TWO VIEWS OF AGENCY IN PATIENT ADVOCATES' PROBLEM-HANDLING WORK ...

226 Pages·2008·0.61 MB·English

by  Emily Heaphy

TWO VIEWS OF AGENCY IN
PATIENT ADVOCATES' PROBLEM-HANDLING WORK:
STORYTELLING AND RULE USE

by
Emily D. Heaphy

A dissertation submitted in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
(Business Administration)
in The University of Michigan
2008

Dissertation Committee:

Professor Jane E. Dutton, Chair
Professor Richard P. Bagozzi
Professor Lloyd E. Sandelands
Assistant Professor Karen M. Staller
Professor Julia P. Adams, Yale University
© Emily D. Heaphy

All Rights Reserved
2008
Acknowledgments

Many people have helped make this dissertation possible. Jane Dutton has been a
constant cheerleader and advisor throughout my doctoral career. After we met over
recruitment weekend and discovered a mutual passion for “human growth and
development in organizations,” I got over my cold feet about moving to Michigan and
haven’t regretted it for an instant. Indeed, I have felt incredibly fortunate. Jane, who has
been a model of creating positive working relationships (or high quality connections), has
encouraged me to do work on a topic and with methods that I care about, and overall has
been a great supporter of me. As I have begun to work with students myself, I emulate
her invaluable approach of encouragement, excitement, dedication, and very speedy
feedback.
Lance Sandelands conveys a kind of positive regard coupled with thoughtful
feedback that invites deep thinking and makes revising feel not-so-scary. I have benefited
from his careful reading and insistence that research should be both simply presented and
profound. I am not sure I have accomplished those twin goals here, but I have come to
hear his interested and playful voice urging me towards them as I muddle through my
work.
Karen Staller has spent countless hours helping me think through and write about
research design and methods. I appreciate Karen taking the time to talk me through the
intricacies of inquiry. She has brought a sense of wonder and delight to the process of
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thinking about how to conduct qualitative inquiry, which makes it at least as interesting
to work on as the theoretical side.
I signed up for a course with Julia Adams my first year at Michigan on the
recommendation of a senior student in my program. “Take anything she teaches,” he said.
And I did take about every course Julia taught during the years we overlapped at
Michigan. Julia’s love of theory and belief in students came through in every class and in
all of our later conversations and emails, and I appreciate her willingness to sit on my
dissertation committee and help me think a little more like a sociologist.
Rick Bagozzi sits on many dissertation committees in part because of his
knowledge of SEM, an analysis technique which is completely absent from this
dissertation. Instead, I asked him because of his reputation as interested and open to many
topics, his care and kindness towards doctoral students, and his excellent feedback. Rick
has proven his reputation true, providing me with helpful advice as I develop my ideas on
paper and for presentation.
Several other faculty members at Michigan have been helpful in my development,
including, Sue Ashford, Wayne Baker, Kim Cameron, Jerry Davis, Bob Quinn, Jeffrey
Sanchez-Burks, Gretchen Spreitzer, and Jim Walsh. All have provided thoughtful
feedback on my ideas. At McGill, Nancy Adler, Sandra Cha, Al Jaeger and Mary Dean
Lee have provided me with an interested and supportive community over the past year.
And reaching back a few years, I was fortunate enough to be introduced to the field of
organizational behavior by working with David Thomas, Amy Edmondson and Jack
Gabarro at Harvard Business School. Seeing them work (very hard) helped me imagine
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that I could do meaningful work as a business school professor, and they have continued
to provide advice, feedback, and support many years later.
Throughout the time I have worked on my dissertation, I have been fortunate to
have several friends and co-travelers with whom I have met on a weekly or daily basis,
including Melissa Wooten, PK Toh, Jacoba Lilius, Francisco Polidoro, Jason Kanov and
Karen Hebert. While writing over the last year in Providence and Montreal, Cody Kinski
and Julie Urda have been welcoming neighbors, dog caretakers and consistent providers
of good cheer and entertainment. A number of University of Michigan students over a
couple of “generations” have been helpful and supportive as I developed as a scholar, and
with my dissertation in particular: Marlys Christianson, Dan Gruber, John Paul Stephens,
Adam Grant, Scott Sonenshein, Ruth Blatt, Mike Troilo, Chris Marquis, Tim Vogus,
Katherine Lawrence, Brianna Barker Caza, Arran Caza, Laura Morgan Roberts and
Monica Worline.
I received funding from several generous sources, including Wellesley College,
Blue Cross Blue Shield of Michigan, the University of Michigan’s Nonprofit and Public
Management Center, Rackham Graduate School, the Center for Education of Women,
and the Institute for Women and Gender. Much of the money they gave me went to
Kathy Wood, who quickly and accurately transcribed my interview recordings, saving me
time, worry and overworked arms.
My dissertation is as old as my relationship with my now-husband, Cedric de
Leon. We met as I was still sorting through my dissertation ideas. I defended my proposal
soon after we moved in together. We adopted our cheerful red dog, Atticus, the day after
I finished data collection, and we married in the midst of data analysis. Cedric is, for
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better or worse, an expert at Emily-in-dissertation-mode. Every dissertation writer should
be so fortunate to have a partner who is also an on-call sociologist, the son of a
professional chef and a great writer. But perhaps what I value most about our relationship
for the particular experience of writing my dissertation is his willingness to laugh at my
jokes and to make me smile when I didn’t think I had it in me. This aspect of our
relationship provided much-needed levity, which has been especially useful on those days
when the dissertation created particularly forceful gravity.
It is often said that research is autobiographical. It does not take long for me to
see reflections of my family in my research. In the patient advocates, I see a careful
attention to and valuing of relationships through a range of experiences, both good and
bad, complex and simple. My mom, Candy, and my dad and his wife, Ed and Lois, my
sister and her husband, Christina and Jafred, are each in their own way deeply committed
to relating to others with care and to living in the world with honor and dignity. Seeing
the care with which they interact with so many different people – including me! – helps
me to see it in others. I also appreciate the way in which all of them have understood my
need to work so much. Special thanks go to Christina for fielding questions on my behalf
from our large extended family and for gently reminding me to visit our parents when I
have been away from home for too long.
Over 50 patient advocates and those who work closely with them let me into their
work lives. The confidentiality I promised them means I cannot thank them by name. But
I deeply appreciate the time and access they granted me. I am especially grateful to the
members of the two patient advocate offices whom I shadowed. They allowed me to peer
over their shoulders and ask endless questions about “the technicalities” of their work,
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and were my hosts and chaperones in their workplaces. One (former) patient advocate I
can thank by name is Deborah Hoffman, my dear high school friend, whose stories about
her job as a patient advocate so fascinated me that I decided to devote some years to
understanding their work.

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Table of Contents

Acknowledgements ii
List of Tables viii
Abstract ix

Chapter 1 Introduction 1

Chapter 2 Research Design and Methods 15
Phase 1: Understanding the Patient Advocate Role 17
Phase 2: Patient Advocates’ Work Practice 21
Data Analysis 36

Chapter 3 The Patient Advocate Role 53
A Historic View 54
A Contemporary View 60

Chapter 4 Storytelling as a Means of Organizational Problem Handling:
The Work of Patient Advocates 74
Problem-Handling Roles 77
Chapter-Specific Research Design and Methodology 83
Findings 85
Discussion 117
Conclusion 125

Chapter 5 Playing with Rules: Patient Advocates’ Rule Use in
Two Hospital Types 133
Chapter-Specific Research Design and Methodology 137
Rule Use in Organizational Settings 143
Discussion 181
Conclusion 188

Chapter 6 Conclusion 189

References 199

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List of Tables

Table 3.1: Stories Told by Patient Advocates in Interviews, Categorized by
Who Brought the Case to Them 72

Table 3.2: Stories Told by Patient Advocates in Interviews, Categorized by
Presenting Problem 73

Table 4.1: Comparison of Problem-Handling Literatures 127

Table 4.2: Evidence Supporting Process Model of Problem Handling as
Organizational Storytelling 128

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Abstract

Patient advocates are hospital employees who handle the non-medical problems
and complaints that patients and their families experience while receiving care in
hospitals. Using qualitative data from interviews and shadowing at teaching and
Veterans Health Administration (VA) hospitals, this dissertation develops two accounts
of agency in patient advocates' problem-handling work. First, my analyses suggest that
patient advocates are organizational storytellers who construct accounts that enlist the
participation of others to resolve patient and family members’ problems. I identify
several relational practices that patient advocates use to accomplish their problem-
handling work. Second, the analyses also suggest that patient advocates draw on
organizational rules to construct legitimate paths of action for patients, families and staff
in hospitals. Four patterns of rule use emerged, but in different frequencies across
teaching and VA hospitals. The different institutional logics in the two hospital types help
explain the variation in rule use practices, in that they supply guidelines for the kinds of
rule use patient advocates may creatively employ within an organizational setting. This
portrait of work is fundamentally relational, in the sense that storytelling and rule use
occur primarily through interaction with others. Through these relational practices,
patient advocates are able to effect small changes within their respective hospitals. In
addressing the work of patient advocates in this way, the dissertation contributes to
research on work, problem-handling roles, and agency.
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