolic outcomes and managerial versus external control outlined by Pfeffer, his theory had an important role in forming the classification system for categorization of observations. Field notes on observations, interviews and documents were reviewed and data labelled according to their relevance to various statements. Data were organized into statements. Each observation or response to an interview question became an item against which the research statement was checked; i.e. multiple implications of each aspect of theory were looked for. A record was kept of the implications against which each statement was checked and the number of 'positive' items compared with the number of 'negative' instances. Data analysis also included developing multiple images of what data could mean. For example Pfeffer states that substantive and symbolic outcomes are loosely linked. Indications that, for example, equipment allocation and beliefs about allocation correspond very l i t t l e were looked for. Evidence was also sought that strength of linkage between equipment allocation and beliefs about allocation were influenced by managerial motivations, characteristics of outcomes, and preferences of individuals. In addition to this deductive approach, the researcher attempted to discover categories from the data. For example, type of symbolic outcome emerged as a category of factors influencing the strength of coupling between substantive and symbolic outcomes Validity of Findings The purpose of this study was to investigate some of Pfeffer's claims about the symbolic role of management. Pfeffer states that the manager's role consists largely of legitimating, explaining and creating shared systems of meaning. It is crucial for validity to try and picture the empirical world as 49 quantify managerial efforts to influence beliefs and attitudes (as well as resultant beliefs), an attempt was made to understand both what the manager's words meant to organizational members and the manager's intentions. Meanings of words, actions and events are best understood by asking people what these things mean to them and by allowing them to express their thoughts and feelings in their own words. Use of open-ended questions facil i t a t e d such responses. The following steps were taken to check other potential sources of invalidity, thereby increasing confidence in the analysis of findings. (i) The researcher attempted to reduce reactivity by spending time in each division and interacting with division members before interviewing them. But such action may result in the researcher becoming an "insider" and losing research questions as a point of reference. She was, however, never in a particular section of a division for longer than three days, which curtailed the development of "insider" status. ( i i ) The researcher searched for r i v a l explanations of relationships. Evidence supporting Pfeffer's claims was sought, as was support for r i v a l explanations (formulated as alternate statements). Explanations for relationships which emerged from the data, were also sought. ( i i i ) If those interviewed and observed try to maintain appearances, data w i l l be invalid (Van Maanen, 1978). In total, 61 people were interviewed and many observed. It i s unlikely that precisely the same appearance was maintained by a l l these people. If people express their beliefs and feelings honestly, the data can be considered valid because the intent of the study i s to identify these views and emotions. (iv) Feedback from study participants regarding whether the researcher i s getting the picture, i s a stringent test of validity (Van Maanen, 1978). With people with whom she interacted frequently, (the manager, 50 head technologists and some technologists) the researcher checked whether her understanding of what they had said about various issues corresponded with what they had intended to convey. But this was not done with a l l study participants. (v) The consistency of information derived from different methods of data collection was cross checked. Observational data, for example, head technologists' statements about union regulations were compared with written statements in union agreements. (vi) A large proportion of the interviews were taped, which reduced the likelihood that verbal information would be misinterpreted or forgotten. Notes were taken during interviews which were not taped, to reduce the possibility of loss of information or inaccurate information r e c a l l . (vii) Time sampling of tapes indicated that investigator behaviour did not change significantly over time. Seventeen of the 61 interviews conducted were taped. Two individuals, working independently, assessed consistency of interviewer behaviour across interviews. Tapes were placed into five groups according to the order in which interviews had been conducted. The f i r s t evaluator randomly selected one tape out of each group for assessment by both evaluators. The ratio of leading to non-leading questions was found constant (9:100) across interviews. The interviewer was assessed as being f a c i l i t a t i v e . Use of open-ended questions and an interview guide sometimes resulted in rambling responses. According to Van Maanen (1981a), the essential test of validity i s the use findings have for those who enter similar organizations at a later time. The original concepts are then changed, discarded or validated on the basis of 51 their a b i l i t y to capture the experiences of another researcher. He adds, however, that In the f i n a l analysis, a l l organization studies rely on the insight and judgement of the investigator because there are no forms of verification that transcend the assumptions built into the technique and theory followed by the investigator (Van Maanen, 1981, p. 17). 52 CHAPTER III ANALYSIS OF FINDINGS Introduction This chapter describes findings of the study. It emphasizes questions posed, but also examines relationships not formally posited in the study. Findings related to the following three issues are presented: 1. the relationship between managerial action and substantive and symbolic outcomes 2. the relationship between external control and symbolic outcomes 3. the relationship between substantive and symbolic aspects of organizational activity Some of the data are relevant to more than one statement and are, accordingly, not repeated in toto. Statement 1 Statement 1 asserts that the manager has a limited impact on substantive  outcomes. This statement examines the magnitude of the impact of four laboratory managers on tangible outcomes (such as equipment allocations and promotions) in relation to external forces (such as hospital administrators and unions). The purpose of this research was to identify extremes in terms of managerial impact on tangible outcomes, i.e., whether he/she is constrained on most tangible outcomes or has a large impact on most of these outcomes. It was thus decided that the statement w i l l be supported i f the manager's influence is found to be external factors on more than 50 percent of tangible 53 outcomes. (Managerial impact on 16 tangible outcomes was examined). Findings that indicate that the manager has a powerful influence on more than 50 percent of substantive outcomes w i l l not support this statement. If the manager and external forces each have a powerful effect on approximately 50 percent of substantive outcomes, findings w i l l be considered inconclusive. People and organizations affecting each tangible outcome are described below, as are beliefs and attitudes about that outcome. Table IV summarizes the extent to which findings related to each substantive outcome support Statement 1. Funding for Capital Equipment The expectation is that laboratory directors and managers w i l l have minimal impact on the amount of money allocated to their departments for capital equipment. Twenty five percent of the cost of diagnostic equipment i s paid by the Regional Hospital District and 75 percent by the Provincial Ministry of Health. For non-diagnostic equipment, the Regional Hospital District pays 66.66 percent of the cost and the Ministry of Health, 33.33 percent. Laboratory equipment i s chiefly diagnostic. The laboratory director and manager pr i o r i t i z e requests from their division heads and submit this l i s t to hospital administrators, who (in consultation with committees) pr i o r i t i z e equipment requests from a l l hospital departments. The l i s t of p r i o r i t i e s i s submitted to the Regional Hospital District and the Provincial Ministry of Health. Officials in these organizations review requests from numerous hospitals. The Regional Hospital District Act stipulates that the Regional Hospital District may not incur capital expenditures without the approval of the Ministry of Health. On the other hand, the Ministry of Health may fund equipment purchases without the approval of the Hospital D i s t r i c t . TABLE IV FINDINGS RELATED TO STATEMENT 1 IN TERMS OF SUBSTANTIVE OUTCOMES Support for Statement 1 No support for Statement 1 Substantive Outcome Amount of Support Hospital A Hospital B Capital equipment funding Operating budget (supplies) Operating budget (personnel) Laboratory costs Hiring professional personnel Promoting professional personnel Firing professional personnel Payment of professional personnel Hiring technical & clerical personnel Promoting technical personnel Firing technical personnel Research Teaching Quality Control Accreditation Large Large Large Large Large Inconclusive Large Inconclusive Large Large Large Large Large Inconclusive Large Ministry of Health a hospital administrators are powerful forces Ministry of Health, hospital administrators & economic conditions are powerful forces Ministry of Health & hospital administrators are powerful forces Demand for tests by physicians & costs of factors of production are powerful forces Affiliation documents between hospitals & university Creation of research position Since external power i s also director, assessment difficult Professionalism and head of pathology at university are constraints Unions exert a powerful influence Unions exert a powerful influence Unions exert a powerful influence Pulmonary research determined by head of pathology Head of pathology (unlv.) service demands & -fiscal restraint are powerful forces Canadian Society of Laboratory Technologists head of pathology at unlv. & Royal College bf Physicians & Surgeons powerful forces Whether external demands or manager has largest effect, difficult to determine Canadian Council on Hospital Accreditation i s a powerful force Pathologists' choice of work setting & fee for ser-vice has large effect in Hospital B Large amount of support: External power holders have greater impact on tangible outcome than manager. No support: Manager's power to influence tangible outcome is constrained very l i t t l e by external power holders. Inconclusive findings: In 50% of instances manager has considerable power to influence tangible outcome; in other 50% external power holders have a greater impact on tangible outcomes than manager. 55 Equipment funds allocated to the laboratory are determined in large part by the Ministry of Health, the Regional Hospital District and hospital administrators (external powers). The director and manager have power to pr i o r i t i z e equipment requests. The manager and director in Hospital A are strongly motivated to influence other power holders (as opposed to subordinates) to allocate greater resources to the laboratory and to legitimate laboratory expenditures to these individuals. Maintenance of adequate services i s the goal of the manager and director at Hospital B. They devote considerably less energy to influencing beliefs than do their counterparts in Hospital A. Management in Hospital A claim they lobby hospital administrators and Ministry of Health o f f i c i a l s regarding the importance of their requests; "we highlight programs that are written up on paper". They state that some allocations have resulted from lobbying efforts. A hospital administrator's concurrence with that statement was evident in the following: "The evidence they bring me sometimes convinces me of the need for more equipment and I allocate more money". Managers in Hospital B do not engage in lobbying. Division heads sometimes apply to external organizations and service clubs for equipment funding. If they obtain 25 percent of the cost of a particular piece of equipment from such an organization, they may request the balance from the provincial government. Requests to the provincial government are channeled through laboratory management and hospital administrators. It i s noteworthy that objectives of the Ministry of Health, hospital administrators and laboratory management diffe r considerably. An important goal of Ministry of Health o f f i c i a l s i s the allocation of funds to health care f a c i l i t i e s across the province i n ways they consider w i l l help their party to be re-elected. The objectives of hospital administrators include compliance with the Ministry of Health mandate to exercise f i s c a l restraint and 56 allocation of resources within the hospital in ways which satisfy the most powerful groups. Management at Hospital A wishes to achieve international recognition for research, which requires up-to-date equipment and an adequate personnel budget. An important objective of the laboratory director at Hospital B i s profit maximization. Overall, findings related to funding for capital equipment support Statement 1, in that the power of laboratory management to obtain this funding i s constrained by the Ministry of Health and hospital administrators. Operating Budget (Supplies) Statement 1 leads to the expectation that the laboratory director and manager w i l l have l i t t l e impact on the size of the supply budget allocated to the laboratory. The supply budget allocated to a hospital by the Ministry of Health i s based on the budget for the previous year with an increment for inf l a t i o n (12 percent in 1981). Administrators allocate supply budgets to the laboratory. Decisions regarding allocations to the divisions are made by the laboratory manager and director. Money for supplies has, traditionally, not been d i f f i c u l t to obtain. Managers report that, for the most part, they have been able to obtain a l l the laboratory supplies they have requested. But with f i s c a l restraint, there has been pressure on managers to reduce the cost of supplies. Laboratory managers are constrained by decisions of Ministry of Health o f f i c i a l s and hospital administrators. These findings support Statement 1. Operating Budget (Personnel) Evidence that management i s constrained in i t s a b i l i t y to influence the personnel budget w i l l support Statement 1. The personnel budget allocated to each department i s larger by a certain percentage than that of the previous 57 year and as such i s sufficient to maintain the previous year's level of staffing. Management at Hospital A lobbies hospital administrators and Ministry of Health o f f i c i a l s regarding additional programs and staff positions. They.think that sometimes they have obtained additional staffing as a result of these lobbying efforts. Fiscal restraint has resulted in a hiring freeze at Hospital A. Laboratory management has found ways around this constraint by allowing laboratory personnel to work overtime. In addition, i f the laboratory budget i s over-expended, the Ministry of Health has had no option but to pick up the tab. Laboratory managers have limited power in relation to the personnel budget; finding which, supports Statement 1. At Hospital B, requests for additional positions have to be j u s t i f i e d by the Hospital Position Committee. There i s competition among departments for these positions and department heads present data justifying position requests. Should the laboratory be allocated some, or a l l , of the positions requested, laboratory management has the power to decide how these are to be distributed. This indicates limited power and supports Statement 1. Overall, findings related to the personnel budget support Statement 1, in that the manager's power i s constrained by the Ministry of Health and hospital administrators. Laboratory Costs and Utilization Factors external to the laboratory are expected to have a great impact on laboratory costs and u t i l i z a t i o n . It i s anticipated that the power of laboratory management i s limited (Statement 1). The laboratory director at Hospital A initiated a series of studies on laboratory costs and u t i l i z a t i o n . The two most significant factors affecting costs were found to be (i) demand for tests and number of test orderers (qualified and trainee) per occupied bed. Medical staffing and training 58 policies are crucial issues here. Demand i s largely outside the control of the laboratory. According to study findings, "The laboratory i s almost totally reactive to work sent to i t . It has legally mandated tests to perform and l i t t l e discretion in refusing to perform tests ordered by physicians" (Study at Hospital A, 1981). Although formal studies of laboratory costs and u t i l i z a t i o n have not been conducted at Hospital B, i t i s l i k e l y that causative factors would differ l i t t l e from those at Hospital A. Studies on laboratory costs conducted in other parts of Canada and the U.S. reach similar conclusions (Freeborn, Baer et a l , 1972; Philip and Hai, 1979). The laboratory director and division heads at Hospital B are on a modified fee for service salary scheme which provides some incentive to increase demand. Substantive evidence that this occurs i s not readily available. ( i i ) Examination of the cost of factors of production in these studies reveals that costs of labour and materials have increased and that this has not been compensated for by increases in productivity or reduction in complexity of testing. Technology can reduce the cost of performing tests; but an increase in ava i l a b i l i t y stimulates c l i n i c a l demand and the net effect is increased total costs. The a b i l i t y to match wage settlements (of technical and c l e r i c a l personnel) with increases in productivity i s not under management control since these personnel are unionized. Findings on laboratory costs provide support for Statement 1, in that factors influencing costs are chiefly external forces. Management's limited power l i e s in the a b i l i t y to select productivity increasing equipment. Hiring of Professional Personnel Statement 1 leads one to expect the laboratory director to be constrained by external factors and to possess limited power only in the hiring of 59 professional personnel. The head of pathology at one of the universities in the province has considerable input into the hiring of professional staff in teaching hospitals in the province. A f f i l i a t i o n documents between the university and hospitals A and B state that "Where a hospital department or division conducts a teaching program, the chairman of the department and/or director of division at the hospital shall be appointed and/or re-appointed by formal joint agreement between the hospital and the university"; and this i s , indeed, what occurs. Since the head of pathology is also the laboratory director at Hospital A, assessment of the impact of an external power holder on hiring in this organization i s d i f f i c u l t . The head of the department of pathology noted that though he has the power to influence hiring in teaching hospitals, he exercises discretion in using that power. He stated, "My role in influencing who i s hired depends largely on the affect of the institution. If people there don't want to be at the forefront of technology, creativity and innovation, i t won't help matters to i n s i s t on placing a top-notch researcher there. That person wouldn't f i t in. " This reflects the situation at Hospital B. The pathology head has for the most part, not actively intervened in hiring decisions there. That he has the power to make this decision supports Statement 1. He did, however, create a position (marginally attached to the laboratory) for a renowned researcher in pulmonary function. Seventy five percent of this individual's salary comes from the university. This finding supports Statement 1. When asked about the impact of the head of pathology on his department, the laboratory director at Hospital B declared vehemently, (head of pathology) controls other teaching hospitals, but has absolutely no input here"; and then he asked, "Are you sure this i s confidential?" In summary, objective indicators of the influence of external power holders ( a f f i l i a t i o n documents and the creation of a research position) 60 support Statement 1; whereas the perception of the laboratory director at Hospital B does not. Objective indicators in this case provide stronger evidence than do perceptions of influence, and are also more numerous. Evidence for the limited power of management i s large; and Statement 1 is su£>ported. Promotion of Professional Personnel The expectation related to Statement 1 regarding promotion of professional personnel is that such decisions are largely outside the purview of laboratory management. At Hospital A, promotions of a l l professional personnel (with and without academic appointments) are based on academic c r i t e r i a i.e., publications. One division head noted, "I suspect that was the director's doing, even though he hasn't said so. I don't think i t ' s right. People who are hired for service, shouldn't be evaluated in terms of academic c r i t e r i a . " It i s the dream of the head of pathology at the university that the complex of teaching hospitals in this province become renowned for laboratory research. His position as laboratory director likely allowed him to introduce academic c r i t e r i a for performance evaluation of professional personnel in Hospital A. Every year he recommends the promotion and/or tenure of certain individuals to a promotion and tenure committee at the university. Since the head of pathology i s also the laboratory director, i t i s d i f f i c u l t to assess the extent to which the head of pathology (an external force) was responsible for introducing these promotion c r i t e r i a . However, this could not have occurred without the consent of the director. Findings suggest support for Statement 1. At Hospital B, there i s no possibility for promotion among professional personnel in the laboratory. Each remains in the position in which he/she was appointed and expects this to be the case when appointed. There are thus, no data regarding promotions in this organization. 61 In summary, data on promotion of professional personnel do not indicate whether these decisions are made chiefly by the head of pathology at the university or by the director. Evidence related to Statement 1 is therefore inconclusive. Firing of Professional Personnel It i s anticipated that the director's power to f i r e professional personnel is limited (Statement 1 ). Firing of professional personnel with academic appointments cannot occur without consultation with the head of the department of pathology. Similarly, the head of the department of pathology may not withdraw the academic appointment of an individual who holds both academic and hospital appointments without prior consultation with the laboratory director. The power of each of these individuals i s constrained by the other. The laboratory manager in Hospital A noted that management's power to fi r e professional personnel (with and without academic appointments) is constrained because the individuals concerned are professionals. His explanation went as follows, "It's a business of my expertise versus yours. Who am I to say, 'You as a professional are not sound?' In my five years here, there's been one demotion, but I've never seen anyone actually fired. The way you get people to leave, i s by not promoting them. You signal to them that way that you're not entirely happy with their performance. There's one division head that I mistrust. I give him no resources and I heard he's been looking for another job." Since professionalism serves as an external constraint, this finding supports Statement 1. The laboratory director in Hospital B is not ambitious. He is quite accepting of professional personnel who function more or less competently and fi r i n g these people is seldom, i f ever, contemplated. The manager made this 62 remark about one of the division heads, "Dr. is more interested in his boat and home than in his job," and added that this didn't mean his position was not secure. However, should the director attempt to f i r e a professional staff member, i t is likely that he would be confronted with similar constraints as those faced by the director Hospital A. In summary, findings in both organizations support Statement 1, in that the manager has no power to f i r e professional staff. Method of Payment of  Professional Personnel Professional personnel in most hospital laboratories in Western Canada are paid on a fee for service basis. In Hospital B the method of payment is a modified fee for service system. Professional personnel at this hospital would prefer a f u l l fee for service system of payment. As the laboratory director phrased i t , "It would give us much more f l e x i b i l i t y . We wouldn't have to go there, hat in hand, and ask for a 10 percent increase and get 8 percent. We'd just hand in our fee schedule. But the president of the hospital is against this." Thus, in Hospital B, method of payment is determined in large part by hospital administrators. The head of pathology at the university was instrumental in establishing salaries as the method of payment in Hospital A. The motivation for this action was to free professional staff to do research. The laboratory manager in Hospital A explained the move thus, "He (head of pathology) doesn't want people worrying about money. He says, 'Here's what i s . Now get on and think higher thoughts'." Method of payment in Hospital A has been determined by an external power. In summary, method of payment of personnel i s largely determined by external power holders. Statement 1 is supported. 63 Hiring of Technical and  Cl e r i c a l Personnel Technical staff belong to a provincial health worker's union. Cleri c a l staff are memebers of the Hospital Employees' Union, a national organization. Union agreements contain clauses (such as the length of time vacancies are to be posted) which limit managerial freedom in hiring. Union agreements also require the employer to provide the union with descriptions of a l l job classifications. Two head technologists claimed to have succeeded in writing job descriptions around individuals they wished to hire. Statement 1 is supported, in that the manager's freedom in hiring i s limited by union agreements. Promotion of Technical and  Cleric a l Personnel Union agreements state that performance, qualifications and seniortity w i l l be determining factors in the promotion of employees. The union to which c l e r i c a l workers belong places much emphasis on seniority. Three head technologists admitted to having written job descroptions to f i t those individuals they wished to promote. One also stated, "If I know the person applying for promotion avoids assuming responsibility, I stress the responsibility factor in this position, and they usually back down. Effective management is curtailed by the unions." Statement 1 is supported. Firing of Technical and  Cl e r i c a l Personnel Union agreements stipulate that no-one may be fired without just cause. Alleged reasons for dismissal must be documented; and employees dismissed for any cause have the right to process a grievance. The power of the manager to dismiss an employee is restricted by union regulations; and Statement 1 is supported. 64 Time Spent on Research Research conducted at these hospital laboratories can be categorized as follows: (i) applied and basic laboratory research conducted by division heads and medical staff. ( i i ) research engaged in by the laboratory director (and colleagues) at Hospital A, whose goal is increased knowledge of factors affecting laboratory costs and u t i l i z a t i o n . The expectation related to Statement 1 is that the amount of time spent on research w i l l be determined largely by external factors. Factors influencing each type of research are outlined below. (i) Research conducted by division heads and medical staff. The goal of the head of pathology at the university is that the network of laboratories in teaching hospitals in the province gain international recognition through producing outstanding research. He has considerable input into the hiring and promotion of professional personnel in teaching hospitals. The laboratory director at Hospital A is also head of pathology at the university. According to the laboratory manager at Hospital A, "The head of pathology has picked key researchers; There i s _ at Hospital A, at Hospital C and at Hospital D. He was instrumental in having professional staff placed on salaries in this institution. This frees these people to think higher thoughts." The head of pathology identified university promotion and tenure decisions as the crucial factors determining the amount of research which occurs. He said that an individual's salary may be paid completely by the hospital, completely by the university or by both institutions. He considered that in arrangements where the university contributed 20 percent or more of the individual's salary, university c r i t e r i a for promotion (which stress publications) would be applied. 65 Of the five division heads interviewed at Hospital A, three agreed that university appointments and recognition that accompanied publications were primary factors in influencing the amount of research they did. Two emphasized that their jobs consisted of service, teaching and research, in that order; and that research was done only when service and teaching commitments allowed this. A division head who is an avid researcher mentioned that a policy of f i s c a l restraint at the hospital had resulted in one less professional person in his division and consequently reduced time for research. Comparatively l i t t l e research is conducted in the laboratory at Hospital B. In 1980 professional personnel in Hospital A produced 17 publications and a pulmonary researcher in Hospital B, five. Division heads claim to have no time for such endeavours. The culture here is very different from that in the laboratory at Hospital A. The priority of management and most division heads in Hospital A is publication of high quality research. Professional personnel in the laboratory in Hospital B place considerably less value on research. They are committed to providing service to the hospital in ways which maximize their profits. They are paid on a modified fee for service system which provides an incentive to perform as many tests as possible. The laboratory director and other professional personnel chose this payment system (or employment in a hospital with such a system), which almost precludes a dedication to research. This does not support Statement 1 which asserts that the amount of time spent on research is largely influenced by external factors. Pharmaceutical companies i n i t i a t e research (in the form of t r i a l s of equipment and chemicals). Such research forms a very small proportion of the research conducted at Hospital A, and a large proportion of that 66 conducted at Hospital B. The only research conducted in the laboratory at Hospital B is that done by an internationally recognized pulmonary researcher, who is marginally attached to the laboratory. His position was created by the head of the department of pathology at the university; and the university pays 75 percent of his salary. This individual's mandate is to conduct research. Since the mandate comes from an external organization, this finding supports Statement 1. ( i i ) The research conducted by the head of the department of pathology at the university/laboratory director at Hospital A and colleagues, examines factors determining laboratory costs and u t i l i z a t i o n . The time devoted to this research is closely related to motivations for performing the research which are twofold (a) to have a tool with which to defend laboratory policies and actions against demands of hospital administrators and Ministry of Health o f f i c i a l s that costs be reduced (an external motivation) and (b) a desire on the part of the head, of pathology/laboratory director to obtain international recognition through publishing this research. The goals of one person (evident in two roles one of which is managerial and one of which is external) hampers classification of the person largely responsible for this research. In summary, objective indicators of external influence on research are university c r i t e r i a for promotion and the appointment of a key researcher to Hospital B. Service and teaching demands, f i s c a l restraint and demands of administrators can be classified as perceived external influences. A perceived internal influence is the fee for service system. Overall, there is strong evidence that external power holders have much influence on research and Statement 1 is supported. 67 Teaching Teaching in laboratories of teaching hospitals occurs at three levels, i.e., with medical technology students, medical students and pathology residents. The expectation related to Statement 1 is that managerial impact on teaching is limited. Factors influencing teaching at each level are outlined below: Technologists: The academic training of medical technologists occurs at a community college, after which they spend one year in a teaching hospital gaining practical experience. The Canadian Society of Laboratory Technologists defines what the students ought to be taught. They write CSLT examinations at the end of the one year time period. The CSLT accredits the hospital teaching program every 2-3 years, and the Canadian Medical Association accredits the quality of personnel and training f a c i l i t i e s . Teaching of student technologists is largely influenced by external organizations. Laboratory personnel in charge of teaching have power to schedule students and to choose teaching methods (Support for Statement 1). Medical Students: Many of the professional staff in laboratories in teaching hospitals have joint appointments with the university and expect to do some teaching. Heads of pathology and microbiology departments allocate teaching assignments to people according to their areas of expertise. The amount of time devoted to pathology (vs. other subjects) is decided by the curriculum committee in the faculty of medicine. The pathology syllabus is determined by the head of the department of pathology. The teaching of pathology to medical students is influenced chiefly by external organizations and people (Support for Statement 1). Pathology residents: The number of residents positions i n each teaching hospital in the province is .established by the provincial Ministry of Health. 68 The resident teaching program is accredited by the Royal College of Physicians and Surgeons of Canada. Accreditation includes assessment of space, case materials and the qualifications of pathologists. If pathologists have l i t t l e teaching and research experience, the time residents are permitted to spend in that institution is limited. Residents' results on fellowship exams are viewed as an indicator of the quality of the residency training program. As with teaching of medical technologists and medical students, the training of residents is largely determined by external organizations (Support for Statement 1). In summary, findings related to teaching indicate that managerial power to influence teaching i s limited. Statement 1 i s supported. Quality Control Quality control procedures are conducted in hospital laboratories in order to ensure a degree of r e l i a b i l i t y of the information generated there. Quality control is a technical procedure, responsibility for which lies at the division head level. It is expected that the amount of time devoted to quality control procedures is chiefly determined by demands of external people or organizations and that the power of division heads is limited (Statement 1). The provincial medical association accreditation committee examines laboratory operations approximately every two years, and considerable emphasis is placed on quality control. Accreditation depends, in part, on the laboratory having contracted to participate regularly in Canadian or U.S. quality control surveys. To some extent, then, quality control i s influenced by external organizations. However, optimal quality control is a professional decision. Many division heads claimed to do more quality control than required by external organizations. Opinions of laboratory staff differed regarding the 69 magnitude of the impact of external demands versus professional decisions on the amount of quality control performed. Complicating assessment of the external vs. managerial influence is the fact that the amount of quality control performed depends largely on the nature of the tests being conducted. For example, information provided by certain tests w i l l be used to make crucial medical decisions; other tests give routine information. Quality control of tests in the former category is considered very important. But i t is not clear whether these are chiefly mandated from inside or outside the laboratory. Accurate determination of the proportion of quality control procedures which are externally mandated and the proportion generated by professional decisions within the laboratory would require a factorial design (test classification by factors influencing performance). In summary, both external demands and managerial decisions determine the amount and type of quality control tests performed. The extent to which each affects quality control is not clear. Findings related to Statement 1 are inconclusive. Accreditation The Canadian Council on Hospital Accrediation conducts accreditation programs in Canadian hospitals. Participation in the accreditation program i s voluntary; but hospitals may not offer teaching programs without accreditation. A hospital may be accredited for a period of one, two or three years. If major changes are required, a one year certificate of accreditation w i l l likely be issued. Standards have been established for laboratory medicine services in the areas of organization and staffing, f a c i l i t i e s , channels of communication, quality control systems, tissue examination, necropsy service, blood 70 transfusion service and c l i n i c a l reports (Canadian Council on Hospital Accreditation, 1977). In 1981, two sections of the division of chemistry at Hospital A were assessed as having inadequate space and given a limited period of time in which to make changes. Managerial power to influence accreditation is limited. Statement 1 i s supported. Conclusions of Findings Related  to Statement 1 Statement 1 asserts that the manager has limited impact on tangible outcomes. Table IV (p. 54) summarizes findings related to this statement in terms of each substantive outcome. Data on 12 (out of 15) outcomes support Statement 1. Findings on 3 outcomes are inconclusive. Since the manager's influence on tangible outcomes i s constrained by external factors i n more than 50 percent of these outcomes, Statement 1 i s supported. Statement 2 Statement 2 asserts that management's action operates largely with and on  symbolic outcomes and that the manager has less impact on instrumental action  than on symbolic outcomes. This statement focuses on whether the behaviour of four laboratory managers has a greater influence on tangible outcomes (such as promotions and equipment allocations) or on attitudes and beliefs of people in and outside the organization (such as beliefs about how equitable an equipment allocation was). The statement w i l l be supported i f findings indicate that the manager's total impact on beliefs (beliefs related to organizational outcomes as well as shared meanings) appear to be greater than his/her total influence on tangible outcomes. If the manager's influence on tangible outcomes appears to be larger than his/her effect on beliefs, the statement w i l l not be supported. And i f data indicate that the manager affects tangible outcomes and beliefs almost equally, findings w i l l be considered inconclusive. 71 Findings related to the manager's influence on beliefs, attitudes and feelings are presented in three sections. (i) the manager's impact on each tangible outcome and his/her impact on beliefs and attitudes related to that outcome. ( i i ) the manager's assessment of the magnitude of his/her impact on symbolic and substantive outcomes. ( i i i ) the manager's impact on shared meanings (unrelated to tangible outcomes). (i) Managerial Impact on Tangible Outcomes vs.  Influence on Beliefs Related to Outcomes. This section focuses on the manager's effect on each tangible outcome and beliefs related to that outcome. It is anticipated that, overall, management's influence on beliefs and attitudes regarding tangible outcomes w i l l be greater than his/her influence on tangible outcomes themselves. Each tangible outcome is discussed below; and findings are summarized in Table V. Funding for Capital Equipment The expectation related to Statement 2 is that the manager w i l l have a far greater impact on beliefs of people about funding for capital equipment than on the magnitude of equipment funds allocated to the department. As described under findings related to Statement 1, administrators in Hospital A allocate equipment dollars to each hospital department. According to one administrator, "Those exerting the most pressure receive the largest allocations. It's the squeaky wheel principle." The laboratory director and manager attempt formally (with documentation) and informally to influence hospital administrators to allocate greater sums to pathology. The laboratory manager outlines his approach in the following way, "Human systems revolve around personal contact. A program written up on paper may or may not interest you. If someone comes and highlights the good news, the chances are 72 TABLE V MANAGERS' INFLUENCE CM TANGIBLE OUTCOMES AND BELIEFS RELATED TO THOSE OUTCOMES Substantive outcome Managers influence tangible outcomes through:  Manager affected beliefs Statement 2 supported Capital equip-ment funds Operating budget (supplies) Operating budget (personnel) Laboratory costs Hiring pro-fessional personnel Promoting professional personnel Firing pro-fessional personnel Payment of professional personnel Hiring techni-cal & clerical personnel Promoting technical & clerical personnel Firing techni-cal & clerical personnel Research Teaching Quality Control Accreditation limited formal power & influenc-ing beliefs power greater than discretionary limited formal power & influencing beliefs limited formal power limited formal power limited formal power limited formal power limited formal power limited formal power limited formal power & influencing beliefs limited formal power limited formal power limited formal power limited formal power limited formal power Hospital A Yes Yes Yes No No No No No No Yes No No No No No Hospital B No No No No No No No No No No No No No No No No (effect on tangible out-comes greater than on be-l i e f s ) No (effect on tangible out-comes greater than on beliefs) No (effect on tangible out-comes greater than on beliefs) No No No No No No No (effect on tangible out-comes greater than on beliefs) No No No No No 73 you'll be influenced. Most of my influence is personal. And I don't go just once. People comment on my three-piece suit. It's part of the strategy of influence." The director and manager each claim to have affected beliefs of hospital administrators and Ministry of Health o f f i c i a l s regarding their need for equipment. As the manager phrased i t , "From time to time we get capital equipment. Occasionally I think i t ' s the result of our lobbying efforts." Administrators concur that they have, indeed, been influenced. One hospital administrator stated, " (the laboratory director and manager) lobby me. They bring me information about the work load, etc., and sometimes convince me of the need or advisability of purchasing new equipment." Do the manager and director influence beliefs of laboratory personnel regarding equipment allocations? The manager outlined how they pr i o r i t i z e equipment requests from the divisions, "We allocate equipment to those areas we want to build up. Divisions don't a l l get the same amount each year. At times some division heads feel the allocation is not equitable. But I go and t e l l them i t is equitable." There was, however, l i t t l e evidence that the manager's legitimations were effective. Most division heads f e l t short changed. One expressed his feelings this way, "There is competition among division heads. Those that make the most noise get the most equipment." The manager stated that the division which produced l i t t l e research, was given no resources. His legitimations to the division head concerned (that divisions have to take turns in receiving a large share of the pie) did not placate this individual. (Statement 2 not supported). Findings related to Hospital A are summarized in Table V. Managers have limited formal power to affect equipment funds. They also influence beliefs of hospital administrators and Ministry of Health o f f i c i a l s . Whether these 74 efforts have a greater effect funds or beliefs about funds is d i f f i c u l t to assess. Management in Hospital B has limited power to allocate equipment and hence l i t t l e motivation to make their use of power unobtrusive; and there is l i t t l e evidence that they influenced beliefs of division heads in relation to equipment allocation. Findings related to Hospital B therefore indicate that management's effect on equipment funds (though limited) is greater than their effect on beliefs related to these funds. This does not support Statement 2. In summary, managers in both organizations have some formal power (though limited) to affect equipment funds. In neither organization did managers influence beliefs of division heads. In Hospital A there is evidence that managers influenced beliefs of administrators and Ministry of Health o f f i c i a l s and that this was often associated with obtaining additional funds (tangible outcomes). Overall, therefore, management's effect on beliefs about equipment funds is not greater than their influence on equipment funds themselves; and Statement 2 is not supported. The influence of external power holders (hospital administrators and Ministry of Health o f f i c i a l s ) on equipment funds, i s , nevertheless, greater than the influence of management on this outcome. Operating Budget (Supplies) The expectation related to Statement 2 is that the laboratory director and manager w i l l have a larger influence on the beliefs of people in and outside the laboratory about the supply budget than the budget i t s e l f . Until recently both laboratories have had the power to obtain a l l the supplies they required. The managers at Hospital B make no attempt to influence beliefs about supplies and consequently have a greater impact on supplies than beliefs about supplies (Statement 2 not supported). 75 With f i s c a l restraint at the provincial government level, there has been some pressure at Hospital A to be accountable for u t i l i z a t i o n of supplies dollars. According to the manager there, "Many suppliers attempt to lock us into using their products. They imply, 'If you don't use our reagents, the machine won't work as well or we won't be able to service you.' I say to them, 'To he l l with your insecurities. If you threaten me, I ' l l take you to court!' which has now got them insecure and they're backing off and beginning to bring prices down." The manager's statements affected both beliefs related to supplies; and Statement 2 is not supported. Operating Budget (Personnel) Statement 2 leads one to expect that managerial influence on beliefs related to the personnel budget w i l l be greater than on that budget i t s e l f . As described under findings related to Statement 1, management has limited power in relation to the personnel budget. Managers screen requests from division heads for additional staff on new programs. Managerial legitimations regarding funding of particular programs and not others are not successful in convincing division heads or technologists. Managerial explanations regarding such decisions, eg: "Chemistry has the greatest need for these two positions", are met with remarks such as that of one head technologist, "The division head of chemistry is much more effective at lobbying than other division heads. That's why that division is so much better off than others. We have a short staffing problem in our division that has been chronic as long as I have been here." The laboratory director and manager at Hospital A choose to s i t on committees with Ministry of Health o f f i c i a l s which allows them to influence these o f f i c i a l s to supply funding for new or expanded programs (which generally require additional s t a f f ) . The manager explained their 76 approach thus, "We don't go to the Minister of Health and say, 'We want funding for a program.' We go through the normal channels in the hospital, and formally apply for that funding from administration. They go through their processes and pr i o r i t i e s ; and some time later, when we happen to be si t t i n g on committees where we can attempt to influence people, we lobby, saying, 'Look, we have a proposal coming forward. Here are the pros and cons.'" The manager claimed that they have influenced the beliefs of Ministry of Health o f f i c i a l s and said, "Occasionally (we think) the approval of a new program is the result of our efforts." Managerial efforts influence both beliefs related to the personnel budget and the budget i t s e l f . According to an administrator in Hospital B, laboratory management approaches the task of obtaining additional staff in an incompetent manner. He elaborated as follows, "The manager says, 'We need another staff member'. The director says, 'Oh, okay'. They present this to a member of the position board who says, 'That's rubbish! Your volume is down 50 percent from last year'. And they go away with egg on their faces." There i s no evidence, then, that their a b i l i t y to influence beliefs of position board members results in obtaining additional positions. In summary, managers have some (though limited) power to influence the personnel budget. Managers in Hospital B do not influence beliefs related to the budget. Their effect on the budget i s , therefore, greater than on beliefs o about the budget. Through lobbying, managers in Hospital A influence both beliefs about the budget and the budget i t s e l f . Overall, management's effect on beliefs about the budget is smaller than on the budget i t s e l f . Statement 2 is not supported. Laboratory Costs Findings indicating that management's influence on laboratory costs is 77 less powerful than on beliefs about cost w i l l provide evidence to support Statement 2. Until very recently there was l i t t l e incentive to reduce costs of laboratory operation. But cost reduction has become an important goal of hospital administrators at Hospital A and their philosophy differs substantially from that of the laboratory manager and director. Administrators assert that resources are limited and that the laboratory must reduce expenditures. The director and manager, referring to their research results, maintain that laboratory managers have minimal power to control costs. Their research reports have been presented to the Ministry of Health and to hospital administrators. One administrator expressed his view of these research results as follows, "You've seen the papers the director and others wrote. They don't think they're managing the system. They respond to demands. That's their philosophy. We, as representatives of the people and the Social Credit Government, have a completely different point of view. We say, 'We give you a fixed amount of resources and you manage them as best you can'. Laboratory management doesn't go along with that. They say, 'We can't control demand or limit tests.'" It appears, therefore, that managerial research reports and accompanying efforts to legitimate laboratory costs have not influenced the beliefs of hospital administrators. Unlike laboratory managers at Hospital A, those at Hospital B are not under pressure to reduce laboratory costs. There is no motivation, therefore, to convince administrators of their a b i l i t y to reduce costs. In summary, managers have limited power to influence costs and beliefs about costs. There is thus, l i t t l e evidence to support Statement 2. Promotion of Technical and Cl e r i c a l Personnel Statement 2 leads one to anticipate that management w i l l have less 78 influence on promotions of technical and c l e r i c a l personnel than on beliefs about these promotions. As outlined under findings related to Statement 1, managerial freedom in hiring i s limited by union agreements. Several head technologists wrote job descriptions around the person they wished to hire, hired this person and explained their actions in terms of requiring an employee with particular s k i l l s . They succeeded in convincing most technologists of the validity of their actios. They effected beliefs and the promotion i t s e l f . Findings thus, do not support Statement 2. Accreditation. Findings indicating that management's effect on accreditation i s less powerful than on beliefs about accreditation w i l l support Statement 2. The decision by the Canadian Council on Hospital Accreditation that aspects of laboratory function are inadequate provides an opportunity for laboratory management to pressure hospital administrators for changes they may have attempted to introduce earlier. Managers in both organizations claim to have uti l i z e d such opportunities for influencing beliefs. Management's influence on accreditation decisions i s minimal; less powerful than on beliefs related to accreditation. Statement 2 i s supported. There i s l i t t l e evidence that laboratory managers influence beliefs in relation to hiring, promoting, f i r i n g or payment of professional personnel; hiring or f i r i n g of technical and c l e r i c a l personnel; teaching, quality control, or research. Managers possess limited power to affect each of these outcomes. One concludes, then, that in relation to the above outcomes, management's effect on the outcomes i s greater than on beliefs about those outcomes. For a l l the above listed tangible outcomes, Statement 2 i s not supported. 79 Conclusion Regarding Managerial Influence on Beliefs About Tangible Outcomes Table V (p. 72) indicates that beliefs related to 4 (out of 15) tangible outcomes were influenced by laboratory managers. In a l l 4 cases managers influenced tangible outcomes through affecting beliefs; and the influence on tangible outcomes was in addition to the manager's discretionary power to affect tangible outcomes. Managers possess discretionary power to influence the other 11 tangible outcomes. Overall, then, management's effect on tangible outcomes is greater than on beliefs about these outcomes. Statement 2 is not supported. ( i i ) Managerial Assessments of  Their Impact Statement 2 leads to the expectation that managers' statements regarding their influence on the organization would indicate a greater impact on symbolic than substantive outcomes. The laboratory director at Hospital A stated that he was the conceptualizer, analyzer and decision maker, roles which he shared with the laboratory manager. Others were responsible for planning and implementing. This does not clearly support Statement 2; but the statement of a hospital administrator eludicates the director's impact, "The laboratory director has three roles. As director of pathology at the university he reports to the dean of medicine; and through this channel has an input at that level. As head of a c l i n i c a l discipline he reports to the president, and is in a position to lobby the board. He is enormously effective in convincing people and obtaining additional resources for the lab. For example, a large amount of space has been allocated to the new lab because he lobbied so effectively." The laboratory manager at Hospital A claims to devote most of his time to lobbying hospital administrators, Ministry of Health o f f i c i a l s , reagent suppliers and rationalizing decisions to division heads. The influence 80 attempts of the manager and director at Hospital A are mostly aimed at obtaining tangible outcomes. Their influence on beliefs i s intertwined with their effect on tangible outcomes. Which influence is greater cannot easily be determined. The laboratory director at Hospital B stated, "I spend approximately 25 percent of my time on administrative functions, like obtaining equipment and getting time for staff to go on educational leave. ' (the manager) used to do this, but she wants me to do i t now. I spend most of my time doing pathology". He spends some energy legitimating equipment allocations to division heads and li k e l y has considerable effect on shared meanings of division heads (though this was not verifiable). This individual's actions operate largely on substantive, not symbolic, outcomes. His influence on substantive outcomes with organizational significance is discretionary; but he has a primary impact on pathology related outcomes. The laboratory manager's time is devoted to finding replacements when technologists are sick, adjusting the payroll (substantive outcomes) and attending to problems of communication and co-ordination between laboratory and ward personnel (symbolic outcomes). In Hospital B, managers' assessments of their impact do not support Statement 2. In summary, managers at Hospital A claim to have considerable influence on beliefs; but such influence often achieves tangible outcomes.Whether influence on beliefs or tangible outcomes is greater, cannot be easily determined. In Hospital B, managers' assessment of their influence indicate a greater impact on tangible outcomes than on beliefs about outcomes. Overall, then, managers' statements regarding their influence do not support Statement 2. 81 ( i i i ) Managerial Impact on Shared Meanings. One of the tasks of management involves the construction and maintenance of shared systems of meaning. One anticipates that laboratory managers' influence on shared meanings w i l l be large. Since beliefs related to tangible outcomes have already been examined, shared meanings in this study refer to beliefs unrelated to tangible outcomes. Holzner (1968) states that authority structures and the nature and structure of ideological systems are deeply connected. Also that the social structure of authority must be related by the individual to his own conception of identity. The central question i s whether the processes of individual identity formation take the shape which permit identification with the existing authority structure or lead to an alienation from i t . In either case, "ideology" provides the bridge. The symbolic system of ideologies connects the functional contexts of authority in the c o l l e c t i v i t i e s and their legitimation on one side with the legitimation of an individual's claim to self-acceptance. Where the latter process is impossible in terms of the established collective ideology, there emerge alienation alternatives. Where i t is possible, loyalty to the group and to i t s symbols results. (Holzner, 1968, p. 150) Ideology systems in laboratories A and B differ greatly. The dream of the laboratory director in Hospital A is that a small network of laboratories producing outstanding research w i l l become internationally recognized. He attempts to mobilize the energies of professional personnel in this direction. With the exception of one individual, who . is alienated, he i s successful. The laboratory director in Hospital A meets with a l l professional staff once a month and also meets with them individually. He spends time with them socially; for example, he invites those who have recently published or been promoted to dinner. There is l i t t l e evidence that the laboratory manager in Hospital A has much impact on shared meanings of organizational participants. Most of his energy is directed towards influencing people outside the laboratory. Neither the manager nor the director is motivated to influence shared meanings of 82 technologists. As Holzner (1968) says, legitimations are always directed towards the most significant audience. Professional personnel at Hospital B are on a modified fee for service system. The laboratory director is concerned with "selling" laboratory services to the hospital. Energies of professional personnel are directed less toward research and more towards profit making. The laboratory director and division heads at Hospital B meet daily for lunch. They dine lavishly periodically; and i t is likely that company profits are discussed on these occasions. It seems likely that the director has some impact on shared meanings. The manager is viewed by many laboratory personnel as incompetent. One technologist expressed her feelings this way, " (manager) was here for ten years and she wasn't good on the benches. Putting her into her present position was about the only place they could put her. Her father was the chairman of the Board at the time. Everyone in the hospital laughs at her. She sends delegates to important meetings she should attend." To summarize, there is evidence that laboratory directors in these two organizations influence shared meanings of professional staff members. The manager in laboratory B has l i t t l e impact on shared meanings; while the energy of the manager in Hospital A is directed chiefly towards lobbying. Conclusion on Findings Related to Statement 2 Data related to Statement 2 consist of three parts. First, findings indicate that laboratory management has a greater impact on tangible outcomes than on beliefs about these outcomes. Second, managers in one organization claim they devote more time to tangible outcomes than to influencing attitudes and beliefs, while in the other organization, managers have a strong impact on both beliefs and tangible outcomes. Third, there is evidence that laboratory 83 d i r e c t o r s are involved i n the construction and maintenance of shared systems of meaning within the organization to a greater extent than managers. The combined findings of the three aspects of Statement 2 do not indicate that the managers' t o t a l impact on b e l i e f s i s greater than t h e i r t o t a l influence on tangible outcomes. Statement 2 i s thus not supported. Findings support P f e f f e r ' s claim that the manager's impact on tangible outcomes i s lim i t e d , but not his contention that the manager's e f f e c t on b e l i e f s i s greater than on tangible outcomes. While t h i s research i s not intended as a precise t e s t i n g of P f e f f e r ' s ideas, evidence gathered i n describing the organization i s i n s t r u c t i v e . What are possible reasons f o r t h i s unexpected finding? P f e f f e r a n t i c i p a t e s managers w i l l devote much energy to l e g i t i m a t i n g organizational a c t i v i t i e s and outcomes; but i n these organizations, few le g i t i m a t i n g e f f o r t s were e f f e c t i v e because the outcomes were tangible and preferences of i n d i v i d u a l s were unambiguous. [These ideas are discussed f u l l y under findings related to Statement 4.] Managers did not invest much energy i n creating s o c i a l consensus. Managers i n Hospital A devoted considerable time to lobbying external power holders; e f f o r t s which a f f e c t both b e l i e f s and tangible outcomes. ( i e . influence on the former cannot be said to be greater than on the l a t t e r ) . Type of symbolic action (e.g. l e g i t i m a t i o n , lobbying) appears to influence the extent to which the manager influences b e l i e f s and a t t i t u d e s . This i s explored f u l l y i n Chapter 4. Another factor a f f e c t i n g the manager's influence on symbolic versus substantive outcomes i s managerial motivation. The desire f o r i n t e r n a t i o n a l recognition by managers i n Hospital A served as an impetus for t h e i r lobbying e f f o r t s . This, too, i s explored i n Chapter 4. 84 Statement 3 Statement 3 asserts that conditions of power and dependence have a small  effect on symbolic outcomes. In terms of the organizations studied, this statement means that external power holders who influence laboratory operation (such as hospital administrators and Ministry of Health o f f i c i a l s ) have very l i t t l e effect on beliefs, attitudes and feelings of laboratory personnel. Pfeffer seems to be referring to intentional influence. There are 10 external power holders. Since the study purpose i s identification of extremes in terms of the impact of external powers, i t was decided that i f laboratory personnel claim that less than 50 percent of external power holders influenced beliefs and attitudes of laboratory staff and external powers concur with this claim, Statement 3 w i l l be supported. If laboratory personnel claim that more than 50 percent of external powers influenced the beliefs of laboratory members, Statement 3 w i l l not be supported. Findings w i l l be considered inconclusive i f approximately 50 percent of external powers have influenced the beliefs of laboratory personnel. The influence of each external power is discussed below. Hospital Administrators As chairman of the hospital finance committee, the director of laboratory A has the opportunity to influence beliefs about f i s c a l allocations throughout the hospital and hospital p r i o r i t i e s . But according to the manager, "Accountants (on the committee) want a token doctor on the committee and haven't taken his advice". Until recently there was l i t t l e incentive to reduce costs of laboratory operation. However, cost reduction has become an important goal of hospital administrators at Hospital A. Their philosophy differs substantially from that of the laboratory director and manager. Administrators assert that 85 resources are limited and that the laboratory must reduce expenditures. The director and manager, on the other hand, maintain that they have minimal power to control costs. The hospital administrator at Hospital A claims to have succeeded i n influencing beliefs and attitudes of the laboratory manager. He stated, "I have seen the manager change his attitude over the last year. It used to be, 'well I have limitless resources.' Now he realizes this is not true." The manager at Hospital A did not directly admit that the administrator had affected his beliefs and seemed to want to convey that this had not occurred. He said, "There are two types of power, structural and sapiential. You get sapiential power from being recognized as knowing what you're talking about. Administrators are there to manage the hospital and have an accounting mentality. There are some structural things they can do to make l i f e d i f f i c u l t for us, like not replacing technologists who leave. But in reality, there are always ways of getting around that type of issue. They don't have sapiential power." That the manager recognized that resources were limited and he had to reduce expenditures, was, however, evident in other statements: "We used to be able to obtain anything we wanted in terms of supplies and there was l i t t l e incentive to cut costs. This is no longer the case. I'm beginning to force people to look at different (less expensive) reagents or reagents from different suppliers ..." His beliefs have changed - li k e l y the outcome of administrators' statements and the reality of receiving fewer resources. At Hospital B, administrators did not claim to intentionally influence beliefs of the laboratory director, manager or other personnel. Reasons for the lack of motivation to do so appear twofold. First, the laboratory director and division heads consider themselves an entity separate from the hospital. 86 One division head expressed the feeling in this way. "We're not employees of the hospital." This attitude is reflected in lack of interest in hospital a f f a i r s . One hospital administrator stated, "The director doesn't understand the concept of department head. The manager comes to meetings when the director should. He doesn't understand the type of things that go on there." Second, administrators consider the laboratory director and manager to be incompetent. According to one hospital administrator, " (director) doesn't know what's going on. (manager) says, 'We need another staff member.' Director says, 'Oh, okay," They go and present this to (Vice President, Medicine). He says, 'That's rubbish! Your volume i s 50 percent lower than last year!' And they go away with egg on their faces." Administrator motivation to influence beliefs of management i s present in Hospital A and lacking at Hospital B. Findings do not support Statement 3, in that administrators influenced beliefs of some managers. Physicians The expectation of Statement 3 i s that physicians ordering tests w i l l not attempt to affect beliefs of laboratory personnel in any way. Division heads, medical staff and technologists in both organizations reported that some physicians intentionally influence beliefs of laboratory personnel. They do this in various ways including indicating that a test i s "stat" (urgent) when, on investigation, i t is not; and by phoning to ask that the results be made available more quickly than usual. A medical staff member phrased i t this way, "Most doctors know the system and use i t well. Others know the system and think that something can be adjusted for their benefit." One division head explained, "They sometimes pressure us to get this done more quickly. We accommodate within the limits of our resources". These findings do not support Statement 3 in that some physicians do influence beliefs of laboratory 87 personnel. There was no evidence that any of the other external power holders (namely, Ministry of Health O f f i c i a l s , Regional Hospital D i s t r i c t o f f i c i a l s , union o f f i c i a l s , the Canadian Society of Laboratory Technologists, the Royal College of Physicians and Surgeons, the Provincial Medical Association, Canadian Council on Hospital Accreditation and the head of pathology at the university, economic conditions or technology) intentionally influenced feelings, attitudes and beliefs of laboratory personnel in the short term. The possiblity that such influence may occur in the long term cannot be excluded. Study findings are summarized in Table VI. Conditions of power and dependence have a small effect on symbolic outcomes in that only 2 out of 10 power holders (less than 50 percent) influence beliefs of .laboratory personnel. Statement 3 i s thus supported. Statement 3a According to Statement 3a, conditions of power and dependence have a  potentially powerful effect on symbolic outcomes in that they allow those with  power to influence symbolic outcomes at the organizational, subunit and  individual levels. When and how this occurs depends on the motivations of  those with power. Findings indicating that beliefs of organizational participants have been influenced by some of the external power holders and that the primary explanation for such influence appears to be motivation of the power holder, w i l l support Statement 3a. No evidence that motivation of the external power holders was the primary reason for the influencing of beliefs w i l l indicate lack of support for Statement 3a. As described under findings related to Statement 3, hospital administrators and physicians were the only external power holders to influence beliefs of laboratory personnel. Both were motivated to affect beliefs of laboratory personnel. It is interesting to note that, in contrast to other external power holders hospital administrators and many physicians 88 TABLE VI INFLUENCE OF EXTERNAL POWERS ON BELIEFS OF LABORATORY PERSONNEL External Force Influenced Beliefs (Intentionally) Hospital administrators Yes Physicians Yes Ministry of Health O f f i c i a l s No Regional Hospital D i s t r i c t O f f i c i a l s No Union Offic i a l s No Head of Pathology at University No Canadian Council on Hospital Accreditation No Provincial Medical Association No Canadian Society of Laboratory Technologists No Royal College of Physicians & Surgeons No Economic conditions No Technology No 89 are located i n close proximity to the laboratory. I t i s l i k e l y , therefore, that proximity i s as important as motivation i n i n f l u e n c i n g symbolic outcomes. Statement 3a i s not accepted. Statement 4 Statement 4 notes that substantive and symbolic aspects of organizational  a c t i v i t y are linked, but the coupling between them i s loose. According to t h i s statement, tangible aspects of organizational a c t i v i t i e s (such as equipment a l l o c a t i o n s and promotions) w i l l not correspond c l o s e l y with b e l i e f s about these a c t i v i t i e s . P f e f f e r ' s expectation i s , for example, that reasons for p a r t i c u l a r equipment a l l o c a t i o n s i n the laboratory w i l l d i f f e r s u b s t a n t i a l l y from b e l i e f s of d i v i s i o n heads and technologists about these reasons. B e l i e f s of laboratory personnel regarding tangible outcomes such as laboratory costs and a c c r e d i t a t i o n were e l i c i t e d . If b e l i e f s of the majority of people interviewed were not c l o s e l y correlated with tangible aspects of a p a r t i c u l a r outcome, Statement 4 would be accepted f o r that outcome. I f , on the other hand, the majority of b e l i e f s corresponded c l o s e l y with tangible aspects of that outcome, Statement 4 would not be accepted f o r that outcome. Findings w i l l be considered inconclusive i f approximately h a l f the b e l i e f s r e l a t e d to an outcome are loosely linked with tangible aspects of that outcome and h a l f t i g h t l y l i n k e d . There are 15 tangible outcomes. If Statement 4 i s accepted f o r more than 50 percent of these outcomes, the Statement w i l l be accepted. If Statement 4 i s not accepted for more than 50 percent of i n d i v i d u a l outcomes that Statement as a whole w i l l not be accepted. Findings w i l l be considered inconclusive i f data or more than 50 percent of outcomes are inconclusive. Table VII summarizes r e l a t i o n s h i p s between tangible and symbolic aspects of organizational outcomes. B e l i e f s of i n d i v i d u a l s who are knowledgeable 90 TABLE VII RELATIONSHIPS BETWEEN TANGIBLE ASPECTS OF OUTCOME & BELIEFS ABOUT OUTCOME Substantive Outcome Funding for equipment Operating budget (supplies) Operating budget (personnel) Laboratory costs Hiring, prof, personnel Firing, prof, personnel Promoting, prof, personnel Payment, prof, personnel Hiring, tech. personnel Firing tech. personnel Promoting tech. personnel Teaching Research Quality control Accreditation Tightness of Coupling Those with Those with l i t t l e knowledge knowledge of of outcome outcome Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Tight Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose Loose 91 about an outcome corresponded closely with tangible aspects of that outcome; whereas beliefs of individuals who possess the knowledge of the outcome correspond very l i t t l e with tangible aspects of that outcome. Funding for equipment, promotion of technical personnel and accreditation are discussed below to i l l u s t r a t e this point. Funding for Equipment Statement 4 leads one to expect to find l i t t l e correspondence between the manager's reasons for equipment allocation and beliefs of division heads and technologists about these allocations. Resource allocation at Hospitals A and B differs and equipment allocation in these organizations is thus discussed separately. At Hospital A, the laboratory director and manager p r i o r i t i z e equipment requests from the divisions. The laboratory manager acknowledges that his allocation of equipment dollars is not always equitable. "One division head lies and continues to l i e . So a l l we can do is to put him in a box; until he breaks out - then we put him in another box. There's no research coming out of that division and we give him no resources." He added that he legitimates minimal resource allocation to this division head by saying, " "Divisions have to take turns in receiving a major portion of the pie." The division head who had (according to the manager) been allocated significantly fewer equipment dollars than other divisions over the past 4 or 5 years expressed anger about this. Technologists in this division spoke of a "personality conflict" between their division head and the manager as a probable cause of small resource allocations to their division. One technologist expressed i t thus: "Our division head does not get along with pathology administration and the whole division suffers. Everyone in the division is aware of these animosities." Beliefs of these technologists and 92 this division head about reasons for lack of equipment allocation correspond remarkably closely with the manager's reasons for minimal equipment allocation to this division. (Findings do not support Statement 4). As noted under findings related to Statement 2, equipment is allocated to those areas the laboratory director and manager wish to build up. A l l division heads acknowledged feeling in competition with other divisions. Two expressed the belief that the division head who exerted the most pressure on the manager, received the largest allocations. Beliefs correspond with tangible aspects of equipment allocations and do not support Statement 4. At Hospital B, division heads pri o r i t i z e equipment requests and submit these to the manager and director, who, in turn, submit a department prioritization to the Hospital Equipment Committee. The departmental prioritization is not necessarily heeded by the Equipment Committee. The manager and director at Hospital B have less power to allocate equipment than at Hospital A, and hence less motivation to legitimate allocations. Four division heads spoke of equipment allocation as a rational process. One expressed i t this way: "You justify the request — the old equipment is broken or this one is more eff i c i e n t . You document technologist time, cost of servicing, the cost of reagents. And the hospital committee makes the decision." One division head claimed to lobby the director about the issue; "I lobby the division head and try to convince him of the importance of my division's need for this equipment". She also expressed awareness of the limits of the director's power. Beliefs of division heads about equipment allocation decisions correspond closely with these decisions; a finding which does not support Statement 4. . In both hospitals, technologists' beliefs were marked by lack of knowledge, and perhaps interest, in the allocation process. Numerous 93 technologists expressed the belief that the division head determined what equipment the division obtained. Decisions regarding equipment allocation and beliefs of technologists about these decisions correspond very l i t t l e . These findings support Statement 4. Findings related to Statement 4 are inconclusive in that beliefs of division heads (knowledgeable in this area) and technologists with an interest in the outcome correspond closely with equipment allocation decisions; while beliefs of many technologists (who possess l i t t l e knowledge in this area) correspond very l i t t l e with these decisions. Promotion of Technical Personnel In both organizations, the promotion of technical personnel has been delegated to the head technologist. Union regulations regarding promotions constrain the head technologist's a b i l i t y to promote the person of his/her choice. Regulations state that union members in the hospital are to be given f i r s t consideration when f i l l i n g a vacancy; and that capability, performance and qualifications should be considered primary factors in promotion. When such factors are equal between employees, seniority shall be the determining factor. The expectation related to Statement 4 i s that beliefs about promotions of technical personnel w i l l correspond very l i t t l e with promotion decisions. The majority of technologists expressed the belief that a b i l i t y and qualification as judged by the head technologist and medical staff were important in promotion. Their beliefs correspond with factors considered in promotion decisions; findings which do not support Statement 4. Accreditation Accreditation occurs at several levels: (i) Hospital accreditation by the Canadian Council on Hospital 94 Accreditation includes an assessment of laboratory staffing f a c i l i t i e s , quality control systems c l i n i c a l reports. ( i i ) The Provincial Medical Association Accreditation focuses on quality control. ( i i i ) The Royal College of Physicians and Surgeons in Canada accredits the pathology resident training program. (iv) The Canadian Society of Laboratory Technologists accredits technologist training programs. Power in each of these cases is centralized and li e s with the accrediting body. If a part of the laboratory is not accredited by the Canadian Council on Hospital Accreditation, that part may have to cease operation temporarily. Loss of Provincial Medical Association accreditation means that hospital w i l l not be paid for laboratory tests performed on outpatients. Loss of accreditation for teaching means that teaching in a particular division of the laboratory must cease. Statement 4 leads one to expect l i t t l e correspondence between the accreditation decisions and beliefs about those decisions. Study findings were that beliefs of division heads and head technologists about accreditation were, for the most part, tightly coupled with these decisions. One head technologist stated, "The accrediting body has said changes are needed in two areas of chemistry. Basically, we need more space and we have to have these changes made by June 1." This corresponded with the documented accreditation decision; a finding which does not support Statement 4. Most technologists expressed a lack of knowledge regarding accreditation procedures, eg. "I really don't know anything about those things." Their beliefs were loosely coupled with accreditation decisions. (This supports Statement 4). Overall, findings related to accreditation are inconclusive. Conclusions Related to Statement 4 In summary, Statement 4 notes that beliefs about an outcome and tangible aspects of that outcome usually correspond very l i t t l e . Findings related to 95 the statement are inconclusive, in that findings related to more than 50 percent of individual outcomes are inconclusive. Beliefs of those who are knowledgeable about the outcome correspond closely with the outcome; while beliefs of those with l i t t l e knowledge/interest in the outcome correspond l i t t l e with the outcome. Statement 4a According to Statement 4a, how strongly or loosely substantive and  symbolic aspects of organizational activity are linked depends on managerial  motivations; characteristics of the outcomes and characteristics of recipients  of outcomes. Statement 4a notes for example, that how closely the manager's decision to allocate equipment coincides with the beliefs of division heads and technologists about that decision w i l l depend on these factors: the manager's motivation to explain the decision differently from the way i t occurred, the tangibility of the outcome (equipment) and how much people receiving the equipment care about the allocation. If the manager is motivated to explain the allocation differently from the way i t occurred, i f the outcome (equipment) is intangible and the people receiving the equipment do not particularly care how much and what type of equipment they receive, then the decision and beliefs about that decision are li k e l y to correspond very l i t t l e . Evidence that the strength of coupling between substantive and symbolic aspects of more than 50 percent of organizational activities can be explained in terms of managerial motivations, characteristics of the outcome and characteristics of recipients of outcomes, w i l l support Statement 4a. If these factors explain strength of coupling in less than 50 percent of organizational a c t i v i t i e s , Statement 4a w i l l not be supported. Findings w i l l be considered inconclusive i f strength of coupling is explained by these factors in approximately 50 percent of organizational a c t i v i t i e s . Findings indicate that managerial motivation, characteristics of the 96 outcomes and characteristics of recipients of outcomes explain strength of coupling between substantive and symbolic aspects of organizational activity when the manager attempts to redefine/legitimate an activity. Examples of managerial attempts to legitimate actions are outlined below. As described under findings related to Statement 4, the manager's allocations of equipment dollars in Hospital A is not always equitable. Decisions regarding equipment allocation and beliefs of division heads about these decisions are f a i r l y closely correlated. Preferences of division heads about equipment allocations are unambiguous in that the quality of service offered by a division and the pride a division head has in his/her division i s intimately connected with the u t i l i z a t i o n of advanced equipment. The allocation is a dollar figure which represents power to purchase particular equipment and as such is something quite tangible. Division heads were not convinced by rational explanations offered by management, li k e l y because the outcome is tangible and the preferences of the recipients of outcomes are unambiguous. This provides support for Statement 4a. Beliefs of technologists in a division which had been allocated minimal resources in the past 4 to 5 years were remarkably close to managerial reasons for not allocating resources. How they became aware of inequities is unknown but i t was evident that they f e l t strongly about the issue. According to one technologist, "The majority don't think he really runs the department. He's almost like a figure head. Pathology administration controls everything and they don't get on with him. It seems like we don't get our f a i r share because of this. We're the biggest lab, yet we don't have enough space or adequate equipment. Their preferences were unambiguous, the outcome is tangible and their beliefs about equipment allocation decisions were closely correlated with those decisions. This supports Statement 4a. 97 As noted earlier, head technologists are constrained by union regulations regarding the promotion of personnel. However, three head technologists admitted having rewritten a job description so as to preclude the promotion of certain people and to promote the person of their choice. In a l l three cases the head technologist explained the decision (promotion) to technologists in that section in rational terms. One explained i t thus, "The person in this position must like, and be able to cope with a lot of responsibility." In two instances, the technologists interviewed were not directly involved in the promotion and their preferences can be described as ambiguous; i.e. they did not care greatly about the outcome. Their beliefs about the promotion and reasons for the promotion did not correspond. One stated, "The most qualified person is always promoted." This supports Statement 4a. The manager was motivated to explain the decision differently than i t occurred; the outcome (promotion) is tangible, in the sense that the new job i s associated with difference responsibilities and perhaps increased salary. But the outcome was not especially important for these technologists. They accepted managerial legitimations about the decision although these explanations corresponded l i t t l e with the decision. In one instance, however, the preference of the technologist was unambiguous. He was a close friend of the person who was not promoted, apparently unjustly, and he stated, "The head technologist wrote the job description around the person she wanted." His beliefs about the promotion decision were tightly coupled with that decision in spite of the head technologist's claim otherwise. This finding supports Statement 4a, in that although the manager was motivated to redefine the . promotion decision, the outcome was tangible and the unambiguous preference of the recipient of the outcome resulted in tight coupling between beliefs about the promotion 98 decision and that decision. Conclusions Related to Statement 4a A l l the outcomes in this study were tangible in nature. It was thus not possible to compare strength of coupling between substantive and symbolic aspects of activity with tangible and intangible outcomes. Managerial motivation, characteristics of outcomes and characteristics of recipients of outcomes explain strength of coupling when legitimation is the symbolic action being employed. These factors do not explain how tightly linked substantive and symbolic aspects of activity w i l l be when other types of symbolic actions are used (e.g. lobbying, creating social consensus). Thus Statement 4a is accepted only for situations in which the symbolic activity i s legitimation. Summary of Findings Statement 1 asserts that the manager's impact on tangible outcomes i s limited. Since findings indicate that the manager's influence on tangible outcomes is constrained by external factors in more than 50 percent of outcomes, Statement 1 is supported. That the manager has a greater impact on beliefs and attitudes than on tangible outcomes is Pfeffer's central claim (Statement 2). The combined findings of the three aspects of this Statement 2 do not support this claim. According to Statement 3, conditions of power and dependence have a small effect on symbolic outcomes. Only two out of ten external power holders (less than 50 percent) were found to influence beliefs of laboratory personnel. Thus Statement 3 i s supported. Statement 3a asserts that conditions of power and dependence have a potentially powerful effect on symbolic outcomes i n that they allow those with power to influence symbolic outcomes at the organizational, subunit and 99 individual levels. When and how this occurs depends on the motivations of those with power. The two external power holders which influence beliefs of laboratory personnel are located in close proximity to the laboratory. Since proximity is likely as important as motivation in influencing symbolic outcomes, Statement 3a is not accepted. Statement 4 notes that substantive and symbolic aspects of organizational activity are linked, but the coupling between them is loose. Findings related to this statement are inconclusive in that with more than 50 percent of tangible outcomes, half the beliefs related to the outcome are loosely linked with tangible aspects of the outcome.and half tightly linked. According to Statement 4a, how strongly or loosely substantive and symbolic aspects of organizational activity are linked depends on managerial motivations, characteristics of the outcomes and characteristics of recipients of outcomes explain strength of coupling when legitimation is used but not when other types of symbolic action (e.g., lobbying) are employed. Statement 4a is accepted only for situations in which legitimation is used. 100 CHAPTER IV CONCLUSIONS Theories of management have traditionally assumed that managers exert considerable control over organizational a c t i v i t i e s . Some theorists argue that external forces such as unionization limit managerial freedom. Almost a l l have focused on the tangible results of managerial action. Pfeffer (1981) developed a new conception of managerial functions. He contends that the manager's role i s largely that of influencing beliefs, attitudes and feelings and that management exerts a limited impact on tangible outcomes. Some of the claims in Pfeffer's theory were empirically investigated. Claims and findings are summarized in Figure 6. The primary claim of this theory i s that management has a far greater effect on symbolic than substantive outcomes. Findings do not support this statement nor the claim that substantive and symbolic aspects of organizational activity are loosely linked. Data do support the statements that management's effect on substantive outcomes i s limited and that conditions of power and dependence have a small effect on symbolic outcomes. Findings related to each statement are discussed, conclusions drawn and ideas for future research presented. The Manager's Impact on Substantive Outcomes Pfeffer claims that the manager's impact on substantive outcomes i s limited (Statement 1). Study findings support this statement. The manager's freedom to influence each substantive outcome was constrained; but the manager 101 FIGURE 6 PFEFFER'S CLAIMS AND STUDY FINDINGS REGARDING THESE STATEMENTS P f e f f e r ' s Claims Substantive & symbolic outcomes are lo o s e l y coupled. Manager has l i m i t e d e f f e c t on t a n g i b l e outcomes External power holders have large e f f e c t on tangible outcomes Manager has greater e f f e c t on b e l i e f s than on tangible outcomes External powers have small impact on b e l i e f s *"| T o t a l i t y of y tangible outcomes J T o t a l i t y of b e l i e f s of ypeople i n organization and i n contact with organization Study Findings Strength of coupling between sub- / stantive* and symbolic outcomes depends on type of symbo-| l i e a ction employed Manager has l i m i t e d e f f e c t on tangible outcomes Manager 'p^has smaller e f f e c t on b e l i e f s than on tangible outcomes External power holders have large e f f e c t on tangible outcomes Manager has unintent-i o n a l influence on b e l i e f s Other influences on b e l i e f s e.g. co-workers External powers have un-i n t e n t i o n a l i n t e n t i o n a l e f f e c t External powers have small| i n t e n t i o n a l e f f e c t [ T o t a l i t y of ^tangible outcomes J T o t a l i t y of b e l i e f s of people i n 'organization and i n contact with organization 1 0 2 always possessed some formal power. Considerable differences were evident between laboratory managers at Hospitals A and B. In spite of possessing approximately equivalent amounts of power, laboratory managers at Hospital A had a far greater impact on certain tangible outcomes than did those at Hospital B. The strong motivation of the former to lobby for particular outcomes appears to explain this difference. In a sense, then, power i s latent, i.e., i t comes into play when a manager wishes and attempts to alter the status quo. International recognition for a laboratory producing outstanding research i s the goal of managers at Hospital A. Achievement of this goal requires updated equipment and an adequate budget and hence their efforts to influence these outcomes, through lobbying. That formal power can be increased through lobbying does not negate findings that the manager's effect on substantive outcomes i s limited. Pfeffer devotes l i t t l e attention to the fact that substantive outcomes may be affected through influencing symbolic outcomes. He emphasizes legitimation and influencing shared meanings. Figure 7 illustrates that substantive outcomes are the result of external (contextual) factors and motivation to lobby. The Manager's Impact on Symbolic Outcomes Pfeffer's central claim that management has a greater impact on beliefs, attitudes and feelings than on tangible outcomes (Statement 2 ) , was not supported. Reasons for this appear to be that managerial effect on symbolic outcomes i s contingent on managerial motivation, type of symbolic action employed, level of management, type of organization and time in organizational l i f e cycle. Each of these factors i s discussed below: (i) managerial motivation. There is considerable variation in motivation and personality across managers. The dream of the laboratory director at Hospital A i s international recognition. The route to recognition 103 FIGURE 7 FACTORS INFLUENCING SUBSTANTIVE OUTCOMES EXTERNAL FORCES Ministry of Health Regional Hospital Dis t r i c t Canadian Council on Hospital Accredition Provincial Medical Association Royal College of Physicians & Surgeons Canadian Society of Laboratory Technologists Head of department of pathology at university Unions HOSPITAL FORCES Hospital administrators Physicians ordering tests Laboratory Management Division heads and Head Technologists Substantive Outcome The result of the interplay of external forces and managers' motivation to lobby forces directly influencing substantive outcomes opportunities to lobby 104 i s publication of high quality research which requires highly qualified researchers. The a b i l i t y to attract such people to one's institution depends largely on favourable working conditions and, in particular, on modern laboratory equipment. The laboratory i s assured of receiving some level of resources (capital equipment, staff and supplies) but allocations can be altered by lobbying efforts. The laboratory director and manager at Hospital B, in contrast, devote no energy to lobbying hospital administrators or Ministry of Health o f f i c i a l s . Managerial impact on beliefs and attitudes at each hospital is very similar except for influences on symbolic outcomes aimed at achieving tangible results. The difference between managers and directors at the two institutions in terms of p o l i t i c a l orientation personality and motivation i s considerable and highlights the fact that individual motivation is a crucial factor determining managerial impact. Motivation affects the extent to which the manager attempts to influence symbolic outcomes (and hence the ratio of symbolic to substantive outcomes) as well as the type of symbolic action employed. ( i i ) the type of symbolic action employed. Pfeffer does not distinguish adequately between three types of symbolic action, namely legitimating, creating social consensus and lobbying. The type of symbolic action chiefly employed influences the extent to which symbolic versus substantive outcomes are influenced. Since lobbying i s aimed at influencing both beliefs and tangible outcomes, whether one i s affected more than the other is d i f f i c u l t to assess. Legitimation was found to be less effective when preferences of individuals were unambiguous. A manager's efforts to influence symbolic outcomes in such situations w i l l l i k e l y be less effective. Thus, a manager who devotes much energy to lobbying and legitimating outcomes to people who care greatly about those outcomes, may not have a greater impact on symbolic 105 than substantive outcomes; whereas a manager whose time is devoted largely to legitimating organizational outcomes to people who do not have strong preferences about the outcomes, w i l l l i k e l y have a greater impact on symbolic than substantive outcomes. ( i i i ) the type of organization. Pfeffer's ideas regarding two levels of analysis (observable outcomes and how they are perceived) come from the writings of Edelman (1977), which describe ways in which p o l i t i c a l actions get some groups what they want and what these actions mean to others. Public organizations are the focus of Edelman's work; and i t i s l i k e l y that managers of government organizations w i l l be largely concerned with resource allocation and hence legitimation (which Pfeffer emphasizes). A manager of a private organization selling a commodity may devote much time to improving the product, adapting the organization to changing conditions in the environment and to improving the advertising campaign; activities which may focus more on tangible than symbolic outcomes. Mintzberg (1979) classifies organizations as simple structures, professional bureaucracies, machine bureaucracies, divisionalized forms and adhocracies. A top level manager in a professional bureaucracy, such as a hospital, may devote more attention to influencing symbolic outcomes than his/her counterpart in a machine bureaucracy. Thus, organizational type may influence whether managers have a greater impact on symbolic than substantive outcomes. (iv) level of management. Parsons (1960) identifies three levels of responsibility and control, namely technical, managerial and institutional levels. (a) At the level of the technical suborganization, problems focus on the effective performance of the technical function (effective performance of tests in the laboratory situation). The nature of the technical task (e.g. types of tests to be done) and kinds of cooperation required are 106 the primary exigencies to which the sub-organization i s oriented. (b) The managerial level mediates between the technical suborganization and users of i t s products and obtains required resources. It decides on the nature of the technical operation and controls the kinds of resource inputs obtained. (c) The function of the institutional level i s articulation of goals, functions and rights to the wider social system (Parsons, 1980). Jobs at this level span boundaries between the organization and external environment. The environment may be homogeneous or heterogeneous; i f the latter, jobs w i l l require the exercise of discretion. In discretionary jobs, p o l i t i c a l actions of individuals are most l i k e l y to influence organizational processes (Thompson, 1967). Head technologists function at the technical level, division heads at the managerial level and managers at the institutional level. The creation of shared meanings and processes of legitimation occur at each level. It i s contended, however, that the percentage of managerial actions which have symbolic (vs. substantive) impact i s lowest at the technical level and highest at the institutional level. This i s illustrated in Figure 8. While managers at the institutional level may have a greater impact on beliefs than on tangible outcomes, this w i l l l i k e l y be less true of managers at lower levels. (v) the time in the l i f e cycle of the organization. Issues of importance in the organization change over time. Consequently, the amount of energy a manager devotes to affecting symbolic versus substantive issues may fluctuate over time. Quinn and Cameron (1980) and Miles (1980) identify stages of development in the l i f e of an organization. The creation of the organization includes marshalling resources, creating an ideology and socialization of members. Symbolic activity i s l i k e l y to be important in the latter two a c t i v i t i e s . In the midlife of the organization, emphasis i s on 107 FIGURE 8 T a n g i b i l i t y of Outcome 108 producing an output ef f i c i e n t l y ; and symbolic activity may be less important here. In summary, i t appears that whether a manager has a greater effect on symbolic than substantive outcomes depends on his/her motivation, the kinds of symbolic action employed, the type of organization, the level of management and the time in the organization's l i f e cycle. Future research might examine these ideas. The Influence of External Power Holders on Symbolic Outcomes Pfeffer contends that external powers have l i t t l e influence on beliefs and attitudes of organizational members (Statement 3). Data support this claim. This statement refers to intentional influence. The unintentional nature of influence of external powers i s not addressed by Pfeffer. Examples of unintentional impact are presented below. Many technologists expressed frustration about physician ordering patterns and the number of tests they were required to perform and considered unnecessary. General economic conditions in the province were an important factor in the premier's imposition of ceilings on wage increases of public employees. Though not aimed at incurring the wrath of public employees, his statement infuriated technologists who had been anticipating large salary increases in upcoming union negotiations. Advances in technology have allowed certain types of laboratory work (e.g. chemistry) to become very automated. The head technologist in chemistry at Hospital A claims that automation has decreased interdependence among technologists and consequently their readiness to help one another. She stated, "People don't help each other as much now as when we did manual procedures. The nature of the work has changed. People used to help each other with reporting. Now the reports come out of machines. And even when 109 they're not busy they don't go and help the others, because they work so independently that there's no feeling of commitment to others." Head technologists and division heads expressed feelings of frustration, even anger, regarding the constraints imposed by union regulations on their freedom to promote, hire and f i r e whom they wished. One head technologist expressed her frustration thus: "With the H.E.U. contract (typists, clerks), everyone has two working days off in a row. We need coverage on weekends; so in order to schedule 10 working days in every 14, we have to do i t so that the same individual always has Wednesday and Thursday off. They don't like i t and they leave. We've had to cope with rapid turnover. And you can't change i t . " Actions of bodies accrediting laboratory function and organization, quality control and teaching evoke feelings and influence beliefs only at those times when accreditation or evaluation i s occuring. External powers can be categorized along two dimensions, namely: (i) physical proximity to the organization being affected; ( i i ) the intentional/unintentional nature of the influence. Figure 9 locates each external power along these dimensions. Only those in close proximity to members of the laboratory intentionally influence symbolic outcomes. Powers which are removed from the organization usually have an unintended impact on symbolic outcomes in the organization. The Linkage Between Symbolic and Substantive Outcomes Pfeffer contends that substantive and symbolic aspects of managerial activity are imperfectly linked (Statement 4), but there i s l i t t l e evidence to support this claim. His statement i s based on the belief that managerial justifications and organizational action w i l l almost always d i f f e r . However, examples of both loose and tight coupling were found when there was an attempt by management to make the use of power unobtrusive. These are summarized in Figure 10. 110 FIGURE 9 EXTERNAL POWERS AFFECTING HOSPITAL LABORATORIES CATEGORIZED ACCORDING TO INTENTIONALITY OF INFLUENCE AND PROXIMITY TO LABORATORIES Close prox-imity Phys-i c a l l y distant Intentional Influence Unintentional Influence Hospital administrators Physicians Physicians Head of pathology, university Physicians Accreditation bodies Ministry of Health Unions College of Physicians and Surgeons Canadian Society of Laboratory Technologists Economic conditions Technology 111 FIGURE 10 LINKAGE BETWEEN SUBSTANTIVE AND SYMBOLIC OUTCOMES WITH AND WITHOUT MANAGERIAL LEGITIMATION Decision/resource important I Power dispersed Manager ^  motivated to redefine situation (Statements 4 and 4a) Decision/resource unimportant Power centralized No motivltion to redefine situation Loose usually when pref- (1) when activity is coupling erences of recipients outside sphere of between of outcomes are knowledge or interest symbolic ambiguous, e.g. of organizational and sub- technologists not participants, e.g. stantive involved in promotion technologists and outcomes accreditation (2) when there is no freedom to express beliefs in tangible ways, e.g. low morale and test performance Tight usually when outcome (1) when power cen-coupling is tangible and pref- tralized or decision between erences of recipients relatively unimportant symbolic of outcomes are unam- and people have some and sub- biguous, e.g. techno- knowledge of the activity, stantive logists involved in e.g. division heads outcomes promotion, division and accreditation heads and equipment requests (2) when there is freedom to express beliefs and feelings in tangible ways e.g., low morale S equipment maintenance 112 Managerial legitimations concerning outcomes which individuals care very l i t t l e about, w i l l l i k e l y result in loose coupling between substantive outcomes. But when people care a great deal about an outcome (e.g., technologists involved in promotion) substantive and symbolic outcomes are likely to be tightly linked. Of interest here is Holzner's (1968) notion that the process of legitimation occurs at various levels of the authority structure. The wider the scope of the audience and the higher the level of authority involved, the broader is the scope of legitimation and the greater is the number of vague symbolizations used. More specific symbols are used at lower levels of authority. Division heads are located high in the authority structure of laboratories. But legitimation of equipment allocation to these individuals was specific; i t can, perhaps, not easily be made vague. The vague/specific nature of the legitimation and the level of authority to which legitimations are directed are additional factors which may influence strength of coupling. Pfeffer never mentions the correspondence between symbolic and substantive outcomes when there is no effort to make the use of power unobtrusive. Examples of loose and tight coupling were found in such circumstances (see Figure 10). Loose coupling was found when the activity was outside the sphere of knowledge or interest of the individual (e.g. technologists' knowledge of accreditation and equipment allocation). Close correspondence between symbolic and substantive outcomes (tight coupling) occurs when power is centralized (as with accreditation) or the resource/decision i s seen as relatively unimportant (teaching or quality control) and when people have some knowledge of the activity. Thus division heads involved in teaching are aware of the decision powers of the Royal College of Physicians and Surgeons and technologists involved in quality 1 1 3 control are well aware of the power of the BCMA Accreditation Committee decisions. . Budget cutbacks resulted in low morale. Morale i s closely coupled with certain substantive outcomes and not with others. Morale i s closely linked with the maintenance of laboratory equipment in that, when morale is high, technologists maintain equipment; when i t is low, they do not. However, beliefs and feelings are loosely coupled with other technical outcomes such as performance of tests. Technologists continue to perform tests, regardless of their mood. Symbolic and substantive outcomes appear, then, to be tightly coupled when there is some freedom to express beliefs and feelings in tangible ways. Pfeffer does not distinguish adequately between three types of symbolic action (lobbying, legitimation and creating social consensus). His claim that substantive and symbolic aspects of organizational ac t i v i t y are loosely linked, appears to be based on the legitimating role of the manager. He says that the symbolic role of the manager i s likely most important in contexts in which assessment of organizational outcomes is d i f f i c u l t , connections between actions and results are uncertain and organizational participants are incompletely involved and have ambiguous preferences. But this statement applies chiefly to the legitimating role. Factors influencing the linkage between beliefs related to legitimations of outcomes and those outcomes diff e r from factors linking symbolic and tangible outcomes of lobbying attempts. Factors affecting the strength of coupling between symbolic and substantive outcomes varies with the type of symbolic action employed. Methods of meaning creation include ceremonies, organizational restructuring, symbols and language. Since managers in both organizations spend l i t t l e time with laboratory personnel, the researcher was afforded few opportunities to 114 observe managers interacting with other individuals. The primary method of obtaining information about managers' effects on individuals was, consequently, language. Rituals related to coffee breaks, etc. were observed; but such actions were not the focus of this study. The ways in which factors influencing the strength of coupling between substantive and symbolic outcomes vary with the type of symbolic action employed, are summarized in Table VTII. Symbolic action may be taken by the manager or others. With legitimation, the motivation of the legitimator, the tangibility of the outcome and preferences of recipients of outcomes influence the strength of coupling. If people have strong preferences concerning a tangible outcome, the likelihood that they w i l l accept statements which contradict tangible evidence, is small. Lobbying often has symbolic and tangible effects. Prior beliefs of the person with power, the control he/she exerts over the outcome and the avai l a b i l i t y of the outcome affect strength of coupling between the symbolic and substantive outcomes of lobbying efforts. For example, physicians attempt to influence laboratory staff to provide them with test results more quickly than usual. The staff member's compliance depends on beliefs about the legitimacy and f e a s i b i l i t y of the request. When symbolic action i s aimed at creating social consensus, the motivation of the person influencing shared meanings affects the strength of coupling between substantive and symbolic outcomes. He/she may be motivated to influence beliefs in such a way that they differ from objective, physical referents of that outcome. If this person is held in high regard, the possibility that symbolic and substantive outcomes w i l l be tightly coupled is increased. Festinger (1954) said that social communication would be used particularly when physical reality was not present to anchor beliefs. Asch 115 TABLE VIII FACTORS INFLUENCING STRENGTH OF COUPLING BETWEEN SUBSTANTIVE AND SYMBOLIC OUTCOMES WITH VARIOUS TYPES OF SYMBOLIC ACTION Intentional Influence Factors Influencing Strength of Coupling Symbolic action related to legitimating Motivation of legitimator Tangibility of outcome Preferences of recipients of outcomes Symbolic action related to lobbying Prior beliefs of power holder Control he/she exerts over outcome Availability of outcome/options for compliance Symbolic action related to creating social consensus Motivation of person creating consensus Esteem with which this person is regarded Preferences of recipients Degree of conformity among recipients Unintentional Influence (a) Sphere of knowledge/interest of organizational participant Centralization of power Importance of issue (b) Amount of freedom/discretion to express beliefs and feelings in a tangible way. 116 (1958) examined variables affecting degree of conformity (or social consensus) and found that degree of conformity was reduced i f even one person took the subject's position. Future research might examine the following hypotheses: (i) The motivation of the legitimator, the tangibility of the outcome and preferences of recipients of outcomes w i l l influence the strength of coupling between substantive and symbolic outcomes when the symbolic action is legitimation. ( i i ) Prior beliefs of the person with power, the control he/she exerts over the outcome and the options for compliance w i l l influence the strength of coupling between substantive and symbolic outcomes when the symbolic action is lobbying. ( i i i ) Motivation of the person creating consensus, the esteem with which he/she is regarded, preferences of recipients, and the degree of conformity among recipients w i l l influence the strength of coupling between substantive and symbolic outcomes when the purpose of symbolic action i s creating social consensus. Significance of Findings Empirical studies on managerial and external influences on organizational outcomes have been directed toward determining the variance in outcomes attributable to each source of influence. These studies utilized existing data (such as profits over 20 years) and as such were not close to data. They also ignored the social nature of organizational reality. In this study, the researcher observed activities and interactions and spoke with organizational members about their perceptions of events and influences. Social and tangible aspects of reality were considered equally important. Pfeffer's ideas about the symbolic role of management have never been 117 examined. This was thus primarily an exploratory study to examine some of Pfeffer's claims. The study did not seek to establish causal linkages between actions of management and symbolic and substantive outcomes. Findings give an indication of patterns of relationships between managerial action and tangible and symbolic outcomes and factors likely to affect these relationships. Study results identify factors which future researchers might attempt to control. Categories developed prior to data analysis (based on Pfeffer's writings) were used, as well as categories which emerged from the data i t s e l f . Emergent concepts captured ideas not brought out by simply using a pr i o r i categories; for example, i t was found the effects of managers and external power holders may be unintentional as well as intentional, and a manager's impact on symbolic versus substantive outcomes may be moderated by several factors. It is contended that the use of both a p r i o r i and emergent categories strengthens study findings. Study findings give some indication of the u t l i t y of Pfeffer's theory. His distinction between symbolic and substantive outcomes i s useful in that i t serves to focus attention on both kinds of outcomes. Study findings support his claims that the manager has a limited effect on tangible outcomes and that external power holders have a small effect on symbolic outcomes. His contention that the manager has a greater effect on symbolic than tangible outcomes did not receive support. The magnitude of managerial influence on symbolic versus substantive outcomes appears to be moderated by five factors (managerial motivation, type of symbolic action employed, level of management, type of organization and time in organizational l i f e cycle). Pfeffer's claim that substantive and symbolic aspects of organizational activity are loosely linked, was not supported. The reason for this i s , possibly, that factors influencing strength of linkage vary with the type of 118 symbolic action employed. Concepts which emerged from the data were as follows: (i) The intentional/unintentional nature of the influence of external power holders and managers on symbolic outcomes. ( i i ) the effects of proximity to/distance from the organization on the extent to which external power holders affect symbolic outcomes. ( i i i ) magnitude of managerial influence on symbolic outcomes may be contingent on managerial motivation, type of symbolic action, level of management, type of organization and time in organizational l i f e cycle. (iv) type of symbolic action employed and existence/absence of managerial attempts to redefine the situation may influence strength of linkage between substantive and symbolic outcomes. There has been no research on the linkage between substantive and symbolic outcomes in organizations. This study identified that factors influencing strength of coupling depend on (a) the presence/absence of managerial attempts to redefine the situation and (b) the type of symbolic action employed. Future Research This study examined relationships which Pfeffer contends exist between actions of managers and external power holders and substantive and symbolic outcomes; as well as the linkage between substantive and symbolic aspects of organizational activity. Cause and effect relationships were not established. Actions of only four managers in two settings were examined and findings are not generalizable to other settings. That such exploratory research precede the s t a t i s t i c a l testing of hypotheses i s , however, important. Study findings have increased understanding of relationships Pfeffer postulates exist. They support some of the relationships he proposes, 119 but not others; and enrich understanding of variables affecting relationships between symbolic and substantive outcomes and the magnitude of the manager's impact on substantive vs. symbolic outcomes. The study has set the stage for more rigorous inquiry. A set of statements based on study findings is list e d below. Future research might examine some of these. 1. The manager has a limited impact on substantive outcomes. 2. The magnitude of managerial impact on symbolic versus substantive outcomes is contingent on managerial motivation, type of symbolic action employed, level of management, type of organization and time in organizational l i f e cycle. (a) managers who are motivated to influence beliefs and attitudes are likely to affect symbolic outcomes more than those less motivated in this direction. (b) managers who devote much time to legitimating outcomes to people who care greatly about those outcomes, w i l l likely have less impact on symbolic than substantive outcomes. (c) managers whose energy is devoted largely to legitimating organizational outcomes to people who do not have strong preferences about the outcomes w i l l likely have a greater impact on symbolic than substantive outcomes. (d) the percentage of managerial actions which have symbolic (versus substantive) impact w i l l likely be lowest at the technical level of management and highest at the institutional level. (e) the extent to which a manager influences symbolic versus substantive outcomes w i l l likely be greater during the creation of an organization than at any other time in the organization's l i f e cycle. 120 Conditions of power and dependence have a small effect on symbolic outcomes. (a) External power holders located in close proximity to the organization may intentionally influence beliefs and attitudes of organizational members. (b) External power holders physically removed from the organization often have an unintentional impact on beliefs, attitudes and feelings of organizational members. (a) When there is no effort to make the use of power unobtrusive, tight coupling between substantive and symbolic outcomes is likely in situations where (i) power is centralized ( i i ) the resource/decision is relatively unimportant ( i i i ) people have some knowledge of the activity (iv) there is freedom to express beliefs and feelings in tangible ways. (b) When there is no effort to make the use of power unobtrusive, loose coupling between substantive and symbolic outcomes i s likely when there is no freedom to express beliefs and feelings in tangible ways. (c) When the manager is motivated to legitimate an action/outcome, tight coupling between symbolic and substantive outcomes is likely when preferences of recipients of outcomes are unambiguous. (d) When the manager is motivated to legitimate an action/outcome, loose coupling between symbolic and substantive outcomes is likely in situations in which preferences of recipients of outcomes are ambiguous. (e) Factors influencing the strength of coupling between substantive and symbolic outcomes vary with the type of symbolic action employed. 121 (i) With legitimation, the motivation of the legitimator, the tangibility of the outcome and preferences of recipients of outcomes influence the strength of coupling, ( i i ) When the symbolic action employed is lobbying, prior beliefs of the person with power, the control he/she exerts over the outcome and the avail a b i l i t y of the outcome affect strength of coupling. ( i i i ) When symbolic action i s aimed at creating consensus, the motivation of the person influencing shared meanings, the esteem with which this person i s regarded, preferences of recipients and degree of conformity among recipients affect strength of coupling, (iv) Ceremonies, settings and the use of symbols are forms of symbolic action not examined in this study. Future research may investigate factors influencing the strength of coupling between substantive and symbolic outcomes with each of these forms of symbolic action. Berger and Luckman (1966) do not distinguish between legitimation and the creation of social consensus. They identify four levels of legitimation. The transmission of kinship vocabulary to a child i s an example of the f i r s t level. The second contains theoretical propositions such as proverbs. The third level consists of theories by which a part of an institution i s legitimated. Symbolic universes form the fourth level. Future research might identify factors influencing the strength of coupling at each level of legitimation. The influence of the manager has, traditionally, been measured in terms of tangible outcomes. This research, based on Pfeffer's writings about the 122 symbolic role of management, emphasizes the importance of examining managerial impact on tangible and i n t a n g i b l e outcomes and f a c t o r s a f f e c t i n g such influe n c e . The i n s t i t u t i o n a l world i s experienced as an objective r e a l i t y ; but that o b j e c t i v i t y i s humanly produced. Those with authority have the power to influence substantive domains and the s o c i a l construction of r e a l i t y . External power holders may l i m i t the a b i l i t y of a manager to influence substantive outcomes. 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Reading Mass.: Addison-Wesley Publishing Co., 3rd edition, forthcoming. Weiner, N., & Mahoney, T.A. A Model of Corporate Performance as a Function of Environmental, Organizational and Leadership Influences. Academy of  Management Journal, 1981, 24, 3, 453-470. If? APPENDIX A QUESTIONS ASKED OF STUDY PARTICIPANTS The Manager As I explained to you some time ago, my research is concerned with the factors and people influencing what happens in a hospital laboratory. The purpose of my questions i s to identify which activities in the lab are under your control (or the control of the director) and which are largely influenced by people outside the lab. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you say to anyone and results w i l l be presented in a way that disguises individual identities. Will i t be okay i f I take notes while we talk? I would like, f i r s t , to ask you about visible, measureable activities and events such as hiring staff and acquiring equipment. What influence do doctors have on the volume and nature of tests that get done? Are people in managerial positions such as you and (the director) able to influence performance of tests? (Yes/No) (If Yes) How do you do this? Do heads of divisions have an influence on test performance? (Yes/No) (If Yes) In what way? In what way does new equipment influence the performance of tests? How does new knowledge (such as developments in knowledge about diabetes) affect this whole area? Do you have any documents that indicate how any of these people/factors affect tests that get done? (If Yes) In what way do the documents indicate this? I'd like now to focus on acquiring capital equipment. What people or factors outside the lab influence equipment you acquire? it* (If several are listed, inquire regarding each one individually) How does influence this? (If not already mentioned) How, then, does the director influence the process? Are you able to influence the acquisition of equipment? (Yes/No) (If Yes) Could you give an example of how you have done this? Do you have written documents supporting what you've said about any of these people having a major influence on acquiring capital equipment? (Yes/No) (If Yes) How do they indicate supporting evidence? Would i t be okay i f I had a look at those at some point? Could we talk about the operating budget for a while — about factors which or people who influence the size of the budget allocated to the lab? Which people or factors influence the size of the supply budget allocated to the lab? (Further questions were aimed at identifying the power of people/ organizations outside the laboratory as well as that of the laboratory manager and director to influence the process.) 1 Which people or factors determine the size of the salary budget allocated to the lab? (Further questions were aimed at determining the power of external organizations and individuals as well as that of the laboratory manager and director to influence these allocations.) Is there any written evidence of what we've been talking about? (Yes/No) (If Yes) Could I have a look at these documents later on? Which people in this laboratory are responsible for the hiring of professional staff? (If more than one) How would you rank the influence each of these people has on the decision making process? What are the reasons for some having much influence and others considerably less? As noted on page 44, questions could not a l l be specified precisely in advance. In such cases an interview guide was u t i l i z e d . It keeps interaction focused but allows individual perspectives to emerge. Are you able to influence the hiring of professional staff in any way? (Yes/No) (If Yes) Would you describe how you do this? Are there people outside the organization who affect the hiring of professional staff? (Yes/No) (If Yes) Who are these people/Who is this person? How strong i s the influence of this person in relation to people in the lab? Could you give examples to support what you've said? (If more than one) How would you rank these people according to influence on decision making? How is this documented? Could I have a look at these documents sometime? Which person/people is responsible for promotions of professional staff? (If more than one) How would you rank these people according to influence on promotion decisions? Do any individuals outside the lab influence decisions about promotions? (Yes/No) (If Yes) Who are these people? Why is i t that they do influence these decisions? How does this influence occur? What power do you or the director have, in terms of f i r i n g professional personnel? Further questions explored factors limiting the power of laboratory management to f i r e personnel.) Which people were responsible for establishing the method of payment of professional personnel i n this hospital? (Further questions were aimed at determining the reasons/motivation for this choice of method of payment.) Which organizations are responsible for accrediting aspects of laboratory functions? What happens i f the lab i s found deficient in some area? (Further questions sought to c l a r i f y the power of accrediting bodies and that of laboratory management.) 1^0 We have talked about pay, hiring, f i r i n g , promotions, capital equipment, budget allocations and lab tests. Are there any other tangible things you are able to influence? (Yes/No) (If Yes) Would you describe this/these? The next questions focus on whether groups or individuals outside the laboratory try to influence the views of laboratory personnel in any way; and whether you, in turn, attempt to convince certain people about the importance of an issue. Have hospital administrators influenced your beliefs or those of other laboratory personnel? (Yes/No) (If Yes) Could you give examples of this? Have you jus t i f i e d or explained activities or decisions to anyone in recent months? (Yes/No) (If Yes) Could you expand on these — to whom your explanation was given and what i t was about? Do you find that you sometimes explain a decision/activity a l i t t l e differently from the way i t occured? (Yes/No) (If Yes) Could you t e l l me about some such occasions? Do you every find that people are unsure about how to interpret events — for example, don't know what to make of the f i r i n g of a staff member they consider competent? (Yes/No) (If Yes) Could you t e l l me about some of these situations and what i f anything, you did about them? Have you tried to influence beliefs of people in the Ministry of Health during your time as manager? (about your need for capital equipment, for example) (Yes/No) (If Yes) How did you go about this? What were the results of your efforts? What factors contributed to your success/failure? Do you have documented related to this which I could examine? Have Ministry of Health o f f i c i a l s influenced your beliefs or those of others in the lab? (Yes/No) (If Yes) How did they do this and what was the issue? Have you ever tried influencing beliefs of doctors about what occurs in the lab or what should be occurring? (e.g. need for computerization) (Yes/No) (If Yes) How did you do this? /3/ How successful were your efforts? Is i t documented? TO LABORATORY MANAGER AT HOSPITAL B Have you ever attempted to influence the behaviour of the head of pathology at the university in any way? (Yes/No) (If Yes) How did you do this? What were the results? Is this documented? (Yes/No) Do you find that from time to time you expend energy generating the support of people in or outside on some issue? (Yes/No) (If Yes) Could you give me examples of how you've gone about this? Could you t e l l me about the support you gained in these attempts? Do you think you influence the importance people attach to certain activities in the lab (by, for example, emphasizing innovation)? (Yes/No) (If Yes) How do you do this? TO LABORATORY MANAGER AT HOSPITAL B Have the actions of the head of pathology at the university influenced your beliefs or the beliefs of others in the lab? (Yes/No) (If Yes) How have they done so? Could you describe how you spend your time? (Further questions explored the extent to which managerial actions were aimed at influencing substantive vs symbolic outcomes.) What do you hope to achieve during your time as manager here? What aspects of the job do you find rewarding? Which parts do you find frustrating/annoying? What sorts of things would motivate you to stay here? What kinds of things would be reasons for you to leave? How would you describe the goals of this lab? To what extent does the lab have the power to achieve these goals? What have been your achievements to date? What would you do differently i f you had your time here over? Could you t e l l me about the way you, the associate director and director work together? Do you have a common strategy, or approach, to running the lab? (Yes/No) (If Yes) What i s this? (If No) How do your approaches differ? Laboratory Director At Hospital B The research I am doing i s concerned with identifying to what extent laboratory activities are influenced by people in the laboratory and to what extent by factors and people in other parts of the hospital or outside the hospital. The questions I'd like to ask you relate to your influence on laboratory functions as well as the influence of external groups on these a c t i v i t i e s . This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you t e l l me to anyone, and results w i l l be presented in such a way that individual identities w i l l be disguised. Will you feel comfortable i f I take notes while we talk? Do you influence the acquisition of lab equipment? (Yes/No) (If Yes) Could you give me some examples of how you've gone about this and how successful you've been? Are you able to influence the size of the operating budget allocated to this lab? (Yes/No) (If Yes) Could you give me some examples of the ways in which you've done this and how successful you have been? Who is responsible for appointments of professional personnel in this lab? Which people have the greatest influence on these decisions? Who i s responsible for promoting professional personnel? What are the c r i t e r i a for promotion? Who i s responsible for firing/demoting professional personnel? What i s your power in this matter? Lab a c t i v i t i e s revolve around performing tests. Are you able to influence the performance of tests? (Yes/No) (If Yes) What sorts of things are you able to influence? How do you do this? How successful are your attempts? Does the method of payment of professional personnel (fee for service) influence the number of tests performed in this lab? Would you expand on that? Who was responsible for instituting the modified fee for service method of payment here? Are you satisfied with the arrangement as i t is? (Yes/No) (If Yes) In what ways to you find i t satisfactory? (If No) In what ways is i t unsatisfactory? Have you attempted to change the arrangement? (Yes/No) (If Yes) What have been the results of your efforts? What factors determine the amount of research produced by division heads and other professional staff? (Additional questions attempted to determine the power of external factors vs those under managerial control.) 51 We've talked about hiring, f i r i n g , promotions, tests, acquiring equipment and the budget. Are there any other act i v i t i e s you are able to influence? (Yes/No) (If Yes) Could you t e l l me what these are and how you influence them? 52 Could you describe how you spend your time? (Questions here were aimed at determining the percentage of time devoted to influencing tangible outcomes vs that devoted to affecting beliefs and attitudes.) S2 Your position probably requires a considerable amount of decision making. In recent months, have you just i f i e d or explained decisions to people in this lab, or in other labs and departments or tried to influence people's views about any issues? (Yes/No) (If Yes) Could you describe some of the issues you've justified or advocated, the people involved, how you've gone about doing this and how successful your efforts have been? Have you ever tried to influence beliefs/views of people in the Ministry of Health? (Yes/No) (If Yes) How did you go about this? What were the results of your efforts? repeat what you t e l l me to anyone, and results w i l l be presented in such a way that individual identities are disquised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Can you think of any occasions in which doctors have attempted to influence you views about something? (Yes/No) (If Yes) Could you t e l l me about this? How the doctor approached you, what the issue was and the outcome? Have doctors' actions ever affected your feelings; for example, have they made demands which angered you? (Yes/No) (If Yes) Could you give me some examples of what happened, what was said and the surrounding circumstances? Does the head technologist ever explain why she has hired a particular person and not another? (Yes/No) (If Yes) Further questions identified the technologist's in the lab. are under the control of lab. management and which are largely influenced by people outside the lab. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you say to anyone and results w i l l be presented in a way that disguises individual identities. Will you feel comfortable i f I use a tape recorder? (Yes/No) (If No) Will i t be okay i f I take notes while we talk? Can you briefly outline what your job entails? I'd like, now, to focus on acquiring capital equipment. What people or factors outside the laboratory influence equipment you acquire? (If several are listed, inquire regarding each one individually.) How does influence this? Are you able to influence the acquisition of equipment? (Yes/No) (If Yes) Can you give an example of how you have done this? Could we talk about the operating budget now — about factors which or people who influence the size of the budget allocated to the lab? What people or factors influence the size of the supply budget allocated to the lab? Are the lab director and manager able to influence the size of the allocation? (Yes/No) What factors contributed to your success/failure? Do you have documents related to this which I could examine? Have you ever attempted to influence the beliefs of hospital administrators? (Yes/No) (If Yes) How did you go about this? What were the results of your efforts? What factors contributed to your success/failure? S1 Are there groups or individuals, in or outside the laboratory, who are dissatisfied with some aspect of laboratory operation? (Yes/No) (If Yes) Who are these people and what is the nature of their dissatisfaction? Do you try to keep them satisfied? (Yes/No) (If Yes) What do you do? Do you find that from time to time you expend energy in generating the support of people in or outside the laboratory on some issue? (Yes/No) (If Yes) Could you give me examples of how you've gone about this? What support did you gain in these attempts? Do you feel you influence the importance lab personnel attach to certain ac t i v i t i e s in the lab; by, for example, emphasizing innovation? (Yes/No) (If Yes) How do you do this? S4a How would you describe the goals of this lab? What do you hope to achieve during your time as director here? What have been your achievements to date? What would you do differently i f you had your time over? What aspects of the job do you find rewarding? Which parts do you find frustrating? Head of Pathology at the University/  Laboratory Director at Hospital A This research i s concerned with the extent to which lab activities are controlled by the people in the lab and the extent to which they are . influenced by people outside the lab. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you t e l l me to anyone else and results w i l l be presented in such a way that individual I2>C> identities are disguised. Will you feel comfortable i f I take notes while we talk? I'd like, f i r s t , to ask you about some of the visible, measureable things that occur in the lab, such as hiring, and the performance of tests, etc. The findings of your research on lab costs and u t i l i z a t i o n state that lab managers have l i t t l e control over these factors. Have you presented these findings to hospital administrators? (Yes/No) (If Yes) What was their reaction to the reports? (Further questions were aimed at identifying the extent to which he considered administrators' beliefs had been changed.) Which people make decisions about the appointment of division heads in teaching hospitals in this province? Could you describe your role — how actively you participate i n suggesting appointments? Who is responsible for promoting professional personnel? What are the c r i t e r i a for promotion? What factors determine the amount of research produced by division heads and other professional staff? (Additional questions attempted to determine the power of external factors vs those under managerial control.) Could you describe how you spend your time? (Further questions were aimed at determining the percentage of time devoted to influencing substantive and symbolic outcomes.) Do you feel you influence the importance lab. personnel attach to certain activities in the lab., by, for example, emphasizing research or innovation? (Yes/No) (If Yes) How do you do this? What sort of atmosphere do you try to promote? How would you describe the goals of this lab? What do you hope to achieve during your time as director here? Assistant Manager - Hospital A My research i s concerned with the factors and people influencing what happens in a hospital laboratory. The purpose of my questions is to identify which activities outside the lab. I'd like to talk to you about some of these issues. /37 This consent form states that you may withdraw from the the study at any time and that your responses w i l l be completely confidential. I w i l l not repeat what you t e l l me to anyone, and results w i l l be presented in such a way that individual identities are disquised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Can you think of any occasions in which doctors have attempted to influence you views about something? (Yes/No) (If Yes) Could you t e l l me about this? How the doctor approached you, what the issue was and the outcome? Have doctors' actions ever affected your feelings; for example, have they made demands which angered you? (Yes/No) (If Yes) Could you give me some examples of what happened, what was said and the surrounding circumstances? Does the head technologist ever explain why she has hired a particular person and not another? (Yes/No) (If Yes) Further questions identified the technologist's in the lab are under the control of lab. management and which are largely influenced by people outside the lab. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you say to anyone and results w i l l be presented in a way that disguises individual identities. Will you feel comfortable i f I use a tape recorder? (Yes/No) (If No) Will i t be okay i f I take notes while we talk? Can you briefly outline what your job entails? I'd like, now, to focus on acquiring capital equipment. What people or factors outside the laboratory influence equipment you acquire? (If several are listed, inquire regarding each one individually.) How does ^ influence this? Are you able to influence the acquisition of equipment? (Yes/No) (If Yes) Can you give an example of how you have done this? Could we talk about the operating budget now — about factors which or people who influence the size of the budget allocated to the lab? What people or factors influence the size of the supply budget allocated to the lab? Are the lab director and manager able to influence the size of the allocation? (Yes/No) v (If Yes) How do they do this? Are you able to influence the size of the supply budget allocated to this lab? (Yes/No) (If Yes) Could you describe how you have influenced budget allocation during your time as assistant manager here? What people or factors influence the size of the salary budget allocated to the lab? Are the lab director and manager able to influence the allocation process in any way? (Yes/No) (If Yes) How do they do this? Are you able to influence this process? (Yes/No) (If Yes) Could you describe how you have done this? S2 You mentioned, in the beginning, what your responsibilities are. Can you t e l l me about the way you, the manager, director and associate director work together? (Further questions were aimed at identifying whether symbolic outcomes differ.) Division Heads I'm doing research on the extent to which lab ac t i v i t i e s are under the control of the director and manager and to what extent they are affected by people/events outside the lab. I'd like to talk to you about some of these issues. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you t e l l me to anyone and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? S1 Are you able to affect the number or type of tests that get done? (If Yes) What do you affect and how do you do this? What factors influence the amount of time staff in your division spends on quality control? (Questions here w i l l be directed at determining the extent to which quality control is influenced by internal or external forces.) Do you spend any time on research? (Yes/No) What factors influence how much time you spend on research? S1 What people/organizations are responsible for the number of medical students and pathology residents you are responsible for teaching? Who determines what you teach them (the content)? Who influences equipment allocation to your division? Does the person/people making the allocations justify/explain their decisions? (Yes/No) (If Yes) How do you react to these explanations? Who determines the size of the operating budget which is allocated to your division? How are these decisions made? Does the decision maker explain these allocations to your? (Yes/No) (If Yes) How do you react to these explanations? S1 Who is responsible for promoting professional personnel? (Further questions explored the relative power of individuals identified, c r i t e r i a for promotion and how these had become established.) Do you have any contact with doctors regarding tests? (Yes/No) (If Yes) What is the nature of these contacts? (Additional questions focused on determining whether physicians influenced this individual's beliefs/actions and whether he/she influenced physicians' beliefs/behaviour). 51 Could you say something about the impact of the director and manager on 52 your division? (Further questions were directed at determining the impact of the director and manager on substantive and symbolic outcomes.) . Medical Staff I'm doing research on the extent to which lab activities are under the control of lab management and to what extent they are affected by people/events outside the lab. I'd like to talk to you about some of these issues. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you t e l l me to anyone and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? No Do you have any contact with doctors regarding tests? (Yes/No) (If Yes) What is the nature of these contacts. (Additional questions focused on determining whether physicians influenced this individual's beliefs/actions and whether he/she influenced physicians' beliefs/behaviour.) Do you spend any time on research? What factors influence how much time you spend on research? Head Technologists I'm doing research on the extent to which lab act i v i t i e s are under the control of the director and manager and to what extent they are affected by people/events outside the lab. I'd like to talk to you about some of these issues. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I w i l l not repeat what you say to anyone, and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Are you able to influence the performance of tests i n any way? (Yes/No) (If Yes) What do you affect and how do you do this? Can you think of occasions i n which doctors have attempted to influence your views about something (for example, the importance of tests being done more quickly)? (Yes/No) (If Yes) Could you t e l l me about this; how doctors approached you, what the issues were and the outcomes? Can you r e c a l l any occasions in which the behaviour of doctors affected your feelings; for example, demands that made you feel angry? (Yes/No) (If Yes) How often has this sort of thing happened? Could you give some examples of what happened, what was said and the surrounding circumstances? I would like, now, to ask you about the hiring, f i r i n g and promotion of technologists and c l e r i c a l personnel. Could we start with technical personnel? In what way does the (technologists' union) influence the hiring of technologists? What sort of power do you have to hire the person of your choice? /V/ Have you found ways to work around union constraints? (Yes/No) (If Yes) Could you give me examples of how you've done this? What are union regulations regarding the promotion of technical personnel? What flexibility/power do you have to promote the person of your choice? Have you found ways to work around union constraints? (Yes/No) (If Yes) Could you give some examples of how you've done this? What are union regulations about f i r i n g employees? What is your power regarding this matter? Could we examine these same issues in terms of c l e r i c a l personnel and their union? (Questions re hiring, promotion and f i r i n g of technologists repeated, with HEU and c l e r i c a l staff replacing technologists and technologists' union respectively.) Approximately how many hours a week does (the manager) spend in this lab? (Questions here were aimed at identifying whether actions of this individual affect the beliefs and feelings of the interviewee.) How much time does (the director) spend in the lab? (Questions here were aimed at determining whether this individual affects beliefs and attitudes of the technologist.) Technologists I'm doing research on the extent to which lab activities are under the control of the director and manager and to what extent they are affected by factors and people outside the lab. I'd like to talk to you about some of these issues. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I w i l l not repeat what you t e l l me to anyone, and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I use a tape recorder? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Can you think of any occasions in which doctors have attempted to Influence your views about something? (Yes/No) (If Yes) Could you t e l l me about this? How the doctor approached you, what the issue was and the outcome? Have doctors' actions ever affected your feelings; for example, have they made demands which angered you? (Yes/No) (If Yes) Could you give me some examples of what happened, what was said and the surrounding circumstances? Does the head technologist ever explain why she has hired a particular person and not another? (Yes/No) (If Yes) Further questions identified the technologist's reactions to such explanations. Does the head technologist explain why a particular person has been promoted and not another? (Yes/No) (If Yes) Additional questions identified the technologist's reactions to these explanations. S3 How did you react to (provincial premier's) recent accouncement about curbing public sector wage increases? (Further questions explored emotional reactions to the announcement.) S1 Does any person or thing set the tone here? (Yes/No) (If Yes) How does he/she do it? 51 What sort of impact does (the manager) have on this division? 52 (Further questions aimed ay identifying impact on symbolic and substantive outcomes.) What effect does (the director) have on this division? (Further questions aimed at determining influence on substantive and symbolic outcomes.) Hospital Administrators My research is concerned with factors influencing what happens in laboratories. I'd like to ask you about the ways in which the decisions of administrators affect laboratory functions. This consent form states that you may withdraw from the study at any time and that your response w i l l be completely confidential. I w i l l not repeat what you t e l l me to anyone, and results w i l l be presented in such a way that individual identities are disguised. Will you feel comfortable i f I take notes while we talk? S1 Can you outline the process by which equipment is allocated to departments in this hospital? my (Further questions were aimed at determining the power of the Ministry of Health, hospital administrators and department heads in relation to equipment allocation.) Has the lab director or manager ever tried to influence your decisions about equipment allocation? (Yes/No) (If Yes) Can you t e l l me about these attempts and how successful they were? How is the operating budget for each department determined? Has the lab director or manager ever attempted to convince you to allocate additional sums to the lab for staff or supplies? (Yes/No) (If Yes) How did they go about this and what were the outcomes of their efforts? Have the lab director or manager ever tried to convince you about other issues (e.g. laboratory costs)? (Yes/No) (If Yes) Could you t e l l me about this and what the outcome was? Have you ever tried to convince the laboratory director or manager of the importance/value of something — reducing costs, for example? (Yes/No) (If Yes) Could you expand on this, your approach and what success you had? (Additional questions here aimed at determining the extent to which, and how, the administrator affected beliefs of the manager and/or director.) Labour Relations Representative My research is concerned with the extent to which laboratory activities are influenced by lab management and to what extent they are affected by factors outside the laboratory. I'd like to ask you about the ways in which the unions affect the hiring, promotion and f i r i n g of technical and c l e r i c a l personnel. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I w i l l not repeat what you say to anyone, and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I tape record our conversation? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Perhaps i t would be best to discuss each union separately. Could we start with the H.E.U. (Hospital Employees' Union)? What are H.E.U. regulations re hiring? (Further questions were aimed at identifying the relative power of laboratory management and the union.) Have there been any disputes about hirings? (Yes/No) What are H.E.U. regulations re promotions? (Additional questions focused on identifying the relative power of the union and laboratory management.) Have there been any disputes about promotions? (Yes/No) (If Yes) What has been the nature of these disputes? (Additional questions examined the manager's role in the dispute.) What are H.E.U. regulations about f i r i n g c l e r i c a l staff? (Further questions to identify relative power of the union and laboratory management.) Have there been any disputes about firings? (If Yes) Could you give some examples of this? (Questions about hiring, f i r i n g and promotions of c l e r i c a l personnel were repeated, inserting ' (the technologists' union) for H.E.U. and technologists for c l e r i c a l staff.) Person in Charge of Training of  Technologists in Laboratory My research is concerned with the extent to which lab activities are controlled by people in the lab and the extent to which they are influenced by people outside the lab. This consent form states that you may withdraw from the study at any time and that your responses w i l l be completely confidential. I shall not repeat what you say to anyone else and results w i l l be presented in such a way that individual identities are disguised. Will i t be okay i f I record our conversation? (Yes/No) (If No) Will you feel comfortable i f I take notes while we talk? Who determines the number of medical technology students trained in this laboratory? Who determines what they are taught? (Additional questions focused on the relative power of the external organization and laboratory personnel over curriculum, methods of teaching, etc.) Is the quality of training assessed/monitored? (Yes/No) (If Yes) Can you t e l l me about the power of the people/organization responsible for this? Have people in any of the external organizations you have talked about ever attempted to influence your beliefs or those of anyone in the lab? (Yes/No) (If Yes) Can you t e l l me about these instances? Does (laboratory director) have any input into the training program? (Yes/No) (If Yes) What is the nature of this input? Mb APPENDIX B ADMINISTRATIVE STRUCTURE OF LABORATORY A Director Associate D i r e c t o r Manager Assistant Manager r Data Dept. Pathology Processing Secretary Stores D i v i s i o n s Nuclear  Medicine D i v i s i o n Head Head Technologist Haematology D i v i s i o n Head Microbiology D i v i s i o n Head Anatomical  Pathology D i v i s i o n Head Head Tech Head Tech Hematology D i v i s i o n Head Immuno. Transplantation Medical Staff Head Tech C l i n i c a l  Chemistry D i v i s i o n Head Head Tech Head Tech ADMINISTRATIVE STRUCTURE OF LABORATORY B Director Secretary Manager I Dept. Secretary D i v i s i o n s Nuclear Medicine D i v i s i o n Head Head Tech Haematology D i v i s i o n Head Microbiology D i v i s i o n Head I Head Tech Anatomical Pathology D i v i s i o n Head C l i n i c a l Chemistry D i v i s i o n Head Head Tech Head Tech Haematology Head Tech 

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