Have you ever wondered why the more we attempt to our healthcare systems and organisations, the more things seem to remain the same? Academics have an explanation for this well-known phenomenon – ‘the paradox of embedded agency’. In a healthcare context, this paradox can be framed as a question: how can healthcare change agents, whose beliefs and actions are determined by existing organisational, sectoral and societal institutions break with these very institutions and change them?

One influential to this paradox is institutional entrepreneurship, which explains how individuals can initiate divergent institutional change without necessarily being at the top of organisations. Indeed, the theory argues that powerful senior managers are unlikely to be real institutional entrepreneurs because they lack the motivation to change the institutions from which they typically benefit. Instead, they usually seek to reproduce them: witness the difficulties the financial services sector has had in ridding itself of the bonus culture. So research in healthcare has shown that institutional entrepreneurship is more likely to be associated with mid-level individuals and groups who have not only sufficient ability and opportunity to produce divergent change, but the motivation to do so, because they do not benefit from the status quo.

To us, institutional entrepreneurship is a very useful counterbalance to an increasingly devalued hero leadership model. However, one question we’ve recently raised concerning this idea is: does institutional change always imply or require purposive action by managers and professionals in healthcare?

We have argued in a recent paper on organisational trust repair1 that purposive action is not always possible or indeed appropriate when trust relations break down in an organisation. Instead managers, who by their very nature are biased towards action, should sometimes consider inaction as a strategic form of action. Our arguments are based on three different streams of research that have demonstrated the negative consequences of managers’ bias for action.

The first of these points to the expectations on managers not only to act but to act ‘big-time’, locking their organisations into transformational strategies that are difficult to put into reverse.

The second questions the need for managers to seek to ‘own’ change instead of letting others own it. Although managers can make their organisations more worthy of being trusted, it is employees and patients who bestow trust in their organisations.

The third stream of research raises serious questions over the ability of managers to actually matter because environments and markets determine success rather than leadership agency. From this perspective, managers are reduced to cutting costs and keeping their organisations flexible to take advantage of environmental changes.

These thoughts on the paradox of embedded agency and criticisms of the leadership literature are unlikely to sell too many business books or form the basis of consulting recipes and training courses. However, they are evidence-based and may be worth reflecting on before your organisation embarks on the next big-bang, top-down change program.

Professor Graeme Martin, PhD is the Academic Fellow CIPD and Chair of the Management Graduate School of Natural Resources Law, Policy and Management, University of Dundee

1 Siebert, S. & Martin, G. (2014) Managerial rationales and organizational effectiveness: the case of organizational trust repair, Journal of Organizational Effectiveness: People and Performance, Vol 1, No. 2