Improvising Prescription: Evidence from the Emergency Room
| Published date | 01 April 2016 |
| DOI | http://doi.org/10.1111/1467-8551.12143 |
| Date | 01 April 2016 |
British Journal of Management, Vol. 27, 406–425 (2016)
DOI: 10.1111/1467-8551.12143
Improvising Prescription: Evidence from the
Emergency Room
Maria da Grac¸a Batista, Stewart Clegg,1Miguel Pina e Cunha,2
Luca Giustiniano3and Arm´
enio Rego4
Economics and Management Department and CEEAplA, Universidade dos Ac¸ ores, Campus de PontaDelgada,
Apartado 1422, 9501–801, Ponta Delgada, Portugal, 1University of Technology Sydney and Nova School of
Business and Economics, UTS Business School, 14–28 Ultimo Road, Ultimo NSW 2007, Australia, 2Nova
School of Business and Economics, Universidade Nova de Lisboa, Campus de Campolide, 1099-032 Lisbon,
Portugal, 3LUISS Guido Carli University, Rome, Italy, Department of Business and Management, Viale
Romania, 32, 00197 Rome, Italy, and 4Universidade de Aveiro and Business Research Unit (BRU-UNIDE),
Instituto Universit´
ario de Lisboa (ISCTE-IUL), Campus Universit´
ario de Santiago, 3810-193 Aveiro, Portugal
Corresponding author email: maria.gc.batista@uac.pt
Global medical practice is increasingly standardizing throughevidence-based approaches
and quality certification procedures. Despite this increasing standardization, medical
work in emergency units necessarily involves sensitivity to the individual, the particu-
lar and the unexpected. While much medical practice is routine, important improvisa-
tional elements remain significant. Standardization and improvisation canbe seen as two
conflicting logics. However, they are not incompatible, although the occurrence of im-
provisation in highly structured and institutionally complexenvironments remains under-
explored. The study presents the process of improvisation in the tightly controlled work
environment of the emergency room. The authors conducted an in situ ethnographic ob-
servation of an emergency unit. An inductive approach shows professionals combining
ostensive compliance with protocols with necessary and occasional ‘underlife’ improvi-
sations. The duality of improvisation as simultaneously present and absent is related to
pressures in the institutional domain as well as to practical needs emerging from the op-
erational realm. The intense presence of procedures and work processes enables flexible
improvised performances that paradoxicallyend up reinforcing institutional pressures for
standardization.
Introduction
Physicians interpreting the nature of patients’ ill-
nesses have to integrate multiple pieces of infor-
mation into a pattern when they make a diagnosis
and prescribe treatments. Sometimes they have to
enact these routines in the context of unexpected
The authors gratefully acknowledge all those who par-
ticipated in the study for their generosity. This paper is
part of project PTDC/IIM/GES/5015/2012. Miguel Pina
e Cunha gratefully acknowledges support fromNova Fo-
rum. The authors are grateful to Associate Editor Heiner
Evanschitzky and to the anonymous reviewers for their
excellent comments and suggestions.
and non-routine situations. The emergency room,
in particular, is a contextin which routines need to
be varied and scripts improvised as eventsunsettle
procedures; thus, it makes a promising setting for
the study of improvisation in an institutional en-
vironment that is, by and large, highly prescribed
rather than improvised.
With the emergency room context in mind, we
formulate our research question as follows: How
does improvisation unfold in a tightly standard-
ized bureaucratic environment? We approach our
research question inductively, exploring the pro-
cess of improvisation in a hospital emergency
room. In general, hospitals are highly bureaucratic
© 2015 British Academy of Management. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4
2DQ, UK and 350 Main Street, Malden, MA, 02148, USA.
Improvising Prescription 407
organizations, relying on professional standard-
ized skills inculcated mostly outside the organiza-
tion (Mintzberg, 1983), operating via the extensive
use of clinical guidelines (also variously called pro-
tocols, recommendations, algorithms, parameters)
that are increasingly pervasive (Adler and Kwon,
2013). However, physicians, as professionals, have
the autonomy and responsibility to provide indi-
vidualized care for their patients, adjusting and
improvising treatments in response to situational
uniqueness (Vogus, Sutclie and Weick, 2010) as
they enact improvisations in changing clinical cir-
cumstances (Weick, 1988, 1990).
A requirement for adherence to the rules and
the practical exigencies of the need for improvi-
sation might well conflict with each other in or-
ganizational fields characterized by institutional-
ized norms of accountability (Brickerho, 2003),
particularly in contexts characterized by a high
degree of institutional complexity (e.g. Besharov
and Smith, 2014; McPherson and Sauder, 2013),
because of the highly professionalized and insti-
tutionalized knowledge that has to be managed.
Such management is usually done through defer-
ence to rules. Much less attention has been paid
to the micro-level mechanisms describing how in-
dividuals experience and manage such complex-
ity (Kraatz and Block, 2008) compared with con-
flicts between macro-level institutions. In order to
fill this gap, we report behaviours that, when con-
trasted with guidelines and protocols, might be
considered as ‘extremes’, ‘deviations’ or ‘outliers’.
We seek to display how clinicians use institution-
alized logics in extreme cases, while improvising
as they engage in emergency care. In particular,
while institutional theory supposes that profes-
sionals comply and adhere to macro-level overar-
ching logics, we describe how improvisation might
unfold, in a tightly regulated field, via dierent
forms and through dierentbehavioural strategies,
including ostensive compliance and ‘underlife’ im-
provisation.We contribute to the improvisation lit-
erature by extending its study to the bureaucratic
context, showing that bureaucracydoes not neces-
sarily restrain improvisation, but can shape its use
and formal expression. We begin by situating con-
flicting logics in medical practice.
Conflicting logics in medical practice
Conflicting institutional logics have been under-
stood variously: as ‘the sensemaking frames that
provide understandings of what is legitimate, rea-
sonable and eective in a given context’ (Guill´
en,
2001, p. 14); as the ‘belief systems and relatedprac-
tices that predominate in an organizational field’
(Scott, 2001, p. 139); as the ‘taken-for-granted
rules guiding behaviour of first-level actors’ (Reay
and Hinings, 2009, p. 629); as the ‘organising
principles that shape the behaviour of the field
participants’ (Reay and Hinings, 2009, p. 631).
In each of these related ways of understanding
them, institutional logics are endemic to the field
of healthcare (Kraatz and Block, 2008) in which
dierent logics coexist or compete against each
other (e.g. D’Aunno, Succi and Alexander, 2000;
Denis, Lamothe and Langley, 2001; Dunn and
Jones, 2010; Guill´
en, 2001; Reay and Hinings,
2009). Clinical health care,composed of many pro-
fessional identities enjoying considerable elements
of indeterminacy (e.g. McPherson and Sauder,
2013; Raaijmakers et al., 2015), is situated in a
tension between evidence-based practice norma-
tively institutionalized and individualized consid-
erations made in on the spot judgements (Haidet,
2007; Janicek, 2006; Naylor, 2001; Shaughnessy,
Slawson and Becker, 1998). On occasion, there
is a need for ‘organizational legitimacy’ to be
established between these if they are construed
as conflicting logics (Kraatz and Block, 2008;
Mykhalovskiy and Weir, 2004).
Medical practice, in theory, is a field domi-
nated by the logicof heavily regulated routines that
are replicable and rational (Elmore et al., 2005;
Hiyama et al., 2006; Sharma et al., 2003). Prac-
tices of clinical guidelines, organizationalcertifica-
tions, accepted best practices and evidence-based
medicine (EBM) (e.g. Sackett and Rosenberg,
1995) frame the field. Such professionalized fram-
ing marginalizes physicians’ reliance on intuition
and experience-based improvisations. Physicians
allegedly operate in what has been labelled a Tay-
lorized, ‘evidence-based everything’ environment
(Mykhalovskiy and Weir, 2004, p. 1060). At the
same time, medicine enjoys a high degree of pro-
fessionalization in the sense of being practised by
personnel who have rules built into them through
the processes of their professional training (Per-
row, 1986). In light of this relative autonomy, some
scholars describe medicine as both ‘an art and
a science’ (Garfield and Garfield, 2000; Kenny,
1997; Saunders, 2000). Haidet (2007), for instance,
used the metaphor of jazz to describe the ‘art of
medicine’ (see also Miller et al., 2001). As such,
© 2015 British Academy of Management.
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