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 ii 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 iii 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 iv 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, v 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. vi 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 vii 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 viii 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. ix