Chreim - Inter Level Influences on the Reconstruction of Professional Role Identity

INTERLEVEL INFLUENCES ON THE RECONSTRUCTION OFPROFESSIONAL ROLE IDENTITY

SAMIA CHREIMUniversity of Ottawa

B. E. (BERNIE) WILLIAMSUniversity of Lethbridge

C. R. (BOB) HININGSUniversity of Alberta

Research on roles and identities generally represents a micro perspective that does notaccount for the reconstruction of professional role identity, owing to insufficientattention to institutional forces. We trace institutional influences on professional roleidentity reconstruction and extend theory by building bridges across institutional,organizational, and individual levels of analysis. Findings indicate that agentic recon-struction of professional role identity is enabled and constrained by an institutionalenvironment that provides interpretive, legitimating, and material resources that pro-fessionals adopt and adapt. Institutional forces also impact organizational arrange-ments that further influence microlevel agency. We elaborate interactions among thesethree levels of analysis.

I will give you an example of what can happen in[the traditional model]. A fellow comes in for aminor problem, a 15-minute appointment. As he isleaving he says, “By the way, I am having some painin my chest.” So the physician tells him to scheduleanother appointment. Next day the patient dies of aheart attack. This is not good patient care. . . . Theway I practice has changed. . . . Now I spend moretime with the patients [and] provide comprehensivecare. I don’t deal with one problem at a time. . . . Iam very satisfied with the whole thing because ofbetter care for patients.

-Physician interviewed at time 2 in this study

I provide better-quality care [now]. . . . I am cer-tainly more dependent on other providers. . . . I’venow gotten to the point where I turn to my nursesand say, “What is left now that I need to do myselfbecause you can’t?” . . . I don’t feel threatened in myclinical autonomy. . . . I feel I’m actually doing abetter job, filling the gaps. I don’t think I knew thosegaps existed before: you just do what you have to doto get through that visit.

-Physician interviewed at time 3 in this study

Professionals perform significant roles in organ-izations and society. It is thus crucial that research-ers understand the dynamics underlying profes-sional role identity change. Professional identity isan individual’s self-definition as a member of aprofession and is associated with the enactment ofa professional role (Ibarra, 1999; Pratt & Dutton,2000). Enacting a particular role gives rise to “roleidentity.” According to Ashforth, a role identity“provides a definition of self-in-role” and includes“the goals, values, beliefs, norms, interaction stylesand time horizons that are typically associated witha role” (2001: 6). The way that professionals viewtheir role identity is central in how they interpretand act in work situations (Pratt, Rockmann, &Kaufmann, 2006; Weick, 1995). In the case of phy-sicians, for example, a change in role identity en-actment can have life or death implications, as thefirst quotation above indicates. Accounts of physi-cians’ resistance to change in their traditional roleidentity continue to surface in the literature (Doo-lin, 2002; Fiol & O’Connor, 2006; Reay & Hinings,2005). Yet such change is possible, as the abovequotations illustrate. At a time when changes inprofessional fields such as accounting, law, andmedicine are being documented (Greenwood &The authors wish to thank John Amis, Blake Ashforth,

Martin Evans, Karen Golden-Biddle, Royston Green-wood, Martin Kitchener, Ann Langley, Thomas Law-rence, Trish Reay, Roy Suddaby, Rob Wedel, EileenPatterson, Linda Janz, and Lisa Halma for their commentson drafts. The manuscript also benefited significantlyfrom the comments by AMJ special issue coeditor Susan

Jackson and three reviewers. The Canadian Health Sci-ences Research Foundation and a number of researchpartners provided financial support for this project.

� Academy of Management Journal2007, Vol. 50, No. 6, 1515–1539.

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Suddaby, 2006; Powell, Brock, & Hinings, 1999)—changes that have ramifications for how professionalsperform their roles and view their identity—under-standing the dynamics underlying professional roleidentity reconstruction is timely. In this article, weinvestigate interlevel influences on professionalrole identity reconstruction.

One literature stream has produced valuable in-sights into the individual dynamics that impactrole identity construction (Ashforth & Saks, 1995;Ibarra, 1999; West, Nicholson, & Arnold, 1987).Research in this stream attends mainly to micro-level phenomena. Its ability to account for influ-ences on professional role identity (re)constructionis more limited. In highly professionalized fields,institutional forces such as professional associa-tions and governments can constrain or enable theconstruction of role identity. For example, domi-nant or alternative institutional templates that de-fine what constitutes professionalism, and govern-ment regulations that specify what a professionalcan or should do impact how professional roleidentities are constructed. Attending to the impactof institutional forces on role identity reconstruc-tion has both practical and theoretical implica-tions. On a practical level, such attention wouldallow professionals who envision changing role en-actments to understand the extent and the bound-aries of their agency and the extraorganizationalinfluences on their roles. Theoretically, when insti-tutional forces are not explicitly accounted for, thepicture of professional role identity constructionthat emerges is one that is contained within organ-izational boundaries, when, in fact, this construc-tion is highly influenced by extraorganizationalforces. As this study will demonstrate, institutionalelements can influence role identity reconstructionalong more than one trajectory.

Another literature stream documents the impactof institutional environment on changing profes-sional organizations and boundaries (Greenwood,Suddaby, & Hinings, 2002; Scott, Ruef, Mendel, &Caronna, 2000; Townley, 2002). These studies tellone little about how such changes affect profession-als operating in micro contexts and whether andhow these changes affect individuals’ professionalrole identities. Yet, in recent years, there have beenrepeated calls for researchers working with institu-tional approaches to cross levels of analysis (Barley& Tolbert, 1997; DiMaggio, 1988; Fiol & O’Connor,2006) and to examine “the interdependence be-tween institutions and individual identity androles” (Dacin, Goodstein, & Scott, 2002: 52).

In general, cross-fertilization between the twocited literature streams has been limited. The pur-pose of this study was to build bridges across macro

and micro levels by integrating institutional, organ-izational, and individual dynamics that influencethe (re)construction of professional role identity.Unlike most work on role identity construction andchange, which has emphasized the individual levelof analysis and perhaps included organizationalcontext as a constraint (e.g., Ashforth & Saks, 1995;Ibarra, 1999; Nicholson, 1984), the present researchintegrates an additional level: the institutionallevel.

Further, unlike previous studies that have fo-cused on the construction of the work and profes-sional identities of individuals at early careerstages (Becker, Geer, Hughes, & Strauss, 1961;Davis, 1968; Ibarra, 1999; Pratt et al., 2006), wetraced the influences on the reconstruction of roleidentities of professionals at later career stages. Weuse the term “reconstruction” to denote a signifi-cant change in a role that a professional has enactedover time and has considered to be self-defining.The careers literature indicates that individualswith more work and personal maturity may havedifferent motivations for seeking career changesthan individuals at earlier career stages (Hall,1986). However, this literature does not attend tothe interactions between individual motivation andinstitutional forces. As will be shown, models thatare legitimate in the institutional environment ofprofessionals may constrain the career choices ofprofessionals motivated to seek role identitychanges.

In this study, we sought to refine and extendtheory by building a model of the interlevel influ-ences on the reconstruction of professional roleidentity. We used a case study as a basis for extend-ing theory (Creswell, 1998; Eisenhardt, 1989;Vaughan, 1992). We focused on change in the pro-fessional role identity of physicians and trackedthese changes longitudinally in a health care unitin Canada. Our findings indicate that the institu-tional environment of these professionals was asource of interpretive, legitimating, and materialresources that both enabled and constrained thereconstruction of professional role identity. Fur-thermore, the institutional dynamics’ influencewas conveyed along a double trajectory: a directone, as the agents in the case adopted and adaptedresources, and an indirect one, whereby institu-tional dynamics affected organization-level ar-rangements that further influenced microlevelagency. As the professionals engaged in microlevelactions aimed at assembling resources supportingprofessional role reconstruction, their agency inter-acted with the macrolevel influences.

1516 DecemberAcademy of Management Journal

PROFESSIONAL ROLEIDENTITY RECONSTRUCTION

Professional Role and Identity

Professional identity is an individual’s self-defi-nition as a member of a profession (Ibarra, 1999;Pratt & Dutton, 2000). It is associated with the en-actment of a professional role (Pratt et al., 2006).Barley pointed out that role and identity are twosides of the same coin: while roles look outwardtoward the interaction structure in a setting, iden-tities look inward toward the self-definition asso-ciated with role enactment (1989: 50). Enacting aparticular role gives rise to role identity, “the goals,values, beliefs, norms, interaction styles and timehorizons that are typically associated with arole . . . a role-identity provides a definition of self-in-role” (Ashforth, 2001: 6). Stryker and Serpestated that “identities are reflexively applied cog-nitions in the form of answers to the question ‘Whoam I?’” (1982: 206) and that these answers refer to“internalized positional designations that representthe person’s participation in structured role rela-tionships. Thus, there is an intimate relationshipbetween role and identity, emphasized in the term‘role identity’” (1982: 206).

Nicholson (1984) stated that there are situationsin which individuals may proactively seek changesin a role so that the role better matches their iden-tity and others in which a role change may engen-der personal development as individuals absorbthe change by altering identity-related attributes.However, research indicates that role and identityevolve interactively (Ashforth, 2001; Ashforth &Saks, 1995; Barley, 1989; Hall, 1986; Ibarra, 1999)and that “there is no simple causal directionality”between social structures, roles, and identity (Westet al., 1987: 301).

Although some research on work roles and iden-tities has appeared in the literature, the profes-sional aspect of roles and identities has receivedlittle attention. Further, studies that focus on pro-fessional models generally demonstrate a macrosociological perspective and tend to ignore the in-dividual dynamics associated with professionalrole identity reconstruction.

Macro- and Microlevel Research

Macrolevel research of particular relevance forour study is work in institutional theory in whichprofessional roles are viewed from a structural per-spective—as fixed within institutionalized sys-tems. Microlevel research tends to focus on theindividual-level dynamics that impact roles andidentities. This literature occasionally integrates

the impact of organization-level elements on rolesand identities. These two literature streams corre-spond to the structural and symbolic interactionistperspectives (Ashforth, 2001; Stets & Burke, 2003;Stryker & Statham, 1985). From the structural per-spective, roles are given positions in a social struc-ture, whereas from the symbolic interactionist per-spective, roles are emergent and negotiated amongindividuals.

Writing from an institutional standpoint, Scott(2001) indicated that some values and norms areapplicable to specific types of positions, giving riseto roles. Certain conceptions of appropriate roles,routines, and scripts are associated with actors andidentities in such a way that these conceptions are“prescriptions (or proscriptions) of behavior”(Scott, 1994: 63). In most professional fields,strongly institutionalized beliefs and values defineprofessionalism (Abbott, 1988; Powell et al., 1999).Both the institutional and sociological perspectiveshave focused on the impact of professions on thedefinition of roles and on the regulation of memberaction as a macro process (Abbott, 1988; Freidson,1993; Greenwood et al., 2002; Macdonald, 1995).Professions are said to exercise control by suchmeans as training, testing, and setting principles foraction (Abbott, 1988; Scott & Backman, 1990).Thus, the view is that strong identification induce-ment processes shape the identity of members ofdeveloped professions.

Although institutional theory has contributed toacademic understanding of the institutional mech-anisms and templates that define professional rolesand boundaries, it has not been helpful in explain-ing how professional roles and identities change orare reconstructed in micro contexts. Understandingthis reconstruction requires attention to the mean-ings, actions, and interactions of agents in organi-zational settings (DiMaggio, 1988; Townley, 2002;Zilber, 2002).

Microlevel theory, on the other hand, focuses onindividuals and the organizational contexts inwhich individuals construct professional role iden-tities. (For a review of the identity constructionliterature that focuses on the micro analysis, seePratt et al. [2006].) Van Maanen and Schein (1979)noted that dissatisfaction with a role can lead pro-fessionals to redefine it by changing the missionassociated with the role. Nicholson (1984) pro-posed that outcomes of work role transitions in-clude four modes of adjustment—replication, ab-sorption, determination, and exploration—thatvary on the basis of role and personal development.For example, role exploration represents cases ofsimultaneous personal change and role change andis likely to occur when a role’s incumbent has a

2007 1517Chreim, Williams, and Hinings

high level of discretion in shaping the role. In Ni-cholson’s model, the institutional factors that influ-ence the level of discretion (given, for example, anincumbent’s position in an institutionally estab-lished hierarchy) are not a focus of analysis.

A few empirical studies that focus on how pro-fessionals are socialized into or adapt to new rolesand construct their professional identities havebeen conducted. Ibarra (1999) found that consult-ing and investment banking professionals’ adapta-tion to new roles involved experimentation withprovisional selves that served as trials for profes-sional identities. Pratt and his colleagues foundthat work-identity integrity violations due to “ex-perienced mismatch between what physicians didand who they were” (2006: 235) triggered the iden-tity construction of medical residents. These stud-ies have produced valuable insights into the micro-dynamics of work/professional role identityconstruction and the organizational contexts inwhich such construction occurs. However, thesestudies do not focus on the role identity reconstruc-tion that may occur later in careers. Neither do theyexplicitly address the influence of a wider institu-tional environment on the content and the dynam-ics of role identity (re)construction.

The macro and micro streams of research havedeveloped in parallel rather than interactively.Each stream leaves out important dynamics of pro-fessional role identity reconstruction. We took se-riously the advice of those who have called forresearch that integrates macro approaches that fo-cus on institutions and structures and micro ap-proaches that focus on agents’ interpretations, ac-tions, and interactions (Barley & Tolbert, 1997;Beamish, Hitt, Jackson, & Mathieu, 2005; Dacin etal., 2002; Stryker & Statham, 1985). Our aim was toexamine the content of and the interlevel influ-ences on professional role identity reconstruction.

METHODOLOGY

Research Setting

The case: A Canadian health clinic. The re-search site was a health clinic that served a popu-lation of several thousand people in a defined geo-graphical area in a Canadian province. The clinicwas owned and operated by a group of eight familyphysicians and employed a varied support staff.The physicians also performed surgeries in the lo-cal hospital. Prior to the implementation of thechanges, the physicians performed their work as aconsortium of independent practitioners and werepaid individually on a fee-for-service basis by theprovincial government. In Canada, each provincial

government funds all medically necessary healthcare services to the citizens of the province. Re-gional Health Authorities (RHAs), set up by provin-cial governments, oversee health services and pro-viders—except physicians—in specific geographicregions. Professional associations representingphysicians negotiate their fee structure with theprovincial governments.

The changes we studied were initiated by theclinic physicians themselves in the late 1990s. Atthis time, the RHA and the government of the prov-ince in which the clinic was located were consid-ering the need for health care innovations focusedon wellness and integration of services. Followinga series of meetings initiated by the physicians andinvolving representatives from their own group, theRHA, and the provincial government, the partici-pants developed a model that included severalchanges. These were a fundamental change in phy-sician compensation: a transition from a fee-for-service system to a capitation system with a fixedsalary based on serving defined populations; theinstitution of an integrated information system; thecolocation of various health care professionals; theadoption of a multidisciplinary, integrated ap-proach to service delivery; and the hiring of a nursepractitioner to do health promotion, among otherthings. These changes were developed into a three-year experimental “project” whose activities werefacilitated by an “integration team.” The role of thisteam was to ease implementation of specific inte-grative programs, and its members included repre-sentatives from different stakeholder groups.Project participants identified health concerns inthe region, and the integration team helped set upmultidisciplinary thematic teams to address the in-tegration of services related to these health con-cerns. The first such team had the theme “wellbaby” and brought together the project coordinator,physicians, and public health nurses. Thematic in-tegration teams were also developed aroundasthma, hypertension, and diabetes. Each thematicteam created strategies to integrate services, removeduplication, and offer education. As decisionsabout payment systems, colocation, and integrativeactivities were being considered, the issue of pro-fessional roles became a significant theme in theproject participants’ discussions.

Rationale. We became interested in this casebecause it featured significant change and recon-struction and gave us the opportunity to track thedynamics of changes at multiple levels. The casecould be considered unique (Yin, 2003) in that thechanges attempted at the clinic were highly inno-vative for this province. The project involved fast-paced, high-magnitude change. Project participants


indicated that they were unaware of any otherproject that had attempted as many changes as theyvisualized in as short a time. As researchers, wehad the opportunity to track the changes occurringat the individual, organizational, and institutionallevels over four years beginning with the inceptionof the project and ending after its completion.

In this article, we focus on physician role iden-tity for two reasons. First, the physicians were in-volved in multiple aspects of integration (such asthe asthma, well baby, and diabetes teams) andwere subject to all the changes that affected thesystem (payment, information system, physical co-location). As the project coordinator stated, “Every-thing that you are trying to change involves thephysician, whereas from the allied providers’perspective . . . you’re only modifying your roleslightly.” Second, physicians are a highly profes-sionalized and institutionalized group, and studieshave documented both their opposition to changesviewed as reducing their autonomy and the impor-tance of their support to the success of innovationsin health care delivery (Denis, Lamothe, Langley, &Valette, 1999; Doolin, 2002; Reay & Hinings, 2005).Because the physicians in our study appeared to beopen to the changes, this case provided the oppor-tunity to extend theory (Eisenhardt, 1989; Hartley,1994; Vaughan, 1992) on enablers of role identityreconstruction for professionals.

We adopted a case study approach with a focuson qualitative data (Creswell, 1998; Hartley, 1994).As we were interested in interlevel dynamics re-quiring data collection from different sources, thecase study approach proved to be particularly help-ful (Creswell, 1998). We used the naturalistic in-quiry method designed to reveal phenomena intheir natural settings (Lincoln & Guba, 1985). Thisapproach was the appropriate vehicle for the thickdescription “so essential for understanding of con-text and situation” (Lincoln & Guba, 2002: 206),which is important in a study aimed at compre-hending the interacting dynamics that influencechange in professional role identity.

Data Sources

The overall research project of which this studywas a part had a longitudinal case research designfocused on tracking a variety of changes over thelife of the provincial health clinic’s pilot projectand beyond. Data collection included observingmeetings, compiling written material, and conduct-ing three sets of interviews with stakeholders at theinception of, during, and at the end of the healthclinic’s pilot project (times 1, 2, and 3, respec-tively). Interviewees included the physicians, key

decision makers in the RHA, and a variety ofproject participants, as is shown in Table 1. Overthe three time periods, we conducted 74 inter-views. We used “purposeful sampling,” approach-ing all key participants in the project and inter-viewing each at least once. Most key participantswere interviewed twice or more. We did not havethree interviews with every participant becauseover the life of the project, various individualschanged positions or were hired late. All the phy-sicians involved in the project were interviewed atboth times 2 and 3. (By time 3, one of the physi-cians had left for reasons unrelated to the project.)Of the eight physicians, four were in later career,three were in mid career, and one was in earlycareer (but had already practiced in other clinics).

Interviews lasted from one to one and half hours.Most interviews were conducted by two membersof the research team, which included the currentauthors. Our interview strategy combined use ofthe interview guide approach (in which topics to becovered are specified in outline form) and the stan-dard open-ended interview approach (in which thewording and sequence of questions are predeter-mined). As Patton (2002: 347) indicated, the strat-egy of combining the two interview approachescalls for specifying certain key questions whileleaving other items to be explored. Interviews weretape-recorded, although two participants preferrednot to be taped, and we took detailed notes duringthe interviews. All interviews were transcribed.

Time 1 interviews were conducted after fundingfor the project had been announced and beforeimplementation had started. Interview questions attime 1 focused on obtaining views on the widercontext surrounding the project (including devel-opments in the health care system), on the prevail-

TABLE 1Interview Participants

ParticipantsTime

1Time

2Time

3

RHA senior administrators 6 4Project coordinator 1 1 1Clinic manager 1 1 1Clinic physicians 4 8 7Clinic nurse practitioner 1 1 1Clinic registered nurse 1 1Clinic staff 2 1 1Public health and home and community

care personnel (supervisors, nurses,and program specialists)

9 7 8

Hospital acute care supervisor 1 1 1Hospital continuing care supervisor 1 1 1

Total 26 22 26


ing service delivery methods and structures, on thelevel of satisfaction with the prevailing operations,on the envisioned organizational changes, on thedrivers of the change, and on the significant stake-holders in the project. The specific notion of pro-fessional role identity was not a central focus in theinterview questions at time 1, although some dataon roles prior to the changes were gathered. How-ever, during the course of our attendance at inte-gration meetings, it became clear that roles hadbecome a significant issue as practitioners fromdifferent professions tried to integrate their ser-vices, and we thus decided to focus on this subject.In the time 2 interviews, we made the notion ofprofessional role identity a central theme. The time2 interviews, conducted about two and a half yearsafter the time 1 set, tapped into participants’ viewsof changes that had occurred in the wider environ-ment and in the organization. They also exploredprofessional roles (including practices, interac-tions, relationships) before and after the changes,the motivation for and experience of change, andthe enablers of and obstacles to role changes. Thetime 3 interviews were conducted one and a halfyears after the time 2 interviews, or about four yearsafter the inception of the pilot project. At that time,the pilot project had ended. At time 3, questionsagain examined participants’ views of the changesthat had occurred in professional roles and rela-tionships as well as their views of the organization-al and institutional changes. Time 3 questions alsotapped into the lessons learned and the possibilityof their diffusion elsewhere in the region. Extensiveprobing was used throughout all the interviews.

In this article, we focus primarily on three maindata sources that provide detailed information ondynamics at different levels. Table 2 details thesedata sources and the associated role identity ele-ments. The first data source of particular impor-tance here is the time 2 set of interviews, becausethey provided the richest information on rolechanges. The time 1 interviews provided usefulinformation on roles before the changes and on themacro- and microcontextual elements of thechanges. The time 3 interviews confirmed the find-ings obtained at time 2 regarding professional roleidentities and further established that the changeswere not temporary. Thus, we drew upon the times1 and 3 interviews for further insight and corrobo-ration. The second focal source of data for the cur-rent study was our observations of 17 integrationmeetings, each attended by at least one researcher.These meetings allowed us to gather informationon how roles were being addressed and negotiatedthroughout the life of the project. Field notes weretaken during each meeting and typed shortly there-

after. Meeting minutes prepared by the project co-ordinator corroborated our meeting notes. Thethird important source of data was the written ma-terial we gathered. Archival material consisted ofprivate studies and government reports on thehealth care system in the province and in Canada,summaries of RHA policy changes affecting healthservices in the region, and medical professionalassociation publications addressing issues of pay-ment systems, medical care models, and healthcare reforms. Additional written material includedthe project mission, objectives, operational model,and milestones, as well as progress reports from thevarious programs (e.g., well baby, asthma) andcharts from these programs outlining the divisionof responsibilities among practitioners. Thus, wederived our data on different elements that influ-enced the reconstruction of physician role identityfrom a variety of sources.

Data Analysis

We adopted a qualitative case study approach touncover a wide variety of dynamics at differentlevels and to achieve a detailed understanding ofthe way that they interacted. We approached thedata analysis with three broad foci of attention. Thefirst was the content of professional role identitychange, as evidenced in descriptions of role iden-tity before and after the change. Physicians were

TABLE 2Sources of Data

Influences on theReconstruction ofProfessional Role

Identity Sources of Data

Institutional dynamics InterviewsSummary of government reportsStudies of the provincial and

Canadian health care sectorStatements of policy changes by

the RHAMedical professional association

publications on paymentsystems, medical care models,and health care reforms

Organizational dynamics InterviewsField notesMinutes of meetingsWritten project material

Microdynamics InterviewsField notesMinutes of meetingsWritten project material


asked to describe their professional role at the timeof the interviews, to elaborate on how it was differ-ent from past role enactments, and to give exam-ples. For instance, such statements as “Now I prac-tice my role as a member of a team of providers. . . .Before, I saw myself as an autonomous provider”indicate a change in the content and enactment ofprofessional role. Physicians’ descriptions of thecontent of role changes converged on four themes,which are presented in Table 3. Although we usedthe physicians’ views as the basis for mapping thecontent of role changes, we found that other prac-titioners described, in similar ways, the changesthey had observed in physicians’ role enactment.

The second focus comprised the macro- and mi-crodynamics that influenced the reconstruction ofprofessional role identity. In the analysis of thesedynamics, we initially coded the data by applying aset of descriptive themes that closely resembled theterms used by the participants. We then derived aset of pattern codes that suggested thematic links inthe data (Miles & Huberman, 1994). For example,we applied such descriptive captions as “govern-ment influences,” “professional influences,” and“RHA influences” to segments of data text thatreferred to each of these influences. We agreed thatthese influences could be subsumed under the pat-tern code “institutional elements,” which was

TABLE 3Physician Role Identity: Past and Present

Role Identity Content Change Representative Quotations from Physicians

From: Autonomous provider; soleresponsibility for patient care

My practice with the project . . . it’s made me more aware of what the other health careprofessionals do and their role in the care of the patient. So it’s given me a betterappreciation for them as sort of parts of the team. So I don’t look on myself so much as anindividual, but as part of a team in patient care.

To: Member of a team; primary,but shared responsibility forpatient care

We’re clearly using more people, we feel much more comfortable sharing responsibilities thanwe did before. And that issue of control is far less important than it was. So I think that’sreally developed. . . . We’ve come a long way.

The way we used to do things is . . . asthma was controlled by the doctor, and the diabetes,there was no integral care with the dietician and the nurse educator. So that I think there isa lot more togetherness (now) . . . (Patients) get more scope to their disease by having thesepeople involved. And I’m still involved with them, but they get additional expert input fromthe team.

From: Focus on treatment The way I practice has changed. . . . Now I spend more time with the patients and practicepreventive care.

To: Focus on treatment andprevention

I’m also on Well Baby Team and the Asthma Team. . . . Now that’s a physician providing inputand direction. . . . and pooling that with expertise of others and trying to develop programs. . . Physician yes, but a physician in a prospective, preventative way.

I think just the whole idea of moving towards wellness, or trying to promote health issignificant. . . . I think the project allows you to try and move in that direction, to beproactive rather than reactive.

From: Limited concern withguidelines

We have changed in the sense that we are looking more at standards as a practice, not only asdoctors—but as a community, public health nurses, those kinds of things—what we provide,making sure . . . to follow standards or guidelines.

To: Focus on best practiceguidelines

Now . . . I’m far more focused on guidelines and quality of care issues. . . . It’s because of myinvolvement in the project.

There’s more team involvement and more pathways for diseases that we never had before.

From: Partial view of patients(focus on present illness)

The style of practice has changed for the better, I think. Certainly I feel much more satisfiedprofessionally when I get more comprehensive, spend more time, and clearly make sure thatthe patient and I deal with the issues appropriately.

To: Holistic view of patients You have to look at the patient as a whole. . . . So if you don’t have the whole picture, then it’smore difficult to make the proper recommendations and decisions.

I think that this integral part will help me to be more aware of things that I might not havethought about in looking at the illness in a broader picture.


viewed mainly as a macro influence. We noted atendency for an element at one level, say at themacro level, to interact with elements at the microlevel. For example, we had considered “coloca-tion” of different practitioners in one physicalspace to be an organization-level (or macrolevel)theme. However, several quotations that addressedcolocation also indicated that presence in the samespace had facilitated interaction between differentprofessional groups, allowing the building of trust.Thus, such quotations were also coded with “inter-actions,” which we considered a microleveldynamic.

The third focus was identifying links betweenthe macro and micro influences. This involvedthree analytical tasks. The first task was identifyingexplicit references to such links in the data (as theabove example on colocation indicates). The sec-ond was comparing the information available indifferent data sources derived from different levels.For example, an examination of themes in govern-ment-commissioned reports addressing the needfor health care reforms (a potential institutionalinfluence) indicated that participants were also re-ferring to several of these themes (such as “preven-tion”) as part of their aspiration (an individual-level dynamic). The third task consisted of lookingat the same data through different analytical lens-es—institutional, organizational, and individual.This examination was significantly facilitated bythe composition of the research team, which hadmembers versed in research in a variety of areas,including, but not limited to, professions and insti-tutions, organizational change, and role and iden-tity. Thus, we brought different perspectives andlevels to bear on the data collection and analysis.Our regular meetings to discuss the data and theemerging model allowed us to hone in on the dy-namics at the macro and micro levels, and on theirinteraction.

In the analysis of the interview material, wesought to discern whether patterns could be estab-lished for multiple physicians. Once we estab-lished a pattern, we sought to determine whetherinterview material from nonphysician participantssupported it. We looked for additional dynamicsrelated to physician roles that were not mentionedin physician interviews but could be found in otherpractitioners’ interviews and other sources of data,such as meeting notes. Thus, in interviews withother practitioners, we found evidence of subtlestrategies these practitioners used to influencechanges in physician views. Although not men-tioned explicitly by the physicians as an elementthat influenced changes in their perspective, weincluded these influence strategies in our discus-

sion as there was evidence of such strategies inother data sources.

Following a strategy of reiteration, we went backand forth between the data and a broad literaturebase—as we integrated different levels of analy-sis—seeking important themes. When a themeemerged either from the data or the literature, wesearched the other to find evidence of the theme orto explain its absence. In case studies, extant theorycan be employed to compare and contrast findingswith the data from one’s own study and to extendor elaborate theory (Creswell, 1998; Eisenhardt,1989; Hartley, 1994).

Throughout the data analysis, we met regularlyto exchange notes and to discuss and refine theemerging model. We also sought feedback on ouremerging model from peers (LeCompte & Goetz,1982). Some were studying the same setting (as partof a larger research project), and others were re-searching a variety of health care changes in thearea. In addition, we sought feedback on our anal-ysis from project participants and received com-ments from three, who indicated that the model wederived was a faithful representation of the dynam-ics. Their more specific comments, and those fromour peers, allowed us to refine our understandingand presentation.

Our methods entailed multiple iterative pro-cesses and were consistent with recommendationsto establish the credibility of findings (LeCompte &Goetz, 1982; Lincoln & Guba, 1985): we triangu-lated by collecting data from multiple sources; weprovided extensive quotes from the data; we usedmultiple investigators who engaged in continualintrateam communication to collect and analyzedata; we relied on peer examination to corroborateour findings; and we used “the most crucial tech-nique for establishing credibility” (Lincoln & Guba,1985: 314), which involved project member confir-mation of the categories, interpretations, and con-clusions of our report. The next section presentsour findings.

THE RECONSTRUCTION OF PHYSICIANS’PROFESSIONAL ROLE IDENTITY

We used an in-depth analysis to elaborate amodel of the interlevel influences on professionalrole identity reconstruction. Figure 1 presents theoutcome of this process. We elaborate on the modelas we proceed with the analysis. Here, initially, wepresent the content of the change in professionalrole identity found in this research, and we thenaddress the macro and micro elements that influ-enced this reconstruction of physicians’ profes-sional role identity.


Content of Physician Role Identity: Pastand Present

When asked about the changes in their profes-sional roles, physicians addressed a variety of con-tent issues. They indicated experiencing majorchanges in the ways they performed their role anddefined themselves as physicians (as Table 3 illus-trates). Physicians stated that they viewed theirprofessional role as having changed from one fo-cused on autonomous service provision, with soleresponsibility for patient care, to one focused onteam provision, with shared responsibility for care:

The change for me has been previously working onthe assumption that most of medical practicedoesn’t lend itself to team, to now me thinking ofmyself as wanting to be part of a health care team ineverything. . . . Being part of a team is when yourecognize that [health issues] are multifaceted, andare better dealt with by the combined resources ofmultiple people. You feel the need to work in com-bination to realize the kind of health care you envi-sion and you value. . . . My role as a physician haschanged for good. I tend to think less autonomously.

Physicians also pointed to a shift in practice fromproviding brief clinical treatment to spending moretime with patients and focusing on prevention:

I see a difference. Before it was just see the problem.They’re in, they’re out the door. Now, for example,when a fifty-year old guy comes in for a driver’smedical, I’ve become more consistent about goingthrough their risk factors for heart, stroke, cancer,even though that’s not the focus of the driver’s medi-cal. . . . You feel more responsible for their overallhealth, rather than just the problem they comein with.

Physicians indicated a change in focus that in-volved placing more emphasis on “best practice”guidelines, as the presence of other practitionersstimulated them to “stay current on what’s goingon.” They also described a change in perspectiveand practice, from giving partial attention to a pa-tient’s present illness to taking a holistic view ofthe patient, as the opening quotation in this articlepoints out. The provision of “comprehensive” carewas associated with a higher level of satisfaction

FIGURE 1Interlevel Influences on the Reconstruction of Professional Role Identity


for the physicians. They referred to the importanceof “look[ing] at the patient as a whole” and “at theillness in a broader picture” (as the quotations inTable 3 indicate).

Thus, there were major changes in how physi-cians interacted with patients, how they related toother practitioners, and how they viewed them-selves as physicians. Physicians’ interactions withpatients transitioned from a transactional mode to arelational mode, and their interactions with otherpractitioners changed from those of autonomousspecialists to those of multidisciplinary team mem-bers. The physicians expressed higher levels of sat-isfaction with practicing preventive and holisticroles. These role identity changes were significantbecause they entailed new behaviors and logics(ends-means chains and justifications) that moti-vated and legitimated behaviors, and new interac-tions and relations among actors (Scott et al., 2000).In the next three sections, we turn to the influenceson the reconstruction of professional role identity.

Institutional Dynamics

Governing and funding bodies. The institu-tional influences mentioned by the physicians in-cluded the impact of the RHA. The RHA governedthe work of health care professionals other thanphysicians and had the potential to be an obstacleor facilitator of reconstruction of the physician roleby hindering or sanctioning the collaboration ofnonphysician professionals in the delivery of pa-tient care. Physicians viewed the RHA role as apositive one in terms of allowing multidisciplinaryteams and the colocation of a variety of healthservices in the physician clinic. They attributedthis positive role to “the good relationship and thefeeling of good trust between the [RHA] and thelocal clinic,” indicating that RHA senior manage-ment gave “permission to go ahead and make somelocal decisions.” Participants also pointed to otherstakeholders that lent their support to the project,including the provincial government, whichfunded a number of “infrastructure changes thatwere needed.” They noted the convergence ofviews among a variety of stakeholder groups thatwere all in favor of the changes. The projectcoordinator said:

We’ve had drivers from the different stake-holders. . . . We’ve had the RHA saying we reallywant this and [the] nurses saying this is good fornurses. . . . We’ve had the same for doctors. So wehaven’t had a group that has said . . . this is not goodfor us [or] for the system. Everybody has said, ourdiscipline can take this and move forward and ele-vate our level of practice.

Another institution-level influence was the phy-sicians’ professional association. Physicians dif-fered in their perceptions of the view of the medicalassociation. Some said it was generally opposed tothe changes, because it was an advocate for “strongphysician autonomy and fee-for-service.” Othersstated that the association was not openly opposedto the changes in physician pay and roles and wasusing the project as an opportunity to learn moreabout alternative payment and operational modelsfor physicians. The view here was that as an advo-cate for physicians, the professional associationwas interested in the conditions sustaining theirretention. Overall, however, the physicians agreedthat the association had not taken a strong stanceon the changes relating to physician pay and role.In fact, changing the physician payment system tocapitation required an agreement among the pro-vincial government, the physicians, and the physi-cians’ association itself.

An analysis of documents issued by the physi-cians’ association indicates both its openness tochanges in methods of paying physicians and itsreservations about such changes. The association’sposition is outlined at the beginning of its publica-tion, the Alternative Payment Plan (APP)Handbook:

While many physicians may be content with theexisting situation (fee-for-service), there are compel-ling reasons to at least explore other options. Re-search tells us that how a physician is paid has aninfluence on both practice patterns and service de-livery. By offering physicians the chance to choosean alternative funding model, . . . other innovativehealth delivery models may develop that could: pro-mote wellness; promote comprehensive primarycare; promote continuity of care. . . . ExploringAPPs is the first step in making it easier for innova-tive medical delivery models to evolve and develop.(Alberta Medical Association, 2001: 1–2)

The Alternative Payment Plan Handbook ex-pressed the view that directing funding into an APPshould be conditional on protection of a “physi-cian’s professional autonomy and clinical indepen-dence” and maintenance of the physician’s right toreturn to a fee for service (Alberta Medical Associ-ation, 2001: 3–4). Thus, although not an eager andunconditional proponent of APPs, the physicians’professional association responded to demands byphysicians and other stakeholders to experimentwith new models of payment and delivery.

The support (or lack of opposition) from variousinstitutional stakeholders facilitated the change inthe physician unit we studied and in the role en-acted by the physicians. Greenwood and Hiningsnoted that the occurrence of a “reformative pattern


of value commitment” enables change in institu-tionalized models; such commitment prevailswhen different stakeholder groups favor an articu-lated alternative over a “template-in-use” (1996:1035). Although Greenwood and Hinings do notdeal specifically with the issue of professional roleidentity, their formulation is helpful in sheddinglight on how reconstruction of role identity wasfacilitated in this case. Effecting a role change in anenvironment similar to that of the physicians westudied here requires the convergence of the viewsof multiple stakeholders on the legitimacy of therole change.

Physician role reconstruction is embedded in aweb of relationships involving a multitude of insti-tutional level governing and funding bodies. Fur-ther, the levels of interdependence among differentproviders and the institutions that govern theirpractices are numerous and complex. Thus, for ex-ample, although the physicians were not directlyaccountable to the RHA, they had to rely on itsapproval of the changes in the practices of otheroccupational groups (nurses, dieticians, etc.) re-porting directly to it. In addition, government andprofessional associations often erect and enforceinstitutional constraints that significantly affect thebehaviors of health care professionals (Luke & Wal-ston, 2003: 207). A change in the role of a group ofprofessionals that has a centrally embedded role ina system—such as family physicians in the healthcare system—is likely to significantly affect theroles of members of other occupational groups thatare unable, on their own, to accept or reject thechange. In the case we studied, the various govern-ing and funding bodies supported the project andprovided the legitimacy and/or material resourcesneeded to help change physician roles. The impactof nonphysician governing bodies and the profes-sional association on colocation of services, estab-lishment of teams, and changes in physician pay(organization-level phenomena) is shown inFigure 1.

Institutional templates. The physicians pointedto the initial difficulty involved in the divestmentof traditional roles defined by dominant templates:

If you have an existing model around what a physi-cian does, and you try and match that up to thisdifferent model of an asthma [integrative] team, theyare in conflict. . . . Professionally you certainly havea lot of paradigms too. . . . One of the implicit thingsis that the physician should always be in charge andthe physician always works autonomously. . . .While we’re in that, is there really room for otherroles that the physician has? . . . That’s somethingthat you probably have to address at a very funda-mental definition level. And a medical school level

and so on. Not that it cannot be done in this sort ofenvironment, once people have been working for awhile. But it does take a lot of time. . . . We’ve had alot of success, but I think we’ve underestimated thepower of people’s impressions and paradigms.

Physicians also indicated that under the tradi-tional model, delegation was difficult as it evoked asense of loss of control over patient care and thepatient-doctor relationship:

When the nurse practitioner started seeing people,like her Well Woman Clinic. And she’d see mypatients and do yearly exams on them. And initiallyI felt a sense of well, if they don’t come see me, howam I going to know what’s going on? And then Iwent through a phase of some irritation, I’mashamed to admit. I’ve been working with MY pa-tients, and using that autonomous mindset. And thenurse practitioner would come along and say, ”Oh Ineed to ask you a quick question. It’s about yourpatient that I’m seeing here.” . . . Now the feelingcould be that the patient-doctor relationship is ac-tually being diluted because part of it’s being dealtwith by someone else. But my feeling is that it’sbetter, because the better the service the patient isable to get, the better I look. Even if it isn’t some-thing that I’ve done.

These quotations are indicative of the physi-cians’ engagement with both the traditional tem-plates and the emerging alternative templates in theinstitutional environment. They talked about alter-native models that were gaining acceptance in thehealth care field and stated that the principles un-derlying their role changes had their roots in suchmodels. A physician stated: “The concept of pri-mary care renewal developed in the literature inthe early nineties and our project came from thathistory.” The physicians indicated having attendedinternational conferences on integrated approachesto health care that provided them with alternativeviews of roles and practices. They also pointed to anumber of government-commissioned reports thataddressed the need for practice changes similar tothe ones they were experiencing.

Numerous archival sources, including studiesconducted by academic researchers and industryanalysts and reports commissioned by federal andprovincial governments, document traditional andalternative ways of providing health care (e.g.,Commission on the Future of Health Care in Can-ada, 2002; Denis et al., 1999; Marchildon, 2005;Premier’s Advisory Council on Health, 2001). Inthese reports, the role of the family physician oftenreceives attention, as a visit to such a physician hasbeen a patient’s point of entry into the health sys-tem. In Canada, the provincial and federal govern-ments strongly influence the role of physicians


(Coburn, 1993). Unlike countries in which the gov-ernment’s influence is more limited, in Canada thegovernment wields much power in shaping medi-cal practice, because it pays physicians. Thus, gov-ernment-commissioned reports and their recom-mendations have a major impact on institutionalthemes and templates that affect how physicianroles are interpreted and possibly shaped.

The archival sources addressed the differencesbetween the old and the new templates. Accordingto these sources, the traditional methods of pay-ment (fee-for-service), of entry into the health caresystem (through a physician), and of organizingwork (fragmentation, professional specialization,and protectionism) were obstacles to delivery ofprimary and comprehensive care (Commission onthe Future of Health Care in Canada, 2002; Marchil-don, 2005; Premier’s Advisory Council on Health,2001). These reports converge in recommendingseveral changes. These changes include “imple-menting alternative approaches for paying physi-cians and providing better alignment between phy-sicians and regional health authorities”;“encouraging groups of health care providers toestablish “care groups” and offer a range of ser-vices”; “providing [citizens] with better informa-tion about how to stay healthy”; “implementingnew models of care like comprehensive primaryhealth care and disease management approaches”;and “consider[ing] greater use of clinical practiceguidelines” (Premier’s Advisory Council on Health,2001: 6–8, 38). (Tables containing additional quo-tations on old and new templates, taken from ar-chival sources, are available by request from thefirst author.)

The professional association engaged with theseemerging themes, but with caution. Although itspublications advocated a collaborative and multi-disciplinary team approach to primary care deliv-ery and noted an “increased interest by policy-makers and providers in alternate deliverysystems” (Alberta Medical Association, 1996: 7),they also cast the family physician as the point ofentry into the system and as the central authorityon patient records. The physicians’ association alsoadvocated family physicians’ maintenance of “astrong patient-doctor relationship,” even in theevent of alternate delivery of health care (AlbertaMedical Association, 1996: 7). Similarly, with re-spect to payment mechanisms, the association’sview was that the traditional fee-for-service methodof remuneration should continue at the same timethat alternate payment mechanisms were explored(Alberta Medical Association, 2002).

Thus, different templates prevailed in the insti-tutional environment. This is not surprising, since

the values and goals of different bodies with legit-imate authority to speak on the health care systemvaried. Even the physicians’ association engagedsimultaneously with themes from the traditionaland the emerging templates, reflecting the perspec-tives of different segments of the profession, as thisphysician quote illustrates: “There is a core of phy-sicians that are forward-thinking and recognize thatsomething has to change. . . . There is also a core ofphysicians that say, . . . We will not toleratechange.” The different themes, deriving from thetraditional and the emerging templates, were avail-able as alternative interpretive and legitimating re-sources that the physicians could and did draw onin enacting traditional or reconstructed roles. How-ever, these templates also limited the range of rolecontent that the physicians could consider in thereconstruction of their role identity. Although theycould exercise some agency in their choice of ad-herence to a traditional role template or the adop-tion of an emerging role template, they were con-strained by those templates viewed as legitimate atan institutional level. In other words, institutionaldynamics both enabled and constrained role iden-tity reconstruction. As these findings indicate, re-search on role identity (re)construction would ben-efit from attention to the impact of institutionalforces on the (re)construction, yet this is generally aneglected area in such research.

A question that remains is, How do professionalsdeal with the tensions emanating from the push oftraditional role templates adopted through exten-sive socialization and experience, and the pull ofalternative role templates circulating in the institu-tional environment? As will be explained in latersections, other influences favored the reconstruc-tion and adoption of new roles; the physicians didnot, however, reconstruct their role or adopt a newone without maintaining links with the past. Figure1 shows the impact of templates (old and new) on anumber of organizational and micro elements. Weelaborate on these relationships in subsequentsections.

Organizational Dynamics

Governing and funding bodies sanctioned or fa-cilitated integrative mechanisms and structuralchanges at the organizational level. Such changes—including the modification of physician pay, colo-cation of services, and establishment of teams em-powered with negotiation and decision-makingability—were mobilized by the physicians, whochose those arrangements that supported changesin practices consistent with their envisioned role.Thus, organization-level changes came to be as a


result of the interaction between microlevel actionand macrolevel institutional forces.

Incentive system. Before the project, physicianswere paid on a fee-for-service basis, the impact ofwhich is described in the following physicianquotation:

Under the old system you have to see between sixand eight patients an hour for most doctors in orderto meet your overhead and make a living. So thatdoesn’t allow for very much teaching time for eachpatient, or any prevention of any type. . . . I thinkmost doctors would admit that they may be able toquickly assess a problem, prescribe a few medica-tions, and that’s about it. . . . How can I say it prop-erly without sounding like all doctors are trying topad their pockets? But it’s an economic reality. . . .The fee-for-service system isn’t a system that re-wards complexity of work, or difficult problemsolving. It simply rewards, in most cases, highvolume. And it’s fee-for-service, not fee for diffi-cult work. . . . There’s a lot of dissatisfaction withthe fee-for-service system, both with the doctorsand patients.

The physicians had negotiated a capitation-basedpayment system as part of the changes. The move-ment to the capitation system, which involved afixed salary based on serving a defined population,had a major impact on how physicians enactedtheir role. They now had incentives to change theirpractice and to spend more time with the complexcases, focus on prevention, and refer patients toother practitioners who offered education services.Referring to the impact of the change in the pay-ment system from fee-for-service to capitation, aphysician stated:

You literally change from one day to the next howyou’re being paid. The whole thought process andthe mind-set of going from “I only get paid when Isee the patient,” to “I’m getting paid to try and keepthese people healthy.” . . . We’re trying more to ac-cess other services for those patients, whether it’s adiabetic clinic, whether it’s seeing the nurse practi-tioner for smoking-related issues. . . . Under the oldsystem you had to see the patient to get paid.

Previous research has shown that changes incompensation can encourage physicians to changetheir practices and to collaborate in multidisci-plinary teams (Denis et al., 1999). This research,however, did not focus specifically on enablers ofrole identity reconstruction. Our findings indicatethat a change in incentive system (an organization-level element) enabled a change in physician rolereconstruction by engendering different patterns ofbehaviors and interactions with patients and otherprofessionals. It is also important to note the im-pact of the institutional environment on the physi-

cian role reconstruction. The change in the pay-ment system would not have been possible withoutthe rise of alternative templates based on criticismsof fee-for-service and the need to explore alterna-tive payment systems, and the willingness of gov-erning and funding bodies to support such systems.

Physical structures (colocation). The physicianshad explored a number of integrative mechanismsand structures, such as implementing new informa-tion systems that would allow “cocharting” of pa-tient information by different practitioners. Imple-mentation of a new system was still at anexperimental stage at the time of the study and hadnot yet yielded substantial results in terms of re-construction of the physician role. However, an-other integrative mechanism was colocation of ser-vices. With the support of the RHA, asthma,diabetes, and well baby services that had been pro-vided by different occupational groups in dis-persed physical locations were moved into the phy-sician clinic. Colocation facilitated communicationand interaction between physicians and other prac-titioners, allowed the building of trust between pro-fessional groups, and supported the change in prac-tices, as a physician pointed out:

When we moved the diabetic lipid education overinto our clinic, the number of referrals took off. . . . Ioriginally envisioned that we didn’t need to be un-der one roof, that we would actually virtually com-municate if we had the appropriate computeriza-tion. But I’ve changed my mind and I believe thatpassing each other in the hall and saying, “Oh by theway,” has made a big difference to the amount ofcommunication and the feeling about workingcollegially.

Studies on the arrangement of physical space inorganizations shed light on the dynamics in thecase. Hatch and Cuncliffe stated that the “physicalmarking of group boundaries is associated withstrong group identity in organizations” (2006: 243).In the present case, colocation removed physicalboundaries that separated the groups and allowedinteraction, engendered trust, and enhanced physi-cian willingness to refer patients to other practitio-ners, who became participants in patient care, shar-ing in the roles reserved for physicians prior tocolocation.

Team structures and mechanisms. Other organ-ization-level elements that facilitated the physicianrole change were team structures and mechanisms.We recognize that a more detailed model could beconstructed with inclusion of a fourth level—thegroup level. However, to simplify our model andpresentation, we included teams acting at the or-ganizational level under organizational dynamics.


We also realize that several organizational (andgroup) dynamics are intertwined with individual dy-namics. Classifying some influences as either organ-izational or individual involves a certain level of ar-bitrariness, as is often the case in classifications.

With the approval of the RHA, an integrationteam and several thematic teams were set up tofacilitate integration of services. This occurred inan institutional environment in which healthcare reform reports were advocating integration,coordination, and delivery of services by multi-disciplinary teams. The integration team broughttogether representatives from the RHA, the phy-sicians, and other professional groups, and over-saw and directed the entire project. The projectcoordinator indicated that the integration teamvetted such issues as the thematic integrativeprograms (well baby, asthma, and hypertension)that would be put in place and helped “identifythe stakeholders who should be on the [thematic]teams.”

Physicians played a key role in the decisions ofthe integration team and led one or more of thethematic teams that were set up. The thematicteams worked out the finer details of the integrationand set policies related to team functioning andprotocols regarding the role of each team member(physician, respiratory technician, nurse practition-er, etc.) Issues that the thematic teams could notresolve were referred to the integration team. Itsstructure and processes enabled physician rolechange as representatives with the power to ap-prove or reject decisions were members of the team;their decisions were thus seen as granting legiti-macy to proceed with different practitioners’ rolechanges. The thematic teams also enabled physi-cian role change by bringing together members in-volved in the change to agree on how roles wouldbe reconstructed.

Team meetings served as a mechanism wherebyrepresentatives of the different professional groupscould negotiate how roles would be redefined inthe integrative environment:

Physician: Well Baby Clinic is a nice example ofthat. It used to be that I talked to the moms aboutbreast feeding and I did the exam and all of thatstuff. And the same with the public health nurse. . . .I think it was tough for both parties, both the publichealth nurses and the doctors because we askedthem to stop doing the exams. And they asked us tostop talking about breast feeding and doing thosekinds of things.

Interviewer: How did you reach an agreement as towho does what?

Physician: We pretty up front said, “Let’s list thethings I do and the things that you do, and those thatare duplicated, let’s negotiate who does it.” So itwas clearly a sit-down negotiation.

Studies indicate that “the phenomenon of theteam is replete with struggles over professionalclaims” that prevail during negotiations (Bucher &Stelling, 1969: 6) and that professional groups oftenattain power by taking it away from other groups(Abbott, 1988). A number of factors help explainwhy role boundary negotiations did not appear tobe particularly contentious in this case. First, thephysicians reconstructed their role in such a way asto allow for an enhanced scope of practice and ahigher level of accountability for other occupa-tional groups. No power was taken away from thosegroups. Rather, by widening the range of servicesprovided to patients, the different occupationalgroups attained satisfactory scopes of practice,which made the change in the physician role anoncontentious issue. Moreover, because the phy-sicians headed the thematic teams and played amajor role in the integration team, no decision wasmade without their approval. Their position at thetop of the institutionally sanctioned power hierar-chy (Scott & Backman, 1990) relative to the occu-pational groups represented during the negotia-tions was not contested.

Figure 1 shows that adherence to the power re-lations prescribed by established templates enabledteam structures and mechanisms. It also shows thatthe RHA and new templates that focused on inte-gration and multidisciplinary team delivery of ser-vices enabled the team structures and mechanisms.In brief, institution-level elements enabled changesin organization-level elements (incentive systems,physical colocation, and team structures and mech-anisms) and, in turn, the organization-level ele-ments facilitated the new behaviors and interac-tions (microlevel elements) that aligned with thenew professional model.

Individual Dynamics

Microdynamics involving interpretation, action,and interaction influenced the reconstruction ofprofessional role identity. Some dynamics were in-tertwined with each other or with forces at theinstitutional or organizational level. Note that weconsidered different strategies for organizing themicrodynamics that follow, including (1) present-ing them according to the sequence in which theyoccurred and (2) categorizing them as involvingeither meanings or actions. However, as several ofthese dynamics took place simultaneously and


most of the dynamics had both meaning and actioncomponents, it became apparent that such catego-rizations would impose artificial distinctions thatthe data did not bear out. Note as well that thedynamics classified as individual can have a groupcomponent and can refer to individual action andinterpretation in the context of a work/professionalgroup, whose members may have had similar expe-riences and/or acted collectively.

Personal life changes and search for more sat-isfactory roles. The older physicians mentioned anindividual-level dynamic that appeared to be a sig-nificant enabler of the reconstruction of profes-sional role identity. They referred to personal lifechanges, such as aging, that had accompaniedshifts in their views of the meaning and value ofwork. They also mentioned identification witholder patients. As the following quotations fromtwo of the older physicians indicate, personal lifechanges were intertwined with changes in profes-sional role identities:

At the time I was clearly earning money to supportmy family, but now I don’t care about the money anymore. This is about professional satisfaction. . . .This is not a job, it’s a way of life I guess, a cause, avocation. . . . That financial aspect of doing thework is not good enough.

I’ve got more difficult patients that I’m dealingwith now. I’m trying to sort out more difficultproblems with them. That could be a function ofmyself getting older. Sometimes your patients getolder with you and your patients start to get morecomplex. . . . Since the Project started, I noticedI’ve been working longer with more difficultpatients.

Among the younger physicians in the group,there was anticipation that embarking on thechange would result in better-quality care for pa-tients and higher satisfaction for the practitioners.The youngest physician, who had joined the clinica few months after the start of the project, antici-pated achieving “rewards that come from beingable to practice your job in a more holistic way.”This physician also indicated working harder thanever before because of enjoyment of the work andstated that his role as a team member had “growntremendously.” Physicians from different careerstage groups commented on the coming together ofall physicians in the clinic to bring about thechanges. An older physician pointed out, “We havea very cooperative group,” and a midcareer physi-cian said, “We kind of all work together already.And that sort of familiarity with one anotherhelped” (in the sense that there was agreement

among the physicians, as a work group, to under-take the changes).

In their study, Pratt and his colleagues (2006)found that resident physicians, who were in theinitial stages of their professional careers, had littlediscretion in reformulating their work roles. Theauthors predicted that more discretion gainedthrough experience or expertise would enable rolechanges. Our study indicates that changes in pro-fessional roles are facilitated not only by a higherlevel of work experience, but also by life experi-ences and personal maturity. Researchers have in-dicated that life influences external to the work-place—such as aging or a midlife crisis—may affectindividuals’ motivations for seeking role changes(Ashforth & Saks, 1995; Nicholson, 1984). Hall(1986) indicated that a change in a person due, forexample, to an increased awareness of values andinterests influences role changes in the individual’slater career, when he or she confronts “such iden-tity issues as, ‘What do I want to do with the rest ofmy life?’” (Hall, 1986: 131). Hall further noted,“Thus, in midcareer, career transitions and lifeevent changes become increasingly intercon-nected” (1986: 135). Nevertheless, the search formore satisfactory roles was not limited to the olderphysicians. For the younger physicians, the enact-ment of a reconstructed role provided the opportu-nity to offer better service and to achieve moreprofessional satisfaction.

Thus, studies have addressed how personal lifechanges or career stages and role identity recon-struction are interrelated. However, the impact ofthe institutional environment surrounding these el-ements is often absent from such studies. Researchon role reconstruction in professional fields wouldrequire attention to institutional forces and, morespecifically, to the templates considered legitimate,and thus available, for individuals seeking role re-construction. Templates provide interpretive re-sources to professionals seeking role reconstructionand, as such, both enable and constrain reconstruc-tion. Had the professionals in our study been oper-ating in a more stable and homogeneous institu-tional context, their ability to seek innovative rolescould have been more limited.

In essence, what happened in the setting westudied was a conjunction between personalchanges and the prevalence of several other insti-tutional, organizational, and individual dynamicsthat interacted in positive ways, enabling the re-construction of professional role identity. No lesssignificant than the physicians’ life changes anddissatisfaction was their construction of an idealidentity that was partly influenced by such changes


(as demonstrated in Figure 1). We pursue thisissue next.

Construction of an ideal identity. Physicianspointed to dissatisfaction with the enactment oftraditional roles focused on piecemeal treatmentand high-volume practice, and a motivation to ex-plore other models. However, although they hadembraced the concepts of integration, holistic care,and prevention in principle, the initial vision theyhad for the project and for their role was not clear,as one physician outlined:

That’s one of the things about this project that’s beenperhaps the most difficult. . . . [Physicians haveconcerns around] “What does this team do? What doI do? What if [patients] are given information that’sdifferent to the information I’ve given them?” I thinkthat to have a more detailed theoretical model thatcould answer those questions and express thingsmore explicitly may be the most valuable thing wecould do now. And then based on that, you need tohave a few people that do it and they could providethe working model for others.

Research shows that the ability to observe rolemodels allows professionals in role transitions toidentify potential identities and to build a reper-toire of tacit knowledge, routines, and attitudes thatthey can use in adapting to a new role (Ibarra,1999). The physicians did not have role modelsthey could observe and thus faced difficulties inreconstructing their role. In one of the meetingsheld early in the project and attended by physi-cians and other participants, we observed that thediscussion turned to the definitions and bound-aries of different practitioners’ roles. A participantsaid, “No one has seen the bigger picture of thepuzzle to be able to put it together.” To this, an-other participant responded that “the analogyshould be more like a pile of blocks” that the prac-titioners themselves could arrange. During inter-views, the physicians indicated that not having aclear role template, although a challenge, was alsoan opportunity in the sense that they were notconstrained by a specific model and thus had thefreedom to tailor the changes to suit their commu-nity’s needs. They made numerous references to“innovations” that they were incorporating intotheir roles.

Ashforth wrote that disappointments and exter-nal and internal changes may trigger doubts aboutthe viability of role occupancy, leading an individ-ual to seek and weigh alternatives and possibly toidentify with favored prospects (2001: 14) in such away that an ideal identity is elaborated. The dis-crepancy between an ideal and a current identitycan motivate change (Markus & Nurius, 1986; Pratt,

2000). In the present case, the ideal identity thephysicians visualized, although not fully elabo-rated, centered on integration, wellness, and com-prehensive care, which were themes gaining prom-inence in the health care field. Thus, themesbeyond individuals and their organizational situa-tions affect the content of ideal identities. Despitethe wide range of themes that are potentially avail-able for inclusion in role reconstruction, thethemes professionals take into account are likely tobe constrained by what is considered legitimate intheir institutional environment. Figure 1 shows thelinks between alternative templates at the macrolevel and the ideal identity at the micro level.

Framing the role change. The physicians indi-cated that the difficulties they faced consisted notonly of finding new ways to perform their role, butalso of giving up aspects of their old role that theydeemed to be important. As one physician stated:

I had problems giving up management of the illness[and] allowing, say, a nurse to manage the insulinadjustment [for patients], but now have allowed thediabetic nurse to do those things. . . . The nurseshave more of a role in the management. They havemore accountability too. But I think the ultimateresponsibility for the patient is still with thephysicians.

Some of the changes introduced produced a per-ception that the physician-patient relationship wasbeing compromised by delegation to other practi-tioners. Having control over patient treatment wasa significant aspect of their professional role thatphysicians found difficult to divest:

My ability to maintain control, I felt that would beeroded. . . . If you really do care about the outcomefor your patients, you want them to take your adviceregarding treatment. . . . This asthma clinic situa-tion has actually increased my sense of influence,because of having other people reinforce the mes-sages. . . . Now my influence has increased by thepower of two. . . . And so the experience has beenone of me feeling much more capable.

A number of dynamics are worth noting here.First, physician role reconstruction was associatedwith reframing. Frames are templates for under-standing and interpreting issues (Weick, 1995).Second, reframing incorporated both change andcontinuity in the definition of professional roles.Third, as they reframed their roles, physiciansdrew on new and old themes prevalent in theirinstitutional environment. Although some work onframing and role identities has appeared in theliterature (e.g., Ashforth & Kreiner, 1999), researchon role change has not paid sufficient attention tothe language role incumbents use to frame changes.


Physician control over patient care was a centraltheme in defining the physician role. This wasevident not only in the physician quotations abouttheir professional socialization and experience, butalso in the medical professional association dis-courses that, despite promoting change, upheld theimportance of maintaining physician autonomyand central authority over patient care. It was thusnot surprising that physicians indicated finding itdifficult to give up or to share some aspects ofpatient care with other providers. However, thedata showed that the physicians, who expressedinitial concern about the loss of control over patientrelationships, reframed control as the ability to in-fluence health outcomes, as the quotation aboveindicates. They viewed their influence as increas-ing, since the message they gave patients was rein-forced by other members of the team. In fact, no-where did the physicians mention giving upcontrol over patient relationships. Research indi-cates that continuity in some aspects of identityfacilitates change in other aspects of identity andthat framing allows the establishment of continuity(Chreim, 2002; Pondy & Huff, 1985). Furthermore,the physicians stated that by giving up routinecomponents of their role and by having other prac-titioners reinforce the education aspects of patientcare, they reaped two rewards. First, they freed uptime for dealing with “complex problems” wheretheir expertise was needed, and second, they al-lowed the patients to receive better education,since other practitioners were highly adept at thistask. Physicians maintained an attractive role iden-tity rooted in their ability to deal with complexityand their desire to provide the best care forpatients.

In another vein, extant research on framing hasgiven insufficient attention to institutional context.Analysis of the frames used by physicians demon-strates the impact of institutional templates on rolereconstruction. The changes in the professionalrole of physicians were enabled by alternative dis-courses focused on delegation and integration thatwere gaining legitimacy in their institutional envi-ronment. However, the traditional discourses em-phasizing physician control over patient care con-strained these changes. By incorporating bothcontinuity and change in the frames they used tounderstand and present their reconstructed role,the physicians discursively managed the tensionsbetween the old and the new templates. Figure 1shows that both established and alternative tem-plates influenced the framing of role changes.

Figure 1 also shows that patterns of action andinteraction impacted framing, which was affectednot only by the interpretive resources available in

the environment but also by the experiences, ac-tions, and interactions of those doing the framing(Weick, 1995). Thus, for example, by delegatingresponsibilities and reaping the rewards of delega-tion, physicians were able to reframe this activity—previously seen as detracting from quality patientcare—as enhancing patient care.

Actions and interactions. Several actions andinteractions involving the physicians enabled pro-fessional role change. These included physicianinitiation of and control over the content and pro-cess of role change, the building of trust, physicianexposure to other perspectives, and confirmation ofthe role change by members of the physicianrole set.

The physicians pointed out as role change en-ablers their own initiation of the change and theirpresenting a united front (overall agreement withthe change) in negotiations with the funding andgoverning bodies and the other occupationalgroups. Other participants were of the same viewbut added another enabler: the fact that the physi-cians maintained control over the process ofchange. As a project participant pointed out, thephysicians had “more autonomy in the pace of thechange” than other practitioners.

Because a physician was assigned to head each ofthe thematic teams and because decisions involv-ing a change in physician practice required physi-cian acceptance, the power of the physicians re-mained unchallenged for the most part. The othergroups’ members recognized that for integration tooccur, physicians had to be satisfied with the pro-cess and outcome. Other practitioners made effortsto accommodate the needs expressed by physi-cians. For example, in one meeting held to discussintegration of well baby activities involving thephysicians and the public health nurses, the issueof location—at the physician clinic or the publichealth building—arose. It appeared that colocationwould involve inconvenience for both groups, yetthe public health nurses agreed to move their wellbaby activities to the physician clinic to allow forthe least inconvenience to the physicians. The gen-eral tendency was for practitioners to defer to phy-sicians on issues that seemed of importance to thelatter.

Participants also mentioned that meetings andfrequent interactions between the physicians andother occupational group members led to betterunderstanding and trust among the groups and fa-cilitated physician delegation of tasks. As a healthspecialist pointed out:

[Doctors view these asthma] programs as black holesthat suck up patients—everything goes in, nothing


comes back. . . . So we had to work with them toprove to them like, “Look, we’re not here to takecontrol or to take management away.” . . . Theystarted seeing patients coming back [and] saying,“That was really good. I never knew this. . . .” And Ithink over time, it was just kind of a trust buildingthing. So they knew the program wasn’t about takingcontrol.

In an integration meeting where physicians andpublic health nurses exchanged information oneach group’s well baby exam schedule, a physiciannoted that the physician schedule was “based onhabit,” whereas the public health schedule was“based on best practice guidelines.” The physiciansthen agreed to adopt the well baby exam schedulethat the public health nurses used. Intensive inter-actions with occupational groups who approachedpatient health from different perspectives exposedthe physicians to alternative practices, leadingthem to examine some of their own practices anddecisions. Of importance is the fact that these prac-titioners did not passively observe physician rolechange but attempted to influence physicians insubtle ways, such as by bringing authoritative pub-lications on clinical guidelines to their attention. Anurse pointed out:

We brought it to the physicians and said, “These arewhat the clinical practice guidelines say around thisstuff.” . . . It brought a lot of conversation around,“Gee, do you do that in your practice?” . . . Theystarted to actually examine some of their own prac-tice. . . . So it started raising the level of awareness,and usage of some of those guidelines.

Furthermore, the physicians experienced confir-mation of changes in their role from significantmembers of their role set, including other practitio-ners and patients. A physician stated:

As a physician, I feel much more part of the team andI feel that feedback from other [practitioners]. . . . Thenurses are starting to approach me with more con-fidence. At two o’clock in the morning a nursephoned and presented extremely well where she feltthat I should take over. And I said, “You’ve done sowell, . . . what would you do now?” She said, “Iwould do this.” So I think there’s been a shift inresponsibility. And I think she never would havesaid that a year ago, never would have approachedme the way she had. And I never would have re-sponded the way I had.

In later meetings, testimonials from the physi-cians indicated that patients had mentioned thatthey valued the changes in physician practice, thatthey were getting better health services, and thatthey were better informed about their conditions.Members of other occupational groups and admin-

istrators also mentioned changes in physicians’role enactment, noting that the physicians had pro-gressively adopted new practices and norms gain-ing prominence in the health care field. Anurse said:

We’re more of a team now. Because it’s multidisci-plinary. . . . It’s better because the public can nowaccess health care other than through a doctor [suchas through] a diabetes educator. Before you couldn’tdo anything without going through the docs. . . . I’mlearning at university all about integration. . . . AndI’m thinking this is where we need to be going.

Research on physician reaction to changes hasproduced findings—unlike those in our case—thatindicate physicians resist changes in their profes-sional roles (Kitchener, 1999; Reay & Hinings,2005). These divergent findings can be explained interms of agency. Kitchener, and Reay and Hinings,studied changes that organizational administratorsand government officials initiated and imposed onphysicians. In our case, the physicians’ initiation ofthe change and their maintenance of power andcontrol over its process and content facilitated thereconstruction of their role. Our findings suggestthat the agency of the professionals involved—andparticularly agents’ presenting a united front—is astronger enabler of role reconstruction than is theimposition of a change by institutional actors. Fur-thermore, Nicholson (1984), who focused on theindividual level of analysis, indicated that an in-cumbent’s discretion facilitates a change in role;the typical dimensions of such discretion includethe capacity to choose goals and means. Researchon discretion is limited; Nicholson wrote, however,that discretion appears to be related to occupa-tional status. In fact, institutional theory helps shedlight on one determinant of level of discretion.Physicians occupy a high position in an estab-lished, institutionally sanctioned hierarchy of oc-cupations in the health care field (Scott & Backman,1990). The physicians in our case were capable ofexercising their power, and thus a high level ofdiscretion, because the members of other occupa-tional groups, who were seen as occupying lowerpositions in the established institutional hierarchy,deferred to them. (Figure 1 shows the influence ofestablished templates on actions and interactions.)

With respect to physicians’ examination and re-vision of their practices and role performances,here again bridging between formulations of dein-stitutionalization and formulations of individualchange is fruitful. Oliver (1992), who focused ondeinstitutionalization, stated that new membersbring interpretive frameworks that differ from ex-


isting ones, fostering diminished adherence to tak-en-for-granted practices. Schein (1996), who dis-cussed individual-level change, stated that dissat-isfaction with the status quo deriving fromdisconfirming information triggers “cognitive re-definition.” Here, interacting with practitionerswith different outlooks helped raise physicianawareness of alternative views of health care and ofdifferent ways to perform their roles. Thus, an or-ganizational context that enables the coming to-gether of perspectives from various occupational orinstitutional fields may facilitate individual cogni-tive redefinition and role reconstruction.

As to confirmation of the physician role identitychange, the literature indicates that such change isnot likely to last if role set members do not affirmthe enactment of the identity (Ashforth, 2001;Ibarra, 1999; Pratt et al., 2006). As members of arole set treat an individual as an exemplar of a role,they help validate the new identity (Ashforth &Humphrey, 1993). Interactions and role set memberconfirmation are closely related (as is demonstratedin Figure 1). Nevertheless, validation of profes-sional role enactment is, again, an issue embeddedin an institutional context. For the other occupa-tional groups, validation of the reconstructed rolefollowed in part from the fact that the physicianshad adopted new norms and practices that weregaining legitimacy in the institutional health careenvironment. Figure 1 shows the influence of alter-native templates on confirmation by members ofthe role set. It also shows the influence of thesetemplates on actions and interactions that put intopractice the emerging themes of integration andcoordination of services provided by differentpractitioners.

In brief, researchers have indicated that studiesof institutional models do not place sufficient em-phasis on agents’ actions, interpretations, and in-teractions and on how these dynamics help changeexisting models (Zilber, 2002). Similarly, the liter-ature on professional role change has placed littleemphasis on the institutional elements that influ-ence such change. However, as we have shown,crossing levels of analysis provides a better under-standing of the dynamics that influence profes-sional role identity reconstruction. In our analysis,we focused mainly on the impact of the macro-dynamics of institutional and organizational forceson micro dynamics. Although this study was notdesigned to elaborate on how the microdynamicsmight influence the macro elements, the data fromtime 3 do suggest that there is diffusion to the widercontext.

Developments beyond Time 2

At time 3, a year after the pilot project had offi-cially ended, the changes in the health unit were nolonger referred to as “the project.” The data gath-ered at time 3 indicated that further changes hadoccurred in the institutional environment and theorganization and that the changes in professionalrole identity observed at time 2 were solidly estab-lished. At an institutional level, there was evidenceof further deinstitutionalization, as the alternativetemplates were becoming more prominent, giventheir endorsement by various funding and govern-ing bodies. The provincial government was makingmore financial resources available for integrativeprojects, and the medical professional associationwas becoming more supportive of alternative pay-ment plans based on capitation for physicians. Sev-eral of these plans were being negotiated in theprovince. Further, the RHA was focusing morestrongly on prevention- and wellness-based pro-grams involving the cooperation of different prac-titioners. These programs were being elaboratedthroughout the region under a program titled“Building Healthy Lifestyles.” The coordinator ofthe project we studied, who was given the positionof coordinator of the regional healthy lifestyles pro-gram, indicated that what was learned in theproject was being used as a platform for developingintegrative programs throughout the region. Fur-ther, by time 3, one of the project physicians hadassumed a senior position in a nationwide physi-cian association that elaborates policy at the levelof accrediting university programs and organizingfor continuing professional development. Thisphysician frequently spoke nationally about expe-riences in the project. The participation of previousproject members in regional and national programsand associations allowed the diffusion of ideasabout the potential process and the outcome ofprofessional role changes (and thus, the dotted linein Figure 1 from the reconstruction of physicianrole identity to the alternative templates).

From an organizational (physician clinic) per-spective, additional integrative programs were be-ing elaborated involving members from a wideningrange of occupational groups. Moreover, whenasked about their roles at time 3, the physicians westudied reiterated the change themes that appearedat time 2, as is shown in Table 3. The secondquotation at the beginning of this article also illus-trates this reiteration. The physicians and otherpractitioners saw the changes in their outlook onpatient care and relationships with other occupa-tional groups as enduring; as one physician said, “Idon’t see us going back to the way we were.”


IMPLICATIONS AND CONCLUSION

The purpose of this study was to extend theoryon the reconstruction of professional role identityby attending to the influence of institutional forcesand by building bridges across the institutional,organizational, and individual levels of analysis.Studies of professional identity construction gener-ally focus on microdynamics within organizationalcontexts and pay little attention to the role of theinstitutional environment surrounding those organ-izational contexts. Yet as Stryker and Serpe (1982)noted, whether roles are made or played dependson the larger forces and structures in which inter-actions are situated. Our findings indicate that in-stitutional forces influenced professional role iden-tity reconstruction through two paths: a direct path,along which the institutional environment of theclinic we studied provided interpretive, legitimat-ing, and material resources that agents adopted andadapted in the reconstruction of their professionalrole identity; and an indirect path, along whichinstitutional dynamics enabled organization-levelstructures and mechanisms that further influencedagency at the micro level.

Our case provides clear evidence of the duality ofstructure and agency (Giddens, 1984) in the recon-struction of professional role identity. The preva-lence of traditional templates and the rise of alter-native templates in an institutional environmentcreate complexity, providing a wide variety ofbuilding blocks that the professionals in the fieldcan assemble (Scott, 1994). A complex context isconducive to the exercise of agency. The Canadianhealth care field had a dominant physician roletemplate focused on autonomy and treatment ofdisease, but also offered alternative discourses fo-cused on integration and wellness. The physiciansadopted and adapted these alternative themes asthey reconstructed their roles, and so did the otherpractitioners who interacted with the physicians.Although offering the opportunity for the exerciseof some discretion and choice, this environmentalso limited the range of role reconstruction possi-bilities considered legitimate. The combination ofstructure and agency in the reconstruction of pro-fessional roles varies in different contexts, as wewill discuss later. We now turn to some of themajor findings of this study, its contributions, anddirections for future studies.

The study adds to micro conceptualizations ofrole identity construction. Microlevel research por-trays role innovation as enabled by the discretion ofrole incumbents. Our findings indicate that thephysicians’ discretion emanated in part from insti-tutional templates that defined the hierarchy of

professional groups in health care and positionedphysicians at the top of this hierarchy. Future re-search on role incumbents’ discretion would bene-fit from attention to the institutional influences onlevel of discretion.

The study also draws attention to the importanceof framing in professional role identity reconstruc-tion and to the impact of an institutional environ-ment on framing. Understanding how framing en-ables professional role identity reconstructionrequires going beyond individual and organization-al situations. Research would benefit from atten-tion to the range of interpretive resources availablein an institutional environment. Our findings indi-cate that physicians’ framing of their reconstructedroles was associated with (1) alternative institu-tional discourses that enabled the employment of achange frame, and (2) traditional institutional dis-courses that fostered the employment of a continu-ity frame. Local interpretations of professional roleidentity changes derive in part from the institu-tional environment surrounding the changes.

The findings also point to the interrelations be-tween organizational systems/structures and theirinstitutional environment on the one hand, andmicrolevel actions and interactions enabling thereconstruction of role identity on the other hand.Past studies have attended to the impact of organ-izational context on role identity construction buthave not given enough attention to the relationbetween institutional environment and organiza-tional context. Future studies on role identitychange may benefit from attention to how organi-zational changes that have an impact on roleboundaries and role enactment are themselves fa-cilitated by extraorganizational forces. Further, at-tention should also be given to how professionals’microlevel agency pulls discriminately from theirinstitutional environment those resources that en-able the construction of locally desired organiza-tional structures and systems, which further facili-tate role changes.

Our model also tentatively suggests that a focuson microlevel phenomena can illuminate the fac-tors that influence actors to engage in entrepreneur-ial activities in institutional environments. In ourstudy, personal life changes and dissatisfactionamong the physicians motivated the search formore meaningful roles. When institutional theoryattends to agency, it generally neglects meaningsand interpretations of agents and focuses insteadon actions of centrally located actors in institu-tional fields (Zilber, 2002). By moving the analyti-cal lens to the meanings and experiences of agents,researchers can shed light on micro influences thatenable change in established templates. Projecting


from the findings of our study, we suggest that aline of research that might enrich macrolevel the-ory would be analysis of the subjective experi-ences, interpretations, and motivations of individ-uals who act as institutional entrepreneurs andhelp destabilize the templates that prevail in insti-tutional fields.

Another fruitful research avenue that incorpo-rates the influence of microdynamics on macro el-ements would be to explore how a role changeinitiated by an actor (a microlevel dynamic) at agiven organizational site may lead to change in theroles of other actors in the role set present at the siteand the impact that such movements have on theprevailing overall organizational structure (a mac-rolevel element). Since role identity is relational(Ashforth, 2001; Stets & Burke, 2003; Stryker &Statham, 1985), one would expect that reconstruc-tion of one role would lead to changes in other roleswithin a set. In our study, the physicians were thekey drivers of the changes in their role; however,other actors who were partners in the changesaided them. The members of other occupationalgroups, such as the nurse practitioner, publichealth nurses, respiratory technicians, and others,assumed bigger roles in patient care and more ac-countability for patient health. Similarly, the in-creased focus on teaching and prevention waslikely to impact patient role identity, as patientsbecame more informed about their medical condi-tions and more capable of managing those condi-tions themselves. Such role reconstructions maycontribute to substantial changes at the organiza-tional level and, if diffused more widely, in theinstitutional order.

The study has a number of practical implica-tions. Pressures for change in the health care sys-tem are strong, as are the pressures for professionalgroups operating in this system to change theirpractices and roles in order to provide more effec-tive and efficient services. Understanding the dy-namics that enable such change in practice is im-portant. We show that, in contrast to changes inprofessional practice imposed by institutional ac-tors, changes initiated by those whose practice isaffected have a higher probability of success. Thisevidence does not, however, negate the role thatinstitutional actors, such as professional associa-tions and governments, can play in a change. Insti-tution-level actors can facilitate microlevel changesby sanctioning role changes, redefining profes-sional boundaries, reconfiguring incentive systems,and providing material resources. Ideally, such ac-tors need to create a context that fosters initiativeand buy-in from those occupational groups thatneed to change their practices. Careful attention by

institutional actors to the impact of public policyon microlevel practices is needed.

Furthermore, the health care sector is a complexsystem involving delivery of services by multipleoccupational groups. There needs to be recognitionthat a change in the role of one group affects theroles of other groups. Professional associations areprotective of the rights and powers of their mem-bers. Associations speaking on behalf of profession-als generally resist role changes that reduce theauthority or power of those professionals. Thismeans that those bodies (government agencies, pro-fessional associations) initiating a change that islikely to impact the authority and power of a cer-tain group need to frame the change as providingmore scope to the different parties, as opposed totaking scope away from a given party. Further, ourfindings indicate that physicians experienced somedifficulties in divesting themselves of aspects oftheir roles ingrained through socialization pro-cesses. Thus, those who play a role in the social-ization of professionals (e.g., professional associa-tions, educational establishments) need to considerthe issues those professionals face in changingwork environments.

In conclusion, we would like to address the ap-plicability of our findings to other cases or situa-tions. Our study is based on one case. Althoughsome may view this as a limitation impeding gen-eralizability, it should be noted that naturalisticcase studies should be judged not on the basis ofgeneralizability, but on the basis of transferabilityand comparability (Denzin & Lincoln, 2000;LeCompte & Goetz, 1982; Lincoln & Guba, 1995,2002). The aim is not to establish statistical gener-alization based on enumerating frequencies (Yin,2003), but to determine whether “transference cantake place between contexts A and B if B is suffi-ciently like A on those elements or factors or cir-cumstances that the A inquiry found to be signifi-cant” (Lincoln & Guba, 2002: 207). We believe thatthe conceptual insights generated from our studyapply to changes in the professional role identity ofindividuals who are in mid or late career stages andwho operate at higher levels of the hierarchy ininstitutionalized fields such as accounting and law.Because we focused specifically on professionals inmiddle and late stages of their careers, some of thefindings may not apply to entry-level professionals,who may have different motivations and experi-ences. In addition, since an individual’s seniorityin a highly institutionalized profession may be adeterminant of her or his level of discretion, entry-level professionals may have limited control overthe process and content of role changes, as Prattand colleagues’ (2006) study demonstrated. Fur-


thermore, the physicians we studied held a highposition in an occupational hierarchy, which facil-itated the exercise of a high level of control. It islikely that individuals in occupational groups thathold lower positions in an institutional hierarchymay resort to more subtle influence strategies intheir attempts to reconstruct their roles, as a studyby Reay, Golden-Biddle, and GermAnn (2006)suggested.

Moreover, the case we studied was situated in aninstitutional sector undergoing transition and char-acterized by the simultaneous presence of tradi-tional and emerging templates. The physicians inour study availed themselves of emerging tem-plates that were seen as granting professional andpersonal satisfaction, but professionals in more sta-ble fields may face more restrictions when aimingfor role reconstruction, as the institutional tem-plates that define legitimate models of roles may bemore restrictive than was the case in the field westudied. However, the evidence is that many pro-fessions are increasingly operating in turbulent,changing environments (Powell et al., 1999). Thissuggests that the findings from our study may beapplicable to a wide range of professional fields.

We also believe that parts of our model areapplicable to changes in work role identities ingeneral (and not only to professional role identityreconstruction). For example, the macro organi-zational changes in physical structures, teammechanisms, and reward systems enabled microchanges in the patterns of interactions. It is con-ceivable that similar changes pursued by partici-pants at other work sites might prompt individualsto question and redefine work role boundaries.Similarly, our findings indicate that reframing rolechanges enables role identity reconstruction andthat such reframing is not entirely generated at amicro level, but is affected by discourses in theprevailing macro environment. Discursive studieshave repeatedly demonstrated that the themes thatpermeate organizational discourse reflect, at leastin part, the themes in the wider environment(Chreim, 2006), such as the themes of quality ser-vice, diversity, and social responsibility. Futurestudies may benefit from extending such findingsto the realm of work role identity construction andreconstruction.

Finally, as we have repeatedly demonstratedthroughout this study, crossing levels of analysisenables richer conceptualizations of phenomena ofinterest to students of organizations. We believethat it is through moving between levels of analysisthat the next important steps in management re-search will be taken.

REFERENCES

Abbott, A. 1988. The system of professions: An essay onthe division of expert labor. Chicago: University ofChicago Press.

Alberta Medical Association. 1996. Primary medicalcare. http://www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDocSearch/87256DB000705C3F87256E05005525D3/$File/PRIMARY_MEDICAL_CARE.PDF?OpenElement.

Alberta Medical Association. 2001. Alternative paymentplan (APP) handbook. http://www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDocSearch/87256DB000705C3F87256E050055298F/$File/app_handbook_version_1.4.pdf?OpenElement.

Alberta Medical Association. 2002. How physiciansare paid. Health reform in Alberta: Issues for dis-cussion. http://www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDocSearch/87256DB000705C3F87256E050055262F/$File/How_physicians_are_paid_Jan%20_11_02.pdf?OpenElement.

Ashforth, B. E. 2001. Role transitions in organizationallife: An identity-based perspective. Mahwah, NJ:Erlbaum.

Ashforth, B. E., & Humphrey, R. H. 1993. Emotional laborin service roles: The influence of identity. Academyof Management Review, 18: 88–115.

Ashforth, B. E., & Kreiner, G. E. 1999. “How can you doit?”: Dirty work and the challenge of constructing apositive identity. Academy of Management Re-view, 24: 413–434.

Ashforth, B. E., & Saks, A. 1995. Work-role transitions: Alongitudinal examination of the Nicholson model.Journal of Occupational and Organizational Psy-chology, 68: 157–175.

Barley, S. R. 1989. Careers, identities, and institutions:The legacy of the Chicago School of Sociology. InM. B. Arthur, D. T. Hall, & B. S. Lawrence (Eds.),Handbook of career theory: 41–65. Cambridge,U.K.: Cambridge University Press.

Barley, S. R., & Tolbert, P. S. 1997. Studying the linksbetween action and institution. Organization Stud-ies, 18: 93–117.

Beamish, P., Hitt, M., Jackson, S., & Mathieu, J. 2005.Special research forum call for papers: Buildingbridges across levels. Academy of ManagementJournal, 48: 910–912.

Becker, H. S., Geer, B., Hughes, E. C., & Strauss,A. L. 1961. Boys in white: Student culture inmedical school. Chicago: University of ChicagoPress.

Bucher, R., & Stelling, J. 1969. Characteristics of profes-sional organizations. Journal of Health and SocialBehavior, 10: 3–15.


Chreim, S. 2002. Influencing organizational identi-fication during major change: A communication-based perspective. Human Relations, 55: 1117–1137.

Chreim, S. 2006. Managerial frames and institutionaldiscourses of change: Employee appropriationand resistance. Organization Studies, 27: 1261–1287.

Coburn, D. 1993. Professional powers in decline: Medi-cine in a changing Canada. In F. W. Hafferty & J. B.McKinlay (Eds.), The changing medical profession:An international perspective: 92–103. New York:Oxford University Press.

Commission on the Future of Health Care in Canada (R. J.Romanow, commissioner). 2002. Building on val-ues: The future of health care in Canada. Ottawa,ON: Commission on the Future of Health Care inCanada.

Creswell, J. W. 1998. Qualitative inquiry and researchdesign: Choosing among five traditions. ThousandOaks, CA: Sage.

Dacin, M. T., Goodstein, J., & Scott, W. R. 2002. Institu-tional theory and institutional change: Introductionto the special research forum. Academy of Manage-ment Journal, 45: 45–57.

Davis, F. 1968. Professional socialization as subjectiveexperience: The process of doctrinal conversionamong student nurses. In H. S. Becker, B. Geer, D.Reisman, & R. S. Weiss (Eds.), Institutions and theperson: 235–251. Chicago: Aldine.

Denis, J., Lamothe, L., Langley, A., & Valette, A. 1999.The struggle to redefine boundaries in health caresystems. In D. Brock, M. Powell, & C. R. Hinings(Eds.), Restructuring the professional organiza-tions: Accounting, health care and law: 105–130.New York: Routledge.

Denzin, N. K., & Lincoln Y. S. (Eds.). 2000. Handbook ofqualitative research (2nd ed.). Thousand Oaks, CA:Sage.

DiMaggio, P. J. 1988. Interest and agency in institu-tional theory. In L. G. Zucker (Ed.), Institutionalpatterns and organizations: 3–21. Cambridge,MA: Ballinger.

Doolin, B. 2002. Enterprise discourse, professional iden-tity and the organizational control of hospital clini-cians. Organization Studies, 23: 369–390.

Eisenhardt, K. M. 1989. Building theories from casestudy research. Academy of Management Review,14: 532–550.

Fiol, C. M., & O’Connor, E. J. 2006. Stuff matters: Arti-facts, social identity, and legitimacy in the U.S. med-ical profession. In A. Rafaeli & M. G. Pratt (Eds.),Artifacts and organizations: Beyond mere symbol-ism: 241–257. Mahwah, NJ: Erlbaum.

Freidson, E. 1993. How dominant are the professions? InF. W. Hafferty (Ed.), The changing medical profes-sion: An international perspective: 54–66. NewYork: Oxford University Press.

Giddens, A. 1984. The constitution of society: Outline ofthe theory of structuration. Berkeley: University ofCalifornia Press.

Greenwood, R., & Hinings, C. R. 1996. Understandingradical organizational change: Bringing together theold and the new institutionalism. Academy of Man-agement Review, 21: 1022–1054.

Greenwood, R., & Suddaby, R. 2006. Institutional entre-preneurship in mature fields: The Big Five account-ing firms. Academy of Management Journal, 49:27–48.

Greenwood, R., Suddaby, R., & Hinings, C. R. 2002. The-orizing change: The role of professional associationsin the transformation of institutional fields. Acad-emy of Management Journal, 45: 58–80.

Hall, D. T. 1986. Breaking career routines: Mid-career choice and identity development. In D. T.Hall & associates (Eds.), Career development inorganizations: 120 –159. San Francisco: Jossey-Bass.

Hartley, J. F. 1994. Case studies in organizational re-search. In C. Cassell & G. Symon (Eds.), Qualitativemethods in organizational research: 208–229. Lon-don: Sage.

Hatch, M. J., & Cunliffe, A. L. 2006. Organizationtheory: Modern, symbolic and post-modern per-spectives (2nd ed.). Oxford, U.K.: Oxford Univer-sity Press.

Ibarra, H. 1999. Provisional selves: Experimenting withimage and identity in professional adaptation. Ad-ministrative Science Quarterly, 44: 764–791.

Kitchener, M. 1999. All fur coat and no knickers:Contemporary organizational change in UnitedKingdom hospitals. In D. Brock, M. Powell, &C. R. Hinings (Eds.), Restructuring the profes-sional organization: Accounting, health careand law: 183–199. New York: Routledge.

LeCompte, M. D., & Goetz, J. P. 1982. Problems of reli-ability and validity in ethnographic research. Re-view of Educational Research, 52: 31–60.

Lincoln, Y. S., & Guba, E. G. 1985. Naturalistic inquiry.Beverly Hills, CA: Sage.

Lincoln, Y. S., & Guba, E. G. 2002. Judging the quality ofcase study reports. In A. M. Huberman & M. B. Mat-thews (Eds.), The qualitative researcher’s compan-ion: 205–216. CA: Sage.

Luke, R. D., & Walston, S. L. 2003. Strategy in aninstitutional environment: Lessons learned from1990s “revolution” in health care. In S. S. Mick &M. E. Wyttenbach (Eds.), Advances in health care


organization theory: 289 –324. San Francisco:Jossey-Bass.

Macdonald, K. 1995. The sociology of the professions.London: Sage.

Marchildon, G. P. 2005. Health systems in transition:Canada. Toronto: University of Toronto Press.

Markus, H., & Nurius, P. 1986. Possible selves. AmericanPsychologist, 41: 954–969.

Miles, M. B., & Huberman, A. M. 1994. An expandedsourcebook: Qualitative data analysis. ThousandOaks, CA: Sage.

Nicholson, N. 1984. A theory of work role transitions.Administrative Science Quarterly, 29: 172–191.

Oliver, C. 1992. The antecedents of deinstitutionaliza-tion. Organization Studies, 13: 563–588.

Patton, M. Q. 2002. Qualitative research and eval-uation methods (3rd ed.). Thousand Oaks, CA:Sage.

Pondy, L. R., & Huff, A. S. 1985. Achieving routine inorganizational change. Journal of Management, 11:103–116.

Powell, M. J., Brock, D. M. & Hinings, C. R. 1999. Thechanging professional organization. In D. M.Brock, M. J. Powell & C. R. Hinings (Eds.), Restruc-turing the professional organization: Account-ing, health care and law: 1–19. New York: Rout-ledge.

Pratt, M. G. 2000. The good, the bad, and the ambiva-lent: Managing identification among Amway dis-tributors. Administrative Science Quarterly, 45:456 – 493.

Pratt, M. G., & Dutton, J. E. 2000. Owning up or optingout: The role of emotions and identities in issueownership. In N. Ashkanasy, C. Hartel, & W. Zerbe(Eds.), Emotions in the workplace: Research, the-ory and practice: 103–129. Westport, CT: QuorumBooks.

Pratt, M. G., Rockmann, K. W., & Kaufmann, J. B. 2006.Constructing professional identity: The work of roleand identity learning cycles in the customization ofidentity among medical residents. Academy ofManagement Journal, 49: 235–262.

Premier’s Advisory Council on Health. 2001. A frame-work for reform: Report of the Alberta Premier’sAdvisory Council on Health. Edmonton, AB: Pre-mier’s Advisory Council.

Reay, T., Golden-Biddle, K., & GermAnn, K. 2006. Legit-imizing a new role: Small wins and microprocessesof change. Academy of Management Journal, 49:977–998.

Reay, T. K., & Hinings, C. R. 2005. The recomposition ofan organizational field: Health care in Alberta. Or-ganization Studies, 26: 351–384.

Schein, E. H. 1996. Kurt Lewin’s change theory in thefield and in the classroom: Notes toward a model ofmanaged learning. Systems Practice, 9(1): 27–47.

Scott, W. R. 1994. Institutions and organizations: Towarda theoretical synthesis. In W. R. Scott, J. W. Meyer, &associates (Eds.), Institutional environments and or-ganizations: Structural complexity and individual-ism. Thousand Oaks, CA: Sage.

Scott, W. R. 2001. Institutions and organizations (2nded.). Thousand Oaks, CA: Sage.

Scott, W. R., & Backman, E. V. 1990. Institutional theoryand the medical care sector. In M. S. Stephen &associates (Eds.), Innovations in health care deliv-ery: Insights for organization theory: 20–52. Ox-ford, U.K.: Jossey-Bass.

Scott, W. R., Ruef, M., Mendel, P. J., & Caronna, C. A.2000. Institutional change and health care organ-izations. Chicago: University of Chicago Press.

Stets, J. E., & Burke, P. J. 2003. A sociological approach toself and identity. In M. R. Leary & J. P. Tangney(Eds.), Handbook of self and identity: 128–152.New York: Guilford Press.

Stryker, S., & Serpe, R. T. 1982. Commitment, identitysalience, and role behavior: Theory and research ex-ample. In W. Ickes & E. S. Knowles (Eds.), Person-ality, roles, and social behavior: 199–218. NewYork: Springer-Verlag.

Stryker, S., & Statham, A. 1985. Symbolic interaction androle theory. In G. Lindzey & E. Aronson (Eds.), Hand-book of social psychology (3rd ed.): 311–378. NewYork: Random House.

Townley, B. 2002. The role of competing rationalities ininstitutional change. Academy of ManagementJournal, 45: 163–179.

Van Maanen, J., & Schein, E. H. 1979. Toward a theory oforganizational socialization. In B. Staw (Ed.), Re-search in organizational behavior, vol. 1: 209–264.Greenwich, CT: JAI Press.

Vaughan, D. 1992. Theory elaboration: the heuristics ofcase analysis. In C. C. Ragin & H. S. Becker (Eds.),What is a case: Exploring the foundations of socialinquiry: 173–202. New York: Cambridge UniversityPress.

Weick, K. E. 1995. Sensemaking in organizations.Thousand Oaks, CA: Sage.

West, M., Nicholson, N., & Arnold, J. 1987. Identitychanges as outcomes of work-role transitions. In T.Honess & K. Yardley (Eds.), Self and identity: Per-spectives across the lifespan: 287–303. New York:Routledge.

Yin, R. K. 2003. Case study research: Design and meth-ods. Thousand Oaks, CA: Sage.

Zilber, T. B. 2002. Institutionalization as an interplaybetween actions, meanings, and actors: The case of arape crisis center in Israel. Academy of Manage-ment Journal, 45: 234–254.


Samia Chreim ([email protected]) is an associateprofessor in the Telfer School of Management at the Uni-versity of Ottawa. She received her Ph.D. from HEC–Mon-treal. Her research investigates the dynamics of change,identity, and discourse.

B. E. (Bernie) Williams ([email protected]) is an associ-ate professor of strategic management and organizationwith the Faculty of Management at the University of Leth-bridge. He received his Ph.D. from the University of To-ronto. His research focuses on the dynamics of organiza-tional change, with a particular emphasis on public sector

organizations in the fields of health care, emergency manage-ment, and amateur sports management.

C. R. (Bob) Hinings ([email protected]) is an emeritusprofessor in the Department of Strategic Organization andManagement in the School of Business at the University ofAlberta. He is a Fellow of the Royal Society of Canada and ofthe Academy of Management. His research interests are ininstitutional theory and organizational change and he is cur-rently pursuing these interests in the context of health careand the Canadian wine industry.


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Chreim - Inter Level Influences on the Reconstruction of Professional Role Identity