Moderators of the relationship between IP&Ps and middle managers’ commitment to innovation implementation

The theory of perceived organizational support suggests that moderators of the relationship between IP&Ps and middle managers’ commitment to innovation

implementation in health care organizations may include (1) whether IP&Ps are under top managers’ control and (2) whether middle managers perceive top managers to be agents of the organization (figure 3). Aim 2 results provide little support for the theory that the degree to which IP&Ps influence middle managers’ commitment to innovation implementation depends upon whether IP&Ps are under top managers’ control and no support for the theory

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that the relationship depends upon whether middle managers perceive top managers to be agents of the organization.

6.6.1. Whether IP&Ps are under top managers’ control

The theory of perceived organizational support posits that IP&Ps are more highly valued if they are offered based on discretionary choice rather than circumstances beyond top managers’ control (Eisenberger et al., 1986; Rhoades & Eisenberger, 2002). For example, if an organization is obligated by law to provide the IP&Ps,then middle managers may not feel that the favorable treatment is as worthy of reciprocation than if IP&Ps were offered based on top managers’ discretion. I found little evidence to suggest that the strength of the relationship between IP&Ps and middle managers’ commitment to HDC implementation depended upon whether IP&Pswere under top managers’ control: Aim 2 results suggest that middle managers were largely indifferent to whether or not IP&Ps were under top managers’ control. One middle manager said, “[The top managers’ motivation] didn’t matter to me as long as they gave me the permission to do it [gain access to IP&Ps]” (097). In fact, most middle managers suggested that a top manager’s failure to provide an IP&P was usually beyond the top manager’s control. Furthermore, many middle managers sympathized with top managers when IP&Pswere scarce. Two middle managers had very similar responses when their top managers denied their requests for increased access to financial resources. One said, “[I]f we don't have the money, we don't have the money” (064). The other said, “I guess I figured that if they didn’t have it in the budget, they didn’t have it in the budget” (141).

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There were two exceptions to my finding that middle managers were indifferent to whether or not IP&Ps were under top managers’ control: First, middle managers often reported feeling exasperated that top managers withheld IP&Ps until the Bureau of Primary Health Care (BPHC) required HDC participation for all federally qualified health centers. One middle manager recalled asking top managers in her organization to hire nurses and patient data entry employees for several months. Only when BPHC required HDC participation did top managers fulfill her request. She recalled:

“It took about six, nine months before I could get the third [employee] on, and then suddenly, of course, Bureau of Primary Health Care announced, ‘Yes, the collaboratives will be part of their evaluation tool of all CHCs,’ and then everybody else came onboard all at once.” (059)

Another employee remembered that top managers in her health center were unsupportive of her efforts to solicit supplementary funding for the HDC until the HDC became a BPHC requirement. When top managers realized that HDC participation could assist the health center in acquiring grant funding, they were more forthcoming with IP&Ps. This finding was not consistent across quadrants, however; top managers associated with middle managers in the high commitment to HDC implementation/high HDC implementation effectiveness quadrant reportedly gave middle managers greater access to human resources than top managers in other quadrants. This finding offers support for the Aim 2 finding that top managers’ support and access to human resources influenced middle managers’ commitment to HDC implementation. This also suggests that access to human resources may mediate the relationship between top managers’ support and middle managers’ commitment to innovation implementation (see table 6.5.2): Top managers’ support often increased middle managers’ commitment to HDC implementation by giving middle managers access to human resources.

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The second exception to my finding that the relationship between IP&Ps and middle managers’ commitment to HDC implementation depended upon whether IP&Ps were under top managers’ control was that middle managers reported that performance reviews had a stronger effect on their commitment to HDC implementation when top managers willfully conducted performance reviews; according to the middle managers whom I interviewed, performance reviews had no effect on their commitment to HDC implementation when an organizational mandate obligated top managers to conduct the performance reviews (see table 6.5.2). As discussed in section 6.5 above, several middle managers indicated that informal feedback was more valuable than formal performance reviews. Most middle

managers reported that formal performance reviews were inconsistent, contrived, and poorly administered. In contrast, many middle managers reported that informal feedback increased their commitment to HDC implementation. These middle managers explained that informal feedback allowed them to resolve issues before they became problematic enough to report during formal performance reviews. As I discuss in detail in Chapter 7: Discussion and Conclusion, informal feedback during regular and open communication about middle managers’ HDC-related performance represents a key facet of top managers’ support.

6.6.2. Whether middle managers perceive top managers to be agents of the organization

The theory of perceived organizational support posits that IP&Ps are more highly valued if employees identify top managers as agents of a benevolent organization as opposed to idiosyncratic actors. Aim 2 results provide no support for this theory. The middle managers whom I interviewed consistently described top managers in terms of top managers’

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manager remembered her relief when a new team of top managers replaced an old team of unsupportive top managers. She described the takeover in terms of the benefit to employees who worked in her health center; they would continue to work in her health center under the new team of top managers. She did not suggest that the health center as she knew it

disintegrated when the old team of top managers left the health center. She recalled: “[I]mmediately [the new team of top managers] had a meeting with us, and they said, ‘This is our company. It is not my company. This is our company. We will either make this company or we will make it fall. But our goal is to make it rise.’ And they’ve had no secrets. They have got us completely out of our bottom of the barrel financial situation.” (059)

Another middle manager remembered that a new top manager struggled to prove his professional competence in her health center. Indeed, the middle manager did not take for granted that the new top manager was an agent of her health center; instead, she viewed him as an individual who had to fight for his position in her health center. Furthermore, none of the middle managers whom I interviewed attributed their attachment to their health center to top managers.

6.7. Mediators of the relationship between IP&Ps and middle managers’ commitment