Description
Study for the Willingness of Public Professionals to Implement Public Policies: Content, Context and Personality Characteristics:- Personality is the particular combination of emotional, attitudinal, and behavioral response patterns of an individual. Different personality theorists present their own definitions of the word based on their theoretical positions.
Study for the Willingness of Public Professionals to Implement Public Policies: Content, Context and Personality Characteristics
Abstract The willingness of public professionals to implement policy programmes is important for achieving policy performance. However, few scholars have developed and tested systematic frameworks to analyse this issue. In this study, we address this by building and testing an appropriate framework. The aims have been: (1) to build a three-factor model (policy content, organizational context and personality characteristics) for explaining willingness to implement policies; and (2) to quantitatively test the model through a survey of Dutch professionals. The results show that policy content is the most important factor in explaining willingness. Nevertheless, organizational context and the personality characteristics of implementers also have a significant effect and should be considered when studying the attitudes of professionals towards policies. This research helps in understanding the willingness or resistance of professionals when it comes to implementing policies.
Keywords 1. Policy implementation 2. Change Management 3. Applied psychology 4. Public professionals 5. Resistance to change
1 Introduction
The implementation of public policies is still "alive and lively" (O'Toole 2000: 263). An important issue in the study of policy implementation - based on the seminal work of Michael Lipsky (1980) - concerns the attitudes and behaviours of 'street-level bureaucrats' (see for instance Marinetto 2011, Smith et al. 2011). How responsive are these bureaucrats when they face new demands that are put forward by clients (Riccucci 2005), by politicians that want to exercise political control (Meyers, Vorsanger 2003) or by public managers who also want to constrain the relative freedom of these bureaucrats (May, Winter 2009)? The degree to which street-level bureaucrats are able to cope with these changing societal, political and managerial demands may to some extent explain their willingness or resistance in implementing new governmental policies addressing these demands. The willingness, or alternatively resistance, of street-level bureaucrats to the implementation of public policies seems important when these bureaucrats are public professionals, especially if we consider the current debate concerning the pressures these professionals face when they are involved in service delivery processes (Freidson 2001). For instance, asked to implement a new work disability decree in the Dutch social security system in 2004, about 240 insurance physicians urged a strike against this new policy, and some decided to quit their job. They could not align their professional values with the policy content (Tummers, Bekkers & Steijn 2009). When public professionals are unwilling to implement policies, this may have serious consequences. First, it can decrease the effectiveness of policy implementation given that committed implementers are crucial for achieving policy goals (Ewalt, Jennings 2004). Second, the quality of interactions between professionals and citizens may be affected, which may eventually influence the output legitimacy of government (Bekkers et al. 2007). Although some prominent policy implementation scholars have emphasized the crucial role of the willingness of implementers to implement a policy (Riccucci 2005, May, Winter 2009, Van Meter, Van Horn 1975), few have developed and tested a systematic framework 3
for analysing this topic (O'Toole 2000). In this article, our goal is to construct and test a model for analysing the willingness of public professionals to implement governmental policies. More specifically, we will examine how different factors influence this (un)willingness. The first factor in this model concerns the policy content and related discretion (the 'what') and is rooted in public administration literature. The second factor looks at the organizational context of the implementation (the 'where'), drawing primarily on change management literature. Third, we examine the personality characteristics of the professionals (the 'who') based on insights from applied psychology. By including these three factors in one model, we combine insights from different bodies of knowledge. In so doing, we will answer the following research question:
What is the influence of (1) policy content and discretion, (2) organizational context and (3) personality characteristics on the willingness of public professionals to implement new public policies?
Next, we first discuss the theoretical framework, considering the relationships between the three proposed explanatory factors and the willingness to implement a policy. Second, we test the hypotheses developed in a survey among 1,317 Dutch psychologists, psychiatrists and psychotherapists implementing a new reimbursement policy. Third, we will discuss the contribution of this study to the policy implementation literature and the debate on the pressures facing public professionals in service delivery.
2 Theoretical framework
2.1 Relevant backgrounds
We focus on the willingness of public professionals to implement new policies and the changes that these policies imply. In so doing, we draw - next to policy implementation and 4
applied psychology research - on insights from change management literature, which has a long history of examining willingness or resistance to changes. Early change management theories were based on the assumption that organizational change is linear (Judson 1991). These are referred to as 'planned change' theories, and are often based on the seminal work of Lewin (1951). Since the early 1980s, however, an 'emergent change' approach has become more prominent. This approach does not view change as a linear process but sees change as a continuous, recursive and unpredictable process (Weick 2000). Weick argued that the 'planned change' approach underestimates the value of innovative sense-making and the extent to which change is continuous and cumulative. The planned change approach resembles to some extent the top-down perspective on policy implementation (Pressman, Wildavsky 1984, Hogwood, Gunn 1984). Here, implementation is defined as a rational process that can be planned, programmed and controlled by policy formulators. The emergent change perspective resembles the bottom-up perspective on implementation. Bottom-up perspectives (Matland 1995) define policy implementation as a dynamic and interactive process of coproduction, in which the personal involvement of street-level bureaucrats helps to overcome resistance because the policies to be implemented fit with their needs. Throughout change management history, it is has been fairly unambiguously claimed that a crucial condition for success is that employees are willing to implement the change (Judson 1991). Metselaar (1997, p. 42 see also Ajzen 1991) defines this change willingness as 'a positive behavioural intention towards the implementation of modifications in an organization's structure, or work and administrative processes, resulting in efforts from the organization member's side to support or enhance the change process.' With respect to our research question, it is important to discover in which way 'willingness to change' influences the actual behaviour of professionals. The concept of 'willingness to change' builds upon the seminal theory of planned behaviour (for an elaborate discussion, see Ajzen 1991). According to this theory, behaviour is a function of intentions 5
and perceived behavioural control. This means that a positive intention to act strongly influences behaviour if someone believes they have control over their actions. For instance, when professionals want to put effort into policy implementation, and feel that they have the opportunity to do so, it is likely that they will put effort into policy implementation. Ajzen (1991 p. 186) concludes that 'As a general rule it is found that when behaviours pose no serious problems of control, they can be predicted from intentions with considerable accuracy'. In this study, we use the 'willingness to change' concept, as developed by Metselaar (1997), to study the willingness of professionals to implement a new public policy as this concept builds upon the seminal theory of planned behaviour and, further, its measurement has been validated in earlier research. 2.2 Building the theoretical framework
We have reviewed the literature in searching for concepts most likely to be related to willingness to implement new policies. The concepts we have included were chosen on the basis of three criteria (see also Judge et al. 1999): (a) there appeared to be a theoretical relationship between the concept and the willingness to implement new policies (b) that wellvalidated measures for the concepts existed; and (c) construct validity evidence existed for the concepts, and they had been successfully used in previous research. By adopting this approach, this study is, with respect to this field, methodologically innovative. To date, most policy implementation studies have had a rather qualitative nature. O'Toole (2000, p. 269) notes that 'the move to multivariate explanation and large numbers of cases exposes the [policy implementation] specialty to new or renewed challenges, which have yet to be addressed fully.' One of the strengths of qualitative research is that it can capture process-related features which are very relevant for studies on policy implementation. Quantitatively analyzing important research questions can yield new insights, thereby adding to the debate. There has been undertaken some valuable quantitative research (Riccucci 2005, May, Winter 2009). However, these studies often did not use validated scales, although they sometimes did apply exploratory factor analyses and 6
reliability techniques to test the quality of their scales. In contrast, we will use validated scales and have tested the selected variables in a large n-study. In the following sections, we will examine variables that possibly influence the willingness to implement public policies. These variables are structured into three main factors: (1) the policy content and discretion; (2) the organizational context; and (3) personality characteristics. These factors have been shown to be theoretically important in explaining willingness to implement a change, such as a new policy (see also Herold, Fedor & Caldwell 2007). Public administration scholars have primarily emphasized the policy content and discretion as determinants of attitudes and behaviour of street-level bureaucrats (Winter 2003). For instance, Lipsky argues that a certain degree of discretion enables street-level bureaucrats, and other public professionals, to cope with the pressures they face. It is noted that effective policy implementation needs a policy structure that is not completely solidified by rules. A certain degree of discretion increases - among else - the willingness to implement a policy, thereby enhancing the effectiveness of implementation. Further, change management and applied psychology scholars stress factors concerning the organizational context and the personality characteristics of the implementers (Herold, Fedor & Caldwell 2007, Holt et al. 2007). 2.3 Factor 1: Policy content and discretion
First, we consider the content of the policy as determinant of the willingness to implement public policies. Based on the three criteria described above, we focus on the meaningfulness of a policy and the discretion available during its implementation. Earlier research suggest a strong relationship between the meaningfulness of a policy - as perceived by professionals - and their willingness to implement it (Matland 1995, Higgs, Rowland 2005). Ultimately, the goal of a public policy is to make a meaningful contribution to society, such as reducing crime rates or creating financial stability. For implementers, it is important to understand the contribution that a policy makes towards such goals (Meyers, 7
Vorsanger 2003). Meaninglessness occurs when implementers are unable to comprehend the contribution of the policy to a greater purpose. Three types of meaninglessness have been identified in earlier research (Tummers, Bekkers & Steijn 2009, Holt et al. 2007). Firstly, professionals will perceive a policy as meaningless if it fails to deliver any apparently beneficial outcomes for society as a whole. This is labelled societal meaninglessness, and is expected to decrease the willingness to implement a policy. Secondly, client meaninglessness is also expected to negatively influence willingness to implement new policies. May and Winter (2009) found that, when frontline workers perceive the instruments they have at their disposal for implementing a policy to be ineffective for their clients, this is likely to frustrate them. They cannot see how the implementation of the proposed policy will help their clients, and therefore wonder why they should implement it. Thirdly, we consider personal meaninglessness, which can be defined as a professional's perceptions that the implementation of a policy has no value for him- or herself. For instance, professionals may feel that a policy has added value for them if it increases their income, status or job security (see also Holt et al. 2007). We expect that the more professionals feel that a policy has added value for them, the more willing they will be to implement it. Lastly, we examine the degree of discretion. We expect that when implementers experience more discretion when implementing a policy, they will be more willing to implement it (Hill, Hupe 2009). This influence may be particularly pronounced in professionals whose expectations of discretion and autonomy contradict notions of bureaucratic control. However, one should not ignore the reality that, when implementing a policy, implementers are in fact making policy. As Matland notes (1995:148) 'Service deliverers ultimately determine policy'. This means that, in addition to its possible indirect effect through 8
willingness to implement, the amount of discretion directly affects policy performance. Hence, when implementers experience a lot of discretion, they might be more 'willing to implement' but, alternatively, might not implement the policy at all, using their discretion to shirk or sabotage (Brehm, Gates 1999). The paradox is therefore that although we expect policy goals to be achieved (because implementers will be more willing to implement given their high discretion, and more willingness affects policy performance positively) this need not be the case. Hence, high discretion might well lead to low policy performance. Conversely, high discretion could lead to higher policy performance, with implementers using their discretion to adapt the policy to the local situation (Palumbo, Maynard-Moody & Wright 1984). These possibilities need to be taken into account when considering the influence of discretion. In our case study, we will extensively review the role of discretion during policy implementation. Based on the discussions above, it is hypothesized that:
H1: Societal meaninglessness will be negatively related to change willingness. H2: Client meaninglessness will be negatively related to change willingness. H3: Personal meaninglessness will be negatively related to change willingness. H4: Discretion will be positively related to change willingness. 2.4 Factor 2: Organizational context
Alongside policy content, the organizational context can be an important determinant of the willingness to implement a new policy. In organization theory, it is argued that behaviour and attitudes have to be understood in terms of the organizational environment (Lawrence, Lorsch 2006 [1967]). Based on the criteria presented in Section 2.2, we examine three aspects of the organizational context: the influence of professionals during organizational implementation, the subjective norm (attitude) of managers and the subjective norm of professional colleagues towards the policy. Change management literature notes that an increase in employee influence on change decisions leads to increased commitment and performance, and reduces resistance 9
to change (Wanberg, Banas 2000). Judson (1991) notes that involving employees is perhaps the most powerful lever that management can use in order to gain acceptance of change. In the realm of policy implementation, we therefore expect that the more that professionals sense that they have a say in the way their organization constructs the policy, the more they will be willing to implement the new policy. Next, we take into account the subjective norm towards the policy. A subjective norm can be defined as 'the perceived social pressure to perform or not to perform behaviour' (Ajzen 1991, p. 188). This subjective norm is based on the attitudes of significant others towards behaviour. The more positive these others are towards a certain behaviour, the stronger should be a person's intention to perform that behaviour. In the case of professionals implementing a policy, relevant others are their colleagues, their subordinates, their managers and their board of directors. Given the possible conflicts between professionals and managers surrounding policy implementation, we distinguish between the subjective norm of the managers (and their board of directors) and the subjective norm of the (non-managerial) professionals (colleagues and sub-ordinates). We would expect that when professional colleagues are in favour of a new policy, this will positively contribute to a professional's willingness to implement it (see also Metselaar 1997). Similarly, we also expect that when professionals feel that the managers in their organization are in favour of the policy, this will positively influence their willingness to implement the policy. However, given the possible conflicts between managers and professionals with respect to policy implementation, it is also possible that a positive attitude by managers towards a policy will have a negative effect on the professionals' willingness to implement this policy. We will examine whether this is the case in our empirical analysis.
H5: Influence during organizational implementation will be positively related to change willingness.
10
H6: When managers are in favour of a policy, this will have a positive effect on change willingness. H7: When professional colleagues are in favour of a policy, this will have a positive effect on change willingness. 2.5 Factor 3: Personality characteristics of the implementers
Lastly, we consider the personality characteristics of the professionals implementing a policy. Personality characteristics are often ignored in literature examining attitudes towards change, such as a new policy (Judge et al. 1999, p. 107). Based on the criteria presented in Section 2.2, we examine two potentially relevant personality traits: rebelliousness and rule compliance. Research involving rebelliousness - or psychological reactance - examines how individuals respond when their behavioural freedoms are restricted. Rebelliousness can be considered as a personality trait to the extent that some individuals interpret actions as a threat to their freedom more than others (Shen, Dillard 2005). Scholars studying rebelliousness have shown that rebellious persons - compared with non-rebellious persons are defensive, autonomous and non-affiliative (Dowd, Wallbrown 1993). Further, rebelliousness has been found to be negatively related to readiness to change (Holt et al. 2007). Based on these studies, we expect rebellious individuals to be more resistant to implementing new policies. Rule compliance is broadly defined as the belief of an individual that people have to obey governmental regulations (Clague 2003). Rule compliance is related to, but logically independent of, rebelliousness. Rebelliousness examines an individual's proneness to see something as a threat to his or her own freedom. Rule compliance, on the other hand, examines the beliefs of that person that people (including themselves) should adhere to rules. We expect highly rule-compliant public professionals to be more willing to implement a new governmental policy, irrespective of its content. Overall, it is hypothesized that: 11
H8: Rebelliousness will be negatively related to change willingness. H9: Rule compliance will be positively related to change willingness. 2.6 Theoretical framework
Figure 1 shows the overall theoretical model representing the hypotheses developed above. In the sections that follow, we present the methodology used to test this model and our empirical results.
Factor 1 - Policy content & discretion (what) Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion
Factor 2 - Organizational context (where) Influence during implementation Subjective norm: Managers Subjective norm: Professional colleagues
+
Effect
+ + +
Willingness to implement policy
+
Factor 3 - Personality characteristics of implementers (who) Rebeliousness Rule obedience
FIGURE 1 Theoretical framework for explaining willingness to implement new policies
12
3 Method
3.1 Case
To test the proposed model, we undertook a survey of Dutch mental healthcare professionals implementing a new reimbursement policy. First, we provide a short overview of this policy. In January 2008, a new Health Insurance Law was introduced in the Netherlands. This was part of a process to convert the Dutch healthcare system into one based on a regulated market. In the Health Insurance Law, a system of Diagnosis Treatment Combinations (DTCs) was developed as a means of determining the level of financial reward for mental healthcare provision. The DTC policy differs significantly from the former method in which each medical action resulted in a payment, i.e. the more sessions that a mental healthcare specialist had with a patient, the more recompense that could be claimed. The DTC policy changed the situation by stipulating a standard rate for each disorder. As such, the new Health Insurance Law and the associated DTCs can be seen as the introduction of regulated competition into Dutch healthcare, a move in line with New Public Management ideas. We chose the DTC policy as the basis for testing our model. Firstly, public professionals, here psychotherapists, psychologists and psychiatrists, will be the ones implementing the policy. This is essential as the model is designed to further the debate on the experiences of public professionals with policies. Secondly, the DTC policy goals focus strongly on economic goals, such as efficiency and client choice, and earlier research indicates that it is policies that pursue these kinds of NPM goals that create problems for public professionals. Third, in the context of the DTC policy, professionals had considerable control over their own actions. This means that willingness, or a lack thereof, to implement could actually influence the behaviour of these professionals when it came to implementing the policy, and this makes studying the willingness of these professionals valuable. Clearly, not all the professionals were in favour of the policy, demonstrations took place and some 13
professionals pressured their associations to defy the DTC policy. Also more subtle forms of subversion were employed, such as reclassifying a patient into a higher diagnosis group (socalled 'up-coding'). If this occurs frequently, the efficiency goal of the DTC policy will be undermined. These examples are all manifestations of unwillingness. 3.2 Sampling and response
Our sampling frame consisted of 5,199 professionals who were members of two nationwide mental healthcare associations. These were all the members of these associations who could, in principle, be working with the DTC policy. Using an email and two reminders, we received 1,317 returns of our questionnaire; a response of 25%. The gender composition of the respondent group was 66% female, which is consistent with the Dutch average (69%) for mental healthcare professionals (Palm et al. 2008). The respondents' average age was slightly higher than that of the mental healthcare professional population (48 against 44). In total, 235 organizations were represented in the respondent group. No organization dominated, with the largest number of respondents from one organization being 43. To rule-out a possible non-response bias, we conducted nonresponse research where we contacted the non-responders for their reasons for not participating. Common reasons for not participating were a lack of time, retirement, change of occupation or not working with the DTC policy (some organizations, including some hospitals, were not yet working with this policy). The large number of respondents, their characteristics in terms of gender and age and the results of the non-response research indicate that our respondents are quite a good representation of the population. Nevertheless, we cannot completely rule out a nonresponse bias since the non-respondents may differ from the respondents in terms of numerous other (unexamined) characteristics.
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3.3
Measures
Here, we report the measurement of variables. All measures had adequate Cronbach alphas (ranging from .71 to .95), as shown in the later results section. Unless stated otherwise, the measures were formatted using five-point Likert scales. For some items, we used templates. Templates allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. For example, instead of stating 'the policy' or 'professionals', the researcher can rephrase these items using the specific policy and group of professionals which are being examined, here 'the DTC policy' and 'healthcare professionals' replaced the template terms. This makes it easier for professionals to understand items, as they are better tailored to their context and this, in turn, increases reliability and content validity (DeVellis 2003:62). The items of all measures are shown in the Appendix.
Factor 1 - Policy content and discretion Societal meaninglessness Tummers (forthcoming 2012) conceptualized and measured societal meaninglessness as one of the dimensions of 'policy alienation'. Policy alienation has been defined as a general cognitive state of psychological disconnection from the policy programme being implemented by a public professional who, on a regular basis, interacts directly with clients. Societal meaninglessness reflects the perception of professionals concerning the benefit of a policy to socially relevant goals. Based on expert interviews and document analysis, we concluded that the introduction of DTCs had three main goals: (1) increasing transparency in costs and quality of mental healthcare, (2) increasing efficiency and (3) increasing patient choice.
15
Client meaninglessness Client meaninglessness - also conceptualized as a dimension of policy alienation (Tummers forthcoming 2012) - refers to the perception of professionals about the benefits of them implementing the DTC policy for their own clients. For instance, do they perceive that they are really helping their patients by implementing this policy?
Personal meaninglessness Personal meaninglessness looks at a professional's perceptions of the added value of them implementing a policy for themselves. Holt et al. (2007) developed and validated a scale for this concept, for which they coined the term 'personal valence'.
Discretion Discretion concerns the perceived freedom of the implementer in terms of the type, quantity and quality of sanctions and rewards delivered (Lipsky 1980). Discretion - or operational powerlessness - was measured using a six-item scale (Tummers forthcoming 2012).
Factor 2 - Organizational context Subjective norm The subjective norm was measured using a validated scale developed by Metselaar (1997). It was designed to examine the perceptions of professionals towards the attitudes of five groups towards a policy: the board of directors, managers, colleagues, subordinates and others in the organizational unit. Based on theoretical arguments and factor analyses, we distinguished between the subjective norm of managers (including the board of directors), and the subjective norm of professionals (including subordinates and others in the organizational unit).
16
Influence during implementation The influence of professionals during the implementation of the policy by the organization was measured using the concept of tactical powerlessness (which is the reverse of influence in the organization) (Tummers forthcoming 2012).
Factor 3 - Personality characteristics Rebelliousness Rebelliousness was measured using a validated scale (Shen, Dillard 2005). Shen and Dillard note that using this scale is 'theoretically and empirically justifiable' (p. 80).
Rule compliance Rule compliance is an persons' belief as to whether he or she feels obliged to obey governmental rules. To measure rule compliance, we used a scale from the European Social Survey.
Effect and control variables Change willingness (willingness to implement) We measured change willingness using a validated scale of Metselaar (1997). This scale also uses templates, which allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. Here, we replaced 'the change' with the 'DTC policy'.
Control variables We included some commonly used control variables: gender, age and management position (yes/no). Further, we included a variable showing whether a professional works independently (to some extent) or only for an institution. This was taken into account since professionals working independently may have different interactions with DTCs. 17
4 Results
4.1 Descriptive statistics
Descriptive statistics and correlations of the variables are presented in Table 1: TABLE 1 Descriptive statistics for the variables in the study Variable M
SD
Cronbach alpha
NA
Control variables 1. Sex (male = ref. cat.) 2. Age 3. Working (partly) independently (only in institution = ref. cat.) 4. Managing position (non-management position = ref. cat.) Policy Content and Discretion 5. Societal meaninglessness 6. Client meaninglessness 7. Personal meaninglessness 8. Discretion Organizational context 9. Influence during implementation 10. Subjective norm: Managers 11. Subjective norm: Professionals Personality characteristics 12. Rebelliousness 13. Rule compliance
0.64 47.94 0.33 0.44
NA 11.01 NA NA
7.70 7.73 6.90 4.62
1.67 1.53 1.46 1.81
.96 .80 .79 .83
4.47 6.16 3.96
1.90 1.67 1.54
.87 .71 .86
4.80 5.53
0.92 1.39
.78 .80
Proposed effect 14. Change willingness 4.32 1.77 Note: the means for variables 5 to 14 are adjusted to an equivalent ten-point scale to ease interpretation.
.85
18
TABLE 2 Correlations for the variables in the study Variable 1 2 3 4 1. Sex 1 2. Age -.34** 1 3. Working (partly) -.16** .32** 1 independently 4. Management -.26** .19** -.05 1 position 5. Societal -.17** .18** .10** .10** meaninglessness 6. Client -.12** .17** .07 -.06* meaninglessness 7. Personal -.01 -.02 -.16** .08**** meaninglessness 8. Discretion .07* -.01 .14** -.12** 9. Influence during .00 -.09** .02 .03 implementation 10. Subjective norm: .00 -.04 -.04 .00 Managers 11. Subjective norm: .05 -.04 .03 .02 Professionals 12. Rebelliousness -.07* .08** .09** .08** 13. Rule compliance .10** -.01 -.03 -.04 14. Change -.16** -.15** -.06 -.01 willingness Note: * p < .05, ** p < .01
5
6
7
8
9
10
11
12
13
14
1 .69** .46** -.39** -.28** -.27** -.48** .02 -.12** -.57** 1 .61**** -.43** -.33** -.24** -.50** .02 -.12** -.56** 1 -.56** -.34** -.15** -.45** .10** -.08* -.50** 1 .42** .08* .42** -.03 .06 .41**
1 .04 .39** -.07* .09** .36** 1 .38** .09** -.03 -23** 1 .05 .03 .48** 1 -.14** -.10**
1 .18**
1
Data based on a single application of a self-reported questionnaire can result in inflated relationships between variables due to common method variance. We conducted a Harman one-factor test to evaluate the extent to which common method variance was a concern. The factors together accounted for 71% of the total variance. The most significant factor did not account for a majority of the variance (only 32%). The fact that a single factor did not emerge, and the first factor did not account for a majority of the variance, suggests that common method variance is not a major concern here. 4.2 Regression results
Regression analyses were conducted to examine which factors predicted change willingness. In the first model, we regressed change willingness on the control variables (R2.of 03). In the subsequent models, we added the policy content variables (model 2, increased R2 to .43), the organizational context variables (model 3, increased R2 to .45) and the personality characteristics variables (model 4, R2 increased to .47). These increases were all statistically significant. Thus, the combination of the various types of variables contributes considerably to an explanation of the change willingness of public professionals. We will now consider the individual hypotheses. Hypothesis 1 predicts that societal meaninglessness will be negatively related to the professionals' willingness to implement DTCs. As Table 3 shows, in the final step of the analysis, societal meaninglessness is significantly related to change willingness (?=-.25 p<.01). The high beta coefficient indicates that societal meaninglessness is especially influential. The second hypothesis looks at the influence of client meaningless on change willingness. This influence is significant (?=-.12 p<.01) So, when professionals do not see a policy as having value for their own clients, they are less willing to implement it. The third hypothesis examines the relationship between personal meaninglessness and change willingness. Our empirical analysis confirmed this hypothesis in that there is a significant influence of personal meaninglessness on change willingness (?=-.17 p<.01).
Hypothesis 4 examines the positive influence of discretion on the willingness of professionals to put effort into a policy. Our results show that this is indeed the case: greater perceived discretion heightens change willingness (?=.07 p<.05). The fifth hypothesis looks at the influence of professionals during the implementation of the policy by their organization. Here, our data do indeed show a positive relationship between influence during organizational implementation and change willingness (?=.10 p<0.1). Hypotheses 6 and 7 examine the subjective norm. Our analysis shows that the subjective norm of managers has a statically significant but low influence (?=.06 p<.05). That is, when managers are perceived as being positive about a change, this somewhat boosts the inclination of professionals to implement the policy. However, the influence of the subjective norm of one's professional colleagues is much stronger (?=.13 p<.01). The more positive that professional colleagues are about the DTC policy, the more effort a professional will put into its implementation. The eighth hypothesis concerns the relationship between rebelliousness and change willingness. As could be expected from the applied psychology literature, the results indicate that rebellious individuals are indeed less willing to implement the policy (?=-.06 p<.05), even after a large number of other factors have been controlled for. Finally, Hypothesis 9 examines the influence of rule compliance on change willingness. The expectation is that public professionals who score highly on rule compliance will feel that public rules and regulations should be adhered to. Based on this, we expected such public professionals to be more willing than others to implement a new governmental policy, irrespective of its content. Our empirical analysis supports this expectation (?=.10 p<.01).
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TABLE 3 Hierarchical regression analyses for variables predicting change willingness
Model 1 Including control variables Control variables Female independently (to some extent) Working in institution Managing position
cat.
Model 2 Including content variables
Model 3 Including context variables
Model 4 Including personality characteristics
.13** .07** Ref. cat. -.05 -.04
.08** Ref. cat. -.05 Working
.07* Male Ref. cat. Age .00 -.03
Ref. cat. -.11** -.04 -.03
Ref. cat. .04 .09** Ref. cat.
Ref. cat. .07* Ref. cat.
Ref. cat.
Ref. cat. Ref.
.07* Non-management Ref. cat.
position Policy content and discretion Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion Organization context Influence during implementation Subjective norm (managers) Subjective norm (professionals) Personality characteristics Rebelliousness Rule compliance ?R2 Overall adjusted R2
.40** .43 .03** .45
-.30** -.16** -.20** .12**
-.26** -.12** -.18** .06
-.25** -.12** -.17** .07*
.11** .05 .12**
.10** .06* .13**
-.06* .10** .01** .47
.03
Note: Beta-coefficients are presented. * p <.05, ** p < .01. Regression Criteria were met (Independent residuals, no multicollinearity, no exclusion of influential outlying, Cook's distance max. 0.02 (criterion < 1), homoscedasticity and normality criteria met).
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Based on the results of our hypothesis testing, we can construct Figure 2. In this Figure, we see that the policy content factor, especially meaninglessness with their relatively high betas (-25,-.12 and -.17). Further, the organizational context and personality characteristics were also influential, albeit to a lower degree. In the concluding section, we will elaborate on these findings.
Factor 1 - Policy content & discretion (what) Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion
Factor 2 - Organizational context (where) Influence during implementation Subjective norm: Managers Subjective norm: Professional colleagues
+
Effect
+ + +
Willingness to implement policy
+
Factor 3 - Personality characteristics of implementers (who) Rebeliousness Rule obedience
FIGURE 2 Theoretical framework for explaining willingness to implement new policies
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4.3
DTC policy: policy content and discretion
To increase the understanding of the case studied, we will now some qualitative data regarding the DTC policy. This provides an additional perspective on the interplay between discretion, policy content and organizational context. First, we note that the DTC policy can impose change with respect to discretion. Professionals have to work in a more 'evidence-based' way, and are required to account for their cost declarations in terms of the mental health DSM (Diagnostic Statistical Manual) classification system. As a result, it becomes harder to use practices that are difficult to standardize and evaluate, such as psychodynamic treatments. Some professionals perceive this as a reduction in their discretion. As Van Sambeek et al. (2011, p. 50) argue: 'Although the DSM and evidence-based guidelines are developed mostly by professionals, they can generate resistance when becoming mandatory [?]. When their use has become obligatory, professionals feel limited in their clinical autonomy'. Discretion regarding the length of treatment is arguably also increasingly limited. Whereas, in the former system, each medical action resulted in a payment, under the DTC policy a standard rate is determined for each disorder. This means that it has become more difficult to adjust the treatment to the specific needs of a patient. As one professional argued (unless stated otherwise, quotations are drawn from open answers from the survey):
'Patients receive a 'label' from a classification system [?] Sometimes a patient fits into a 'depression' but really needs something more than a neat 'Cognitive Behavioural Therapy protocol of ten sessions'. If time and number of sessions rather than content start leading, it becomes impossible to provide patient-centred care.'
As a result, many professionals felt a loss of discretion (also evidenced by the relatively low average score of 4.6). Two illustrative quotes from professionals are 'the profession is reduced to mere procedures' and 'the DTC policy is a straightjacket'. This means that the 24
possibility of there being high discretion (positively affecting change willingness, but eventually negatively influencing policy performance) did not occur in the case studied. Contrary to this, there was relatively low discretion, which negatively influenced willingness to change, but could nevertheless be fruitful for policy performance, as implementers had less possibility to shirk or sabotage the policy. When examining the meaningfulness of the policy, we see that the mean score is quite high (7.7): many professionals do not have the feeling that societal goals are being achieved (i.e. a high societal meaninglessness). This is mainly due to the characteristics of the DTC policy. For instance, when considering the efficiency goal, we see that the DTC policy can have financially perverse incentives. An example can clarify this. The DTC time allocation for treating a personality disorder is between 800 minutes and 1800 minutes. An implication of this is that the treatment yields the same amount of money for the professional regardless of the time spent on the treatment. This provides an incentive to complete the treatment at 800 minutes. Furthermore, it provides an incentive to classify a patient in a higher diagnosis group (the so-called 'up-coding'). As a result, the efficiency goal is unlikely to be reached through the DTC policy. We also conclude that many professionals felt that the DTC policy is not very meaningful for their own patients (average score 7.7 on client meaninglessness). For instance, one requirement of the DTC policy is that professionals have to provide patient information to a national DTC Information System. This patient information, such as details of the disorder, used to be fully protected under the duty of professional confidentiality but, now, many professionals feel that the patients' privacy is insufficiently protected. Many thought this was not beneficial for their patients. When studying personal meaninglessness (average score 6.6), we first found that, following the introduction of the DRG policy, the revenues of professionals (especially freelancers) often declined, but that later many professionals experienced positive financial consequences. Quotes that illustrate this are: 'After a miserable time of major financial 25
problems, it is going well at the moment' and 'I think I earn more money because of the DTC policy, that's nice'. Second, and related to client meaninglessness, many professionals felt that their professional confidentiality was being impinged upon. As one professional put it: 'I consider the delivery of a diagnosis to health insurers contrary to my professional confidentiality'. Third, many professionals felt that the DTC policy resulted in an increased administrative workload, something which was not welcomed. In our survey, 90% (fully) agreed with the statement 'As a result of the policy, I have to do more administrative work'. To summarize, in terms of personal meaninglessness, the DRG policy affected in particular the professionals' income, professional confidentiality and administrative workload. This section has highlighted the policy content and organizational context behind the statistical data, as such providing some background to interpret the results of this study (for more information, see Palm et al. 2008, van Sambeek, Tonkens & Bröer 2011).
5 Conclusions
Our main goal was to examine factors that might influence the willingness, or reluctance, of public professionals to implement new policies. Based on literature from public administration, change management and applied psychology fields, a theoretical model was constructed. This model was tested in a survey of 1,317 mental healthcare professionals implementing a new reimbursement policy. It works adequately in that the factors included in the model explain 47% of the variance in change willingness. The high internal consistency values (Cronbach alphas ranging from .71 to .96) and the meeting of regression criteria strengthens the reliability and validity of the study. As such, we can conclude that our quantitative, interdisciplinary approach adds to the literature concerning the attitudes of professionals towards public policies. The results show that policy content is the most important factor in explaining this willingness. However, the organizational context and the personality characteristics of the implementers are also influential and should be taken into account if one is to properly study 26
the attitudes of professionals towards public policies. Alongside these general conclusions, we can draw three more-specific conclusions. Firstly, the three meaninglessness factors (societal, client and personal) have the strongest influences on willingness to change. When professionals do not see benefits for themselves they were less willing to implement it. Although this is influential, even after controlling for this factor, societal meaninglessness remained the most influential. When professionals feel that a policy does not contribute to societal goals, such as transparency or increasing patient choice, they are far less willing to implement it. These findings show how important the perceived benefit of a policy is to professionals. Despite this, the current debate on policy implementation is primarily focused on the influence and discretion of the implementers. Our study shows that while influence and discretion are important, taking account of the perceived meaninglessness (or its counterpart meaningfulness) of a policy is vital, and should be included in further research. Secondly, we can see that the subjective norm of especially professional colleagues in an organization is an important factor in explaining the willingness of public professionals to implement new policies. This is a relevant observation given the current debate on pressured public professionals (Freidson 2001). It has been stated that public professionals nowadays feel pressure from many sides due to the emancipation of their clients, the demands of politicians and the (ir)rationalities of their managers. Although we will not deny that many professionals do indeed feel such pressure, the created discourse, of feeling pressured, also seems to influence professionals who would not otherwise sense such pressure. Thirdly, this study is one of the first policy implementation studies that explicitly considers the personality characteristics of the implementers. Our research shows that these are important. For instance, the more rebellious professionals were less willing to implement the DTC policy, irrespective of the content and the organizational context. Elaborating on Judge et al. (1999), we note that there is a real possibility that successfully coping with a new policy is determined by the psychological predispositions of professionals. 27
As with all studies, this study has limitations. First, we examined factors influencing the willingness to implement public policies. However, willingness or alternatively resistance to implementation may not always predict behaviour (Ajzen 1991). In the theoretical framework we noted the important role of discretion during implementation in the policy behaviour of professionals. High discretion can enhance policy performance as it can increase the willingness to implement, with implementers being given the opportunity to adapt the policy to the situations of their clients. However, if professionals do not agree with the policy, they can use this high discretion to shirk or sabotage. In the present study, we analysed only the influence of discretion on the willingness to implement policies. Future studies could go deeper into the relationship between discretion, willingness to implement policies and policy performance. For instance, one could explore the conditions under which a high level of discretion positively influences both willingness to implement new policies and policy performance, and under what conditions a high level of discretion stimulates willingness to implement new policies, but negatively influences performance. Second, the results of this study, and the implications outlined, should be interpreted in light of the study's context, sample and response rate. Although the study's generalizability is improved by the fact that the sample included a large number of public professionals, working in different occupations, positions and places, one should be cautious in generalising this to other public-sector policies or domains. Another area for further research would therefore be to test the proposed model using other types of policies in a range of public domains. A third limitation was that we did not include all the possible factors that might influence willingness to implement. In future research, scholars could, for instance, examine the influence of other organizational factors such as the level of trust between professionals and management, or the level of organizational identification. Further, other personality characteristics could be taken into account, such as optimism.
28
Concluding, we see that the three factors - related to policy content, organizational context and personality characteristics - are all important in explaining the willingness of professionals to implement public policies. This indicates the complexity and multidimensional character of policy implementation. It suggests that, to increase the understanding of public policy implementation, researchers and practitioners should move beyond taking single factors into consideration, and try to include multiple factors for explaining the willingness or otherwise resistance of public professionals to implement policies. This would add to the understanding of the attitudes of professionals towards governmental policies, which could ultimately lead to policy implementation being more effective.
References
Ajzen, I. 1991, "The theory of planned behavior", Organizational behavior and human decision processes, vol. 50, no. 2, pp. 179-211. Bekkers, V.J.J.M., Edwards, A., Fenger, M. & Dijkstra, G. 2007, Governance and the democratic deficit, Assessing the legitimacy of governance practices, Ashgate, Aldershot. Brehm, J. & Gates, S. 1999, Working, shirking, and sabotage: Bureaucratic response to a democratic public, University of Michigan Press, Michigan. Clague, C. 2003, "Rule obedience, organizational loyalty, and economic development" in Democracy, Governance & Growth, ed. S. Knack, University of Michigan Press, Michigan, pp. 227-251. DeVellis, R.F. 2003, Scale development: Theory and applications, Sage, Thousand Oaks. Dowd, E.T. & Wallbrown, F. 1993, "Motivational components of client reactance", Journal of Counseling and Development, vol. 71, pp. 533-538. Ewalt, J.A.G. & Jennings, E.T. 2004, "Administration, governance, and policy tools in welfare policy implementation", Public administration Review, vol. 64, no. 4, pp. 449-462. Freidson, E. 2001, Professionalism: The third logic, Cambridge University Press, Cambridge.
29
Herold, D.M., Fedor, D.B. & Caldwell, S.D. 2007, "Beyond change management: A multilevel investigation of contextual and personal influences on employees' commitment to change", Journal of Applied Psychology, vol. 92, no. 4, pp. 942-951. Higgs, M. & Rowland, D. 2005, "All changes great and small: exploring approaches to change and its leadership", Journal of Change Management, vol. 5, no. 2, pp. 121-151. Hill, M. & Hupe, P. 2009, Implementing public policy, 2nd edn, Sage, Thousand Oaks. Hogwood, B.W. & Gunn, L.A. 1984, Policy analysis for the real world, Oxford University Press, Oxford. Holt, D.T., Armenakis, A.A., Feild, H.S. & Harris, S.G. 2007, "Readiness for organizational change: The systematic development of a scale", The Journal of applied behavioral science, vol. 43, no. 2, pp. 232-255. Judge, T.A., Thoresen, C.J., Pucik, V. & Welbourne, T.M. 1999, "Managerial coping with organizational change: A dispositional perspective", Journal of Applied Psychology, vol. 84, no. 1, pp. 107-122. Judson, A.S. 1991, Changing Behavior in Organization: Minimizing Resistance to Change, Basil Blackwell, Cambridge, MA. Lawrence, P.R. & Lorsch, J.W. 2006, Organization and environment, Harvard University, Boston. Lewin, K. 1951, Field theory in social science, New York: Harper. Lipsky, M. 1980, Street-Level Bureaucracy, Russell Sage Foundation, New York. Marinetto, M. 2011, "A Lipskian analysis of child protection failures from Victoria Climbié to 'Baby P': a street?level re?evaluation of joined-up governance", Public Administration, vol. 89, no. 3, pp. 1164-1181. Matland, R.E. 1995, "Synthesizing the implementation literature: The ambiguity-conflict model of policy implementation", Journal of Public Administration Research and Theory, vol. 5, no. 2, pp. 145-174. May, P.J. & Winter, S.C. 2009, "Politicians, Managers, and Street-Level Bureaucrats: Influences on Policy Implementation", Journal of Public Administration Research and Theory, vol. 19, no. 3, pp. 453. Metselaar, E.E. 1997, Assessing the willingness to change: Construction and validation of the DINAMO, Free University of Amsterdam. Meyers, M.K. & Vorsanger, S. 2003, "Street-level bureaucrats and the implementation of public policy" in Handbook of public administration, eds. B. Guy Peters & J. Pierre, Sage, London, pp. 245-254. 30
O'Toole, L.J. 2000, "Research on policy implementation: Assessment and prospects", Journal of public administration research and theory, vol. 10, no. 2, pp. 263-288. Palm, I., Leffers, F., Emons, T., Van Egmond, V. & Zeegers, S. 2008, De GGz ontwricht: Een praktijkonderzoek naar de gevolgen van het nieuwe zorgstelsel in de geestelijke gezondheidszorg, SP, Den Haag. Palumbo, D.J., Maynard-Moody, S. & Wright, P. 1984, "Measuring degrees of successful implementation", Evaluation review, vol. 8, no. 1, pp. 45-74. Pressman, J. & Wildavsky, A. 1984, Implementation, 3rd edn, University of California press, Berkeley, CA. Riccucci, N.M. 2005, "Street-level bureaucrats and intrastate variation in the implementation of temporary assistance for needy families policies", Journal of Public Administration Research and Theory, vol. 15, no. 1, pp. 89-111. Shen, L. & Dillard, J.P. 2005, "Psychometric properties of the Hong psychological reactance scale", Journal of personality assessment, vol. 85, no. 1, pp. 74-81. Smith, M.J., Richards, D., Geddes, A. & Mathers, H. 2011, "Analysing policy delivery in the United Kingdom: the case of street crime and anti-social behaviour", Public Administration, vol. 89, no. 3, pp. 975-1000. Tummers, L.G. forthcoming 2012, "Policy alienation of public professionals: The construct and its measurement", Public Administration Review, . Tummers, L.G., Bekkers, V.J.J.M. & Steijn, A.J. 2009, "Policy alienation of public professionals: Application in a New Public Management context", Public Management Review, vol. 11, no. 5, pp. 685-706. Van Meter, D.S. & Van Horn, C.E. 1975, "The Policy Implementation Process: A Conceptual Framework", Administration & Society, vol. 6, no. 4, pp. 445-488. van Sambeek, N., Tonkens, E. & Bröer, C. 2011, "Sluipend kwaliteitsverlies in de geestelijke gezondheidszorg", Beleid en Maatschappij, vol. 38, pp. 47-64. Wanberg, C.R. & Banas, J.T. 2000, "Predictors and outcomes of openness to changes in a reorganizing workplace", Journal of Applied Psychology, vol. 85, no. 1, pp. 132-142. Weick, K.E. 2000, "Emergent change as a universal in organizations" in Breaking the code of change, eds. M. Beer & N. Nohria, Harvard Business School Press, Boston, pp. 223-241. Winter, S.C. 2003, "Implementation perspectives: Status and reconsideration" in Handbook of Public Administration, eds. B. Guy Peters & J. Pierre, Sage, London, pp. 213-222.
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Appendix: Questionnaire
Background questions 1. What is your gender? 2. What is your year of birth? 3. What is your highest completed education? Male/female ______________
? Vocational training ? University ? Post-doctoral University ?
Other: ______________ Y/N
4. Do you have a managerial function? 5. What is your institutional setting?
? Working independently ? Working partly independently, partly in
institution
? Working in institution ? Other: ______________
[Unless stated otherwise, all measures were formatted using five-point Likert scales. As indicated in the main text, we used templates to specify the change. Templates allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. Template words are underlined. The templates are in this case: Policy: DTC-policy Goal: (1) increasing transparency in costs and quality of mental healthcare, (2) increasing efficiency and (3) increasing patient choice among mental healthcare providers Patients Clients: Professionals: Healthcare professionals Organization: Institution]
Policy content and discretion
Societal meaninglessness
1. I think that the policy, in the long term, will lead to goal 2. I think that the policy, in the short term, will lead to goal 3. I think that the policy has already led to goal 4. Overall, I think that the policy leads to goal
Client meaninglessness
1. 2. 3. 4. 5.
The policy is harmful for my clients privacy With the policy I can better solve the problems of my clients The policy is contributing to the welfare of my clients Because of the policy, I can help clients more efficiently than before I think that the policy is ultimately favourable for my clients 32
Personal meaninglessness
1. 2. 3. 4. 5. 6. 7.
As a result of the policy, I experience positive financial consequences On the long term, the policy is beneficial for me I have won little as a result of the introduction of the policy My future in this job will be limited because of the policy I am worried I have lost some of my status due to the introduction of the policy As a result of the policy, I have to do more administrative work The policy erodes my duty of professional confidentiality
Discretion
1. 2. 3. 4. 5. 6.
I have freedom to decide how to use the policy While working with the policy, I can be in keeping with the client's needs Working with the policy feels like a harness in which I cannot easily move When I work with the policy, I have to adhere to tight procedures While working with the policy, I cannot sufficiently tailor it to the needs of my clients While working with the policy, I can make my own judgments
Organizational context
Influence during organizational implementation
1. In my organisation, especially professionals could decide how the policy was being implemented 2. In my organisation, professionals have - by means of working groups or meetings - taken part in decisions on the execution of the policy 3. The management of my organisation should have involved the professionals far more in the execution of the policy 4. Professionals were not listened to over the introduction of the policy in my organisation 5. In my organisation, professionals could take part in conversations regarding the execution of the policy 6. I and my fellow professionals were completely powerless in the introduction of the policy in my organisation
Subjective norm
Please indicate how the following people feel about the DTC policy (5-point scale, from very negative to very positive): 1. My board of directors [group: managers] 2. My manager [group: managers] 3. My professional colleagues [group: professionals] 4. My subordinates [group: professionals] 5. Others in my organization unit [group: professionals] Personality characteristics
Rebelliousness
1. 2. 3. 4.
I become frustrated when I am unable to make free and independent decisions It irritates me when someone points out things which are obvious to me I become angry when my freedom of choice is restricted Regulations trigger a sense of resistance in me 33
5. I find contradicting others stimulating 6. When something is prohibited, I usually think, "That's exactly what I am going to do." 7. I am contented only when I am acting of my own free will. 8. I resist the attempts of others to influence me. 9. It makes me angry when another person is held up as a role model for me to follow 10. When someone forces me to do something, I feel like doing the opposite 11. I consider advice from others to be an intrusion 12. Advice and recommendations usually induce me to do just the opposite
Rule compliance
1. A good citizen always complies with the rules and laws 2. You always have to strictly abide by the law, even it that means that good opportunities will be lost as a result 3. Occasionally it is acceptable to ignore the law to do what you want 4. A good citizen lives on the rules and laws 5. The law must always be respected, regardless of the circumstances
Effect Willingness to implement 1. I intend to try to convince employees of the benefits the policy will bring 2. I intend to put effort into achieving the goals of the policy 3. I intend to reduce resistance among employees regarding the policy 4. I intend to make time to implement the policy 5. I intend to put effort in order to implement the policy successfully
34
doc_631475897.docx
Study for the Willingness of Public Professionals to Implement Public Policies: Content, Context and Personality Characteristics:- Personality is the particular combination of emotional, attitudinal, and behavioral response patterns of an individual. Different personality theorists present their own definitions of the word based on their theoretical positions.
Study for the Willingness of Public Professionals to Implement Public Policies: Content, Context and Personality Characteristics
Abstract The willingness of public professionals to implement policy programmes is important for achieving policy performance. However, few scholars have developed and tested systematic frameworks to analyse this issue. In this study, we address this by building and testing an appropriate framework. The aims have been: (1) to build a three-factor model (policy content, organizational context and personality characteristics) for explaining willingness to implement policies; and (2) to quantitatively test the model through a survey of Dutch professionals. The results show that policy content is the most important factor in explaining willingness. Nevertheless, organizational context and the personality characteristics of implementers also have a significant effect and should be considered when studying the attitudes of professionals towards policies. This research helps in understanding the willingness or resistance of professionals when it comes to implementing policies.
Keywords 1. Policy implementation 2. Change Management 3. Applied psychology 4. Public professionals 5. Resistance to change
1 Introduction
The implementation of public policies is still "alive and lively" (O'Toole 2000: 263). An important issue in the study of policy implementation - based on the seminal work of Michael Lipsky (1980) - concerns the attitudes and behaviours of 'street-level bureaucrats' (see for instance Marinetto 2011, Smith et al. 2011). How responsive are these bureaucrats when they face new demands that are put forward by clients (Riccucci 2005), by politicians that want to exercise political control (Meyers, Vorsanger 2003) or by public managers who also want to constrain the relative freedom of these bureaucrats (May, Winter 2009)? The degree to which street-level bureaucrats are able to cope with these changing societal, political and managerial demands may to some extent explain their willingness or resistance in implementing new governmental policies addressing these demands. The willingness, or alternatively resistance, of street-level bureaucrats to the implementation of public policies seems important when these bureaucrats are public professionals, especially if we consider the current debate concerning the pressures these professionals face when they are involved in service delivery processes (Freidson 2001). For instance, asked to implement a new work disability decree in the Dutch social security system in 2004, about 240 insurance physicians urged a strike against this new policy, and some decided to quit their job. They could not align their professional values with the policy content (Tummers, Bekkers & Steijn 2009). When public professionals are unwilling to implement policies, this may have serious consequences. First, it can decrease the effectiveness of policy implementation given that committed implementers are crucial for achieving policy goals (Ewalt, Jennings 2004). Second, the quality of interactions between professionals and citizens may be affected, which may eventually influence the output legitimacy of government (Bekkers et al. 2007). Although some prominent policy implementation scholars have emphasized the crucial role of the willingness of implementers to implement a policy (Riccucci 2005, May, Winter 2009, Van Meter, Van Horn 1975), few have developed and tested a systematic framework 3
for analysing this topic (O'Toole 2000). In this article, our goal is to construct and test a model for analysing the willingness of public professionals to implement governmental policies. More specifically, we will examine how different factors influence this (un)willingness. The first factor in this model concerns the policy content and related discretion (the 'what') and is rooted in public administration literature. The second factor looks at the organizational context of the implementation (the 'where'), drawing primarily on change management literature. Third, we examine the personality characteristics of the professionals (the 'who') based on insights from applied psychology. By including these three factors in one model, we combine insights from different bodies of knowledge. In so doing, we will answer the following research question:
What is the influence of (1) policy content and discretion, (2) organizational context and (3) personality characteristics on the willingness of public professionals to implement new public policies?
Next, we first discuss the theoretical framework, considering the relationships between the three proposed explanatory factors and the willingness to implement a policy. Second, we test the hypotheses developed in a survey among 1,317 Dutch psychologists, psychiatrists and psychotherapists implementing a new reimbursement policy. Third, we will discuss the contribution of this study to the policy implementation literature and the debate on the pressures facing public professionals in service delivery.
2 Theoretical framework
2.1 Relevant backgrounds
We focus on the willingness of public professionals to implement new policies and the changes that these policies imply. In so doing, we draw - next to policy implementation and 4
applied psychology research - on insights from change management literature, which has a long history of examining willingness or resistance to changes. Early change management theories were based on the assumption that organizational change is linear (Judson 1991). These are referred to as 'planned change' theories, and are often based on the seminal work of Lewin (1951). Since the early 1980s, however, an 'emergent change' approach has become more prominent. This approach does not view change as a linear process but sees change as a continuous, recursive and unpredictable process (Weick 2000). Weick argued that the 'planned change' approach underestimates the value of innovative sense-making and the extent to which change is continuous and cumulative. The planned change approach resembles to some extent the top-down perspective on policy implementation (Pressman, Wildavsky 1984, Hogwood, Gunn 1984). Here, implementation is defined as a rational process that can be planned, programmed and controlled by policy formulators. The emergent change perspective resembles the bottom-up perspective on implementation. Bottom-up perspectives (Matland 1995) define policy implementation as a dynamic and interactive process of coproduction, in which the personal involvement of street-level bureaucrats helps to overcome resistance because the policies to be implemented fit with their needs. Throughout change management history, it is has been fairly unambiguously claimed that a crucial condition for success is that employees are willing to implement the change (Judson 1991). Metselaar (1997, p. 42 see also Ajzen 1991) defines this change willingness as 'a positive behavioural intention towards the implementation of modifications in an organization's structure, or work and administrative processes, resulting in efforts from the organization member's side to support or enhance the change process.' With respect to our research question, it is important to discover in which way 'willingness to change' influences the actual behaviour of professionals. The concept of 'willingness to change' builds upon the seminal theory of planned behaviour (for an elaborate discussion, see Ajzen 1991). According to this theory, behaviour is a function of intentions 5
and perceived behavioural control. This means that a positive intention to act strongly influences behaviour if someone believes they have control over their actions. For instance, when professionals want to put effort into policy implementation, and feel that they have the opportunity to do so, it is likely that they will put effort into policy implementation. Ajzen (1991 p. 186) concludes that 'As a general rule it is found that when behaviours pose no serious problems of control, they can be predicted from intentions with considerable accuracy'. In this study, we use the 'willingness to change' concept, as developed by Metselaar (1997), to study the willingness of professionals to implement a new public policy as this concept builds upon the seminal theory of planned behaviour and, further, its measurement has been validated in earlier research. 2.2 Building the theoretical framework
We have reviewed the literature in searching for concepts most likely to be related to willingness to implement new policies. The concepts we have included were chosen on the basis of three criteria (see also Judge et al. 1999): (a) there appeared to be a theoretical relationship between the concept and the willingness to implement new policies (b) that wellvalidated measures for the concepts existed; and (c) construct validity evidence existed for the concepts, and they had been successfully used in previous research. By adopting this approach, this study is, with respect to this field, methodologically innovative. To date, most policy implementation studies have had a rather qualitative nature. O'Toole (2000, p. 269) notes that 'the move to multivariate explanation and large numbers of cases exposes the [policy implementation] specialty to new or renewed challenges, which have yet to be addressed fully.' One of the strengths of qualitative research is that it can capture process-related features which are very relevant for studies on policy implementation. Quantitatively analyzing important research questions can yield new insights, thereby adding to the debate. There has been undertaken some valuable quantitative research (Riccucci 2005, May, Winter 2009). However, these studies often did not use validated scales, although they sometimes did apply exploratory factor analyses and 6
reliability techniques to test the quality of their scales. In contrast, we will use validated scales and have tested the selected variables in a large n-study. In the following sections, we will examine variables that possibly influence the willingness to implement public policies. These variables are structured into three main factors: (1) the policy content and discretion; (2) the organizational context; and (3) personality characteristics. These factors have been shown to be theoretically important in explaining willingness to implement a change, such as a new policy (see also Herold, Fedor & Caldwell 2007). Public administration scholars have primarily emphasized the policy content and discretion as determinants of attitudes and behaviour of street-level bureaucrats (Winter 2003). For instance, Lipsky argues that a certain degree of discretion enables street-level bureaucrats, and other public professionals, to cope with the pressures they face. It is noted that effective policy implementation needs a policy structure that is not completely solidified by rules. A certain degree of discretion increases - among else - the willingness to implement a policy, thereby enhancing the effectiveness of implementation. Further, change management and applied psychology scholars stress factors concerning the organizational context and the personality characteristics of the implementers (Herold, Fedor & Caldwell 2007, Holt et al. 2007). 2.3 Factor 1: Policy content and discretion
First, we consider the content of the policy as determinant of the willingness to implement public policies. Based on the three criteria described above, we focus on the meaningfulness of a policy and the discretion available during its implementation. Earlier research suggest a strong relationship between the meaningfulness of a policy - as perceived by professionals - and their willingness to implement it (Matland 1995, Higgs, Rowland 2005). Ultimately, the goal of a public policy is to make a meaningful contribution to society, such as reducing crime rates or creating financial stability. For implementers, it is important to understand the contribution that a policy makes towards such goals (Meyers, 7
Vorsanger 2003). Meaninglessness occurs when implementers are unable to comprehend the contribution of the policy to a greater purpose. Three types of meaninglessness have been identified in earlier research (Tummers, Bekkers & Steijn 2009, Holt et al. 2007). Firstly, professionals will perceive a policy as meaningless if it fails to deliver any apparently beneficial outcomes for society as a whole. This is labelled societal meaninglessness, and is expected to decrease the willingness to implement a policy. Secondly, client meaninglessness is also expected to negatively influence willingness to implement new policies. May and Winter (2009) found that, when frontline workers perceive the instruments they have at their disposal for implementing a policy to be ineffective for their clients, this is likely to frustrate them. They cannot see how the implementation of the proposed policy will help their clients, and therefore wonder why they should implement it. Thirdly, we consider personal meaninglessness, which can be defined as a professional's perceptions that the implementation of a policy has no value for him- or herself. For instance, professionals may feel that a policy has added value for them if it increases their income, status or job security (see also Holt et al. 2007). We expect that the more professionals feel that a policy has added value for them, the more willing they will be to implement it. Lastly, we examine the degree of discretion. We expect that when implementers experience more discretion when implementing a policy, they will be more willing to implement it (Hill, Hupe 2009). This influence may be particularly pronounced in professionals whose expectations of discretion and autonomy contradict notions of bureaucratic control. However, one should not ignore the reality that, when implementing a policy, implementers are in fact making policy. As Matland notes (1995:148) 'Service deliverers ultimately determine policy'. This means that, in addition to its possible indirect effect through 8
willingness to implement, the amount of discretion directly affects policy performance. Hence, when implementers experience a lot of discretion, they might be more 'willing to implement' but, alternatively, might not implement the policy at all, using their discretion to shirk or sabotage (Brehm, Gates 1999). The paradox is therefore that although we expect policy goals to be achieved (because implementers will be more willing to implement given their high discretion, and more willingness affects policy performance positively) this need not be the case. Hence, high discretion might well lead to low policy performance. Conversely, high discretion could lead to higher policy performance, with implementers using their discretion to adapt the policy to the local situation (Palumbo, Maynard-Moody & Wright 1984). These possibilities need to be taken into account when considering the influence of discretion. In our case study, we will extensively review the role of discretion during policy implementation. Based on the discussions above, it is hypothesized that:
H1: Societal meaninglessness will be negatively related to change willingness. H2: Client meaninglessness will be negatively related to change willingness. H3: Personal meaninglessness will be negatively related to change willingness. H4: Discretion will be positively related to change willingness. 2.4 Factor 2: Organizational context
Alongside policy content, the organizational context can be an important determinant of the willingness to implement a new policy. In organization theory, it is argued that behaviour and attitudes have to be understood in terms of the organizational environment (Lawrence, Lorsch 2006 [1967]). Based on the criteria presented in Section 2.2, we examine three aspects of the organizational context: the influence of professionals during organizational implementation, the subjective norm (attitude) of managers and the subjective norm of professional colleagues towards the policy. Change management literature notes that an increase in employee influence on change decisions leads to increased commitment and performance, and reduces resistance 9
to change (Wanberg, Banas 2000). Judson (1991) notes that involving employees is perhaps the most powerful lever that management can use in order to gain acceptance of change. In the realm of policy implementation, we therefore expect that the more that professionals sense that they have a say in the way their organization constructs the policy, the more they will be willing to implement the new policy. Next, we take into account the subjective norm towards the policy. A subjective norm can be defined as 'the perceived social pressure to perform or not to perform behaviour' (Ajzen 1991, p. 188). This subjective norm is based on the attitudes of significant others towards behaviour. The more positive these others are towards a certain behaviour, the stronger should be a person's intention to perform that behaviour. In the case of professionals implementing a policy, relevant others are their colleagues, their subordinates, their managers and their board of directors. Given the possible conflicts between professionals and managers surrounding policy implementation, we distinguish between the subjective norm of the managers (and their board of directors) and the subjective norm of the (non-managerial) professionals (colleagues and sub-ordinates). We would expect that when professional colleagues are in favour of a new policy, this will positively contribute to a professional's willingness to implement it (see also Metselaar 1997). Similarly, we also expect that when professionals feel that the managers in their organization are in favour of the policy, this will positively influence their willingness to implement the policy. However, given the possible conflicts between managers and professionals with respect to policy implementation, it is also possible that a positive attitude by managers towards a policy will have a negative effect on the professionals' willingness to implement this policy. We will examine whether this is the case in our empirical analysis.
H5: Influence during organizational implementation will be positively related to change willingness.
10
H6: When managers are in favour of a policy, this will have a positive effect on change willingness. H7: When professional colleagues are in favour of a policy, this will have a positive effect on change willingness. 2.5 Factor 3: Personality characteristics of the implementers
Lastly, we consider the personality characteristics of the professionals implementing a policy. Personality characteristics are often ignored in literature examining attitudes towards change, such as a new policy (Judge et al. 1999, p. 107). Based on the criteria presented in Section 2.2, we examine two potentially relevant personality traits: rebelliousness and rule compliance. Research involving rebelliousness - or psychological reactance - examines how individuals respond when their behavioural freedoms are restricted. Rebelliousness can be considered as a personality trait to the extent that some individuals interpret actions as a threat to their freedom more than others (Shen, Dillard 2005). Scholars studying rebelliousness have shown that rebellious persons - compared with non-rebellious persons are defensive, autonomous and non-affiliative (Dowd, Wallbrown 1993). Further, rebelliousness has been found to be negatively related to readiness to change (Holt et al. 2007). Based on these studies, we expect rebellious individuals to be more resistant to implementing new policies. Rule compliance is broadly defined as the belief of an individual that people have to obey governmental regulations (Clague 2003). Rule compliance is related to, but logically independent of, rebelliousness. Rebelliousness examines an individual's proneness to see something as a threat to his or her own freedom. Rule compliance, on the other hand, examines the beliefs of that person that people (including themselves) should adhere to rules. We expect highly rule-compliant public professionals to be more willing to implement a new governmental policy, irrespective of its content. Overall, it is hypothesized that: 11
H8: Rebelliousness will be negatively related to change willingness. H9: Rule compliance will be positively related to change willingness. 2.6 Theoretical framework
Figure 1 shows the overall theoretical model representing the hypotheses developed above. In the sections that follow, we present the methodology used to test this model and our empirical results.
Factor 1 - Policy content & discretion (what) Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion
Factor 2 - Organizational context (where) Influence during implementation Subjective norm: Managers Subjective norm: Professional colleagues
+
Effect
+ + +
Willingness to implement policy
+
Factor 3 - Personality characteristics of implementers (who) Rebeliousness Rule obedience
FIGURE 1 Theoretical framework for explaining willingness to implement new policies
12
3 Method
3.1 Case
To test the proposed model, we undertook a survey of Dutch mental healthcare professionals implementing a new reimbursement policy. First, we provide a short overview of this policy. In January 2008, a new Health Insurance Law was introduced in the Netherlands. This was part of a process to convert the Dutch healthcare system into one based on a regulated market. In the Health Insurance Law, a system of Diagnosis Treatment Combinations (DTCs) was developed as a means of determining the level of financial reward for mental healthcare provision. The DTC policy differs significantly from the former method in which each medical action resulted in a payment, i.e. the more sessions that a mental healthcare specialist had with a patient, the more recompense that could be claimed. The DTC policy changed the situation by stipulating a standard rate for each disorder. As such, the new Health Insurance Law and the associated DTCs can be seen as the introduction of regulated competition into Dutch healthcare, a move in line with New Public Management ideas. We chose the DTC policy as the basis for testing our model. Firstly, public professionals, here psychotherapists, psychologists and psychiatrists, will be the ones implementing the policy. This is essential as the model is designed to further the debate on the experiences of public professionals with policies. Secondly, the DTC policy goals focus strongly on economic goals, such as efficiency and client choice, and earlier research indicates that it is policies that pursue these kinds of NPM goals that create problems for public professionals. Third, in the context of the DTC policy, professionals had considerable control over their own actions. This means that willingness, or a lack thereof, to implement could actually influence the behaviour of these professionals when it came to implementing the policy, and this makes studying the willingness of these professionals valuable. Clearly, not all the professionals were in favour of the policy, demonstrations took place and some 13
professionals pressured their associations to defy the DTC policy. Also more subtle forms of subversion were employed, such as reclassifying a patient into a higher diagnosis group (socalled 'up-coding'). If this occurs frequently, the efficiency goal of the DTC policy will be undermined. These examples are all manifestations of unwillingness. 3.2 Sampling and response
Our sampling frame consisted of 5,199 professionals who were members of two nationwide mental healthcare associations. These were all the members of these associations who could, in principle, be working with the DTC policy. Using an email and two reminders, we received 1,317 returns of our questionnaire; a response of 25%. The gender composition of the respondent group was 66% female, which is consistent with the Dutch average (69%) for mental healthcare professionals (Palm et al. 2008). The respondents' average age was slightly higher than that of the mental healthcare professional population (48 against 44). In total, 235 organizations were represented in the respondent group. No organization dominated, with the largest number of respondents from one organization being 43. To rule-out a possible non-response bias, we conducted nonresponse research where we contacted the non-responders for their reasons for not participating. Common reasons for not participating were a lack of time, retirement, change of occupation or not working with the DTC policy (some organizations, including some hospitals, were not yet working with this policy). The large number of respondents, their characteristics in terms of gender and age and the results of the non-response research indicate that our respondents are quite a good representation of the population. Nevertheless, we cannot completely rule out a nonresponse bias since the non-respondents may differ from the respondents in terms of numerous other (unexamined) characteristics.
14
3.3
Measures
Here, we report the measurement of variables. All measures had adequate Cronbach alphas (ranging from .71 to .95), as shown in the later results section. Unless stated otherwise, the measures were formatted using five-point Likert scales. For some items, we used templates. Templates allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. For example, instead of stating 'the policy' or 'professionals', the researcher can rephrase these items using the specific policy and group of professionals which are being examined, here 'the DTC policy' and 'healthcare professionals' replaced the template terms. This makes it easier for professionals to understand items, as they are better tailored to their context and this, in turn, increases reliability and content validity (DeVellis 2003:62). The items of all measures are shown in the Appendix.
Factor 1 - Policy content and discretion Societal meaninglessness Tummers (forthcoming 2012) conceptualized and measured societal meaninglessness as one of the dimensions of 'policy alienation'. Policy alienation has been defined as a general cognitive state of psychological disconnection from the policy programme being implemented by a public professional who, on a regular basis, interacts directly with clients. Societal meaninglessness reflects the perception of professionals concerning the benefit of a policy to socially relevant goals. Based on expert interviews and document analysis, we concluded that the introduction of DTCs had three main goals: (1) increasing transparency in costs and quality of mental healthcare, (2) increasing efficiency and (3) increasing patient choice.
15
Client meaninglessness Client meaninglessness - also conceptualized as a dimension of policy alienation (Tummers forthcoming 2012) - refers to the perception of professionals about the benefits of them implementing the DTC policy for their own clients. For instance, do they perceive that they are really helping their patients by implementing this policy?
Personal meaninglessness Personal meaninglessness looks at a professional's perceptions of the added value of them implementing a policy for themselves. Holt et al. (2007) developed and validated a scale for this concept, for which they coined the term 'personal valence'.
Discretion Discretion concerns the perceived freedom of the implementer in terms of the type, quantity and quality of sanctions and rewards delivered (Lipsky 1980). Discretion - or operational powerlessness - was measured using a six-item scale (Tummers forthcoming 2012).
Factor 2 - Organizational context Subjective norm The subjective norm was measured using a validated scale developed by Metselaar (1997). It was designed to examine the perceptions of professionals towards the attitudes of five groups towards a policy: the board of directors, managers, colleagues, subordinates and others in the organizational unit. Based on theoretical arguments and factor analyses, we distinguished between the subjective norm of managers (including the board of directors), and the subjective norm of professionals (including subordinates and others in the organizational unit).
16
Influence during implementation The influence of professionals during the implementation of the policy by the organization was measured using the concept of tactical powerlessness (which is the reverse of influence in the organization) (Tummers forthcoming 2012).
Factor 3 - Personality characteristics Rebelliousness Rebelliousness was measured using a validated scale (Shen, Dillard 2005). Shen and Dillard note that using this scale is 'theoretically and empirically justifiable' (p. 80).
Rule compliance Rule compliance is an persons' belief as to whether he or she feels obliged to obey governmental rules. To measure rule compliance, we used a scale from the European Social Survey.
Effect and control variables Change willingness (willingness to implement) We measured change willingness using a validated scale of Metselaar (1997). This scale also uses templates, which allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. Here, we replaced 'the change' with the 'DTC policy'.
Control variables We included some commonly used control variables: gender, age and management position (yes/no). Further, we included a variable showing whether a professional works independently (to some extent) or only for an institution. This was taken into account since professionals working independently may have different interactions with DTCs. 17
4 Results
4.1 Descriptive statistics
Descriptive statistics and correlations of the variables are presented in Table 1: TABLE 1 Descriptive statistics for the variables in the study Variable M
SD
Cronbach alpha
NA
Control variables 1. Sex (male = ref. cat.) 2. Age 3. Working (partly) independently (only in institution = ref. cat.) 4. Managing position (non-management position = ref. cat.) Policy Content and Discretion 5. Societal meaninglessness 6. Client meaninglessness 7. Personal meaninglessness 8. Discretion Organizational context 9. Influence during implementation 10. Subjective norm: Managers 11. Subjective norm: Professionals Personality characteristics 12. Rebelliousness 13. Rule compliance
0.64 47.94 0.33 0.44
NA 11.01 NA NA
7.70 7.73 6.90 4.62
1.67 1.53 1.46 1.81
.96 .80 .79 .83
4.47 6.16 3.96
1.90 1.67 1.54
.87 .71 .86
4.80 5.53
0.92 1.39
.78 .80
Proposed effect 14. Change willingness 4.32 1.77 Note: the means for variables 5 to 14 are adjusted to an equivalent ten-point scale to ease interpretation.
.85
18
TABLE 2 Correlations for the variables in the study Variable 1 2 3 4 1. Sex 1 2. Age -.34** 1 3. Working (partly) -.16** .32** 1 independently 4. Management -.26** .19** -.05 1 position 5. Societal -.17** .18** .10** .10** meaninglessness 6. Client -.12** .17** .07 -.06* meaninglessness 7. Personal -.01 -.02 -.16** .08**** meaninglessness 8. Discretion .07* -.01 .14** -.12** 9. Influence during .00 -.09** .02 .03 implementation 10. Subjective norm: .00 -.04 -.04 .00 Managers 11. Subjective norm: .05 -.04 .03 .02 Professionals 12. Rebelliousness -.07* .08** .09** .08** 13. Rule compliance .10** -.01 -.03 -.04 14. Change -.16** -.15** -.06 -.01 willingness Note: * p < .05, ** p < .01
5
6
7
8
9
10
11
12
13
14
1 .69** .46** -.39** -.28** -.27** -.48** .02 -.12** -.57** 1 .61**** -.43** -.33** -.24** -.50** .02 -.12** -.56** 1 -.56** -.34** -.15** -.45** .10** -.08* -.50** 1 .42** .08* .42** -.03 .06 .41**
1 .04 .39** -.07* .09** .36** 1 .38** .09** -.03 -23** 1 .05 .03 .48** 1 -.14** -.10**
1 .18**
1
Data based on a single application of a self-reported questionnaire can result in inflated relationships between variables due to common method variance. We conducted a Harman one-factor test to evaluate the extent to which common method variance was a concern. The factors together accounted for 71% of the total variance. The most significant factor did not account for a majority of the variance (only 32%). The fact that a single factor did not emerge, and the first factor did not account for a majority of the variance, suggests that common method variance is not a major concern here. 4.2 Regression results
Regression analyses were conducted to examine which factors predicted change willingness. In the first model, we regressed change willingness on the control variables (R2.of 03). In the subsequent models, we added the policy content variables (model 2, increased R2 to .43), the organizational context variables (model 3, increased R2 to .45) and the personality characteristics variables (model 4, R2 increased to .47). These increases were all statistically significant. Thus, the combination of the various types of variables contributes considerably to an explanation of the change willingness of public professionals. We will now consider the individual hypotheses. Hypothesis 1 predicts that societal meaninglessness will be negatively related to the professionals' willingness to implement DTCs. As Table 3 shows, in the final step of the analysis, societal meaninglessness is significantly related to change willingness (?=-.25 p<.01). The high beta coefficient indicates that societal meaninglessness is especially influential. The second hypothesis looks at the influence of client meaningless on change willingness. This influence is significant (?=-.12 p<.01) So, when professionals do not see a policy as having value for their own clients, they are less willing to implement it. The third hypothesis examines the relationship between personal meaninglessness and change willingness. Our empirical analysis confirmed this hypothesis in that there is a significant influence of personal meaninglessness on change willingness (?=-.17 p<.01).
Hypothesis 4 examines the positive influence of discretion on the willingness of professionals to put effort into a policy. Our results show that this is indeed the case: greater perceived discretion heightens change willingness (?=.07 p<.05). The fifth hypothesis looks at the influence of professionals during the implementation of the policy by their organization. Here, our data do indeed show a positive relationship between influence during organizational implementation and change willingness (?=.10 p<0.1). Hypotheses 6 and 7 examine the subjective norm. Our analysis shows that the subjective norm of managers has a statically significant but low influence (?=.06 p<.05). That is, when managers are perceived as being positive about a change, this somewhat boosts the inclination of professionals to implement the policy. However, the influence of the subjective norm of one's professional colleagues is much stronger (?=.13 p<.01). The more positive that professional colleagues are about the DTC policy, the more effort a professional will put into its implementation. The eighth hypothesis concerns the relationship between rebelliousness and change willingness. As could be expected from the applied psychology literature, the results indicate that rebellious individuals are indeed less willing to implement the policy (?=-.06 p<.05), even after a large number of other factors have been controlled for. Finally, Hypothesis 9 examines the influence of rule compliance on change willingness. The expectation is that public professionals who score highly on rule compliance will feel that public rules and regulations should be adhered to. Based on this, we expected such public professionals to be more willing than others to implement a new governmental policy, irrespective of its content. Our empirical analysis supports this expectation (?=.10 p<.01).
21
TABLE 3 Hierarchical regression analyses for variables predicting change willingness
Model 1 Including control variables Control variables Female independently (to some extent) Working in institution Managing position
cat.
Model 2 Including content variables
Model 3 Including context variables
Model 4 Including personality characteristics
.13** .07** Ref. cat. -.05 -.04
.08** Ref. cat. -.05 Working
.07* Male Ref. cat. Age .00 -.03
Ref. cat. -.11** -.04 -.03
Ref. cat. .04 .09** Ref. cat.
Ref. cat. .07* Ref. cat.
Ref. cat.
Ref. cat. Ref.
.07* Non-management Ref. cat.
position Policy content and discretion Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion Organization context Influence during implementation Subjective norm (managers) Subjective norm (professionals) Personality characteristics Rebelliousness Rule compliance ?R2 Overall adjusted R2
.40** .43 .03** .45
-.30** -.16** -.20** .12**
-.26** -.12** -.18** .06
-.25** -.12** -.17** .07*
.11** .05 .12**
.10** .06* .13**
-.06* .10** .01** .47
.03
Note: Beta-coefficients are presented. * p <.05, ** p < .01. Regression Criteria were met (Independent residuals, no multicollinearity, no exclusion of influential outlying, Cook's distance max. 0.02 (criterion < 1), homoscedasticity and normality criteria met).
22
Based on the results of our hypothesis testing, we can construct Figure 2. In this Figure, we see that the policy content factor, especially meaninglessness with their relatively high betas (-25,-.12 and -.17). Further, the organizational context and personality characteristics were also influential, albeit to a lower degree. In the concluding section, we will elaborate on these findings.
Factor 1 - Policy content & discretion (what) Societal meaninglessness Client meaninglessness Personal meaninglessness Discretion
Factor 2 - Organizational context (where) Influence during implementation Subjective norm: Managers Subjective norm: Professional colleagues
+
Effect
+ + +
Willingness to implement policy
+
Factor 3 - Personality characteristics of implementers (who) Rebeliousness Rule obedience
FIGURE 2 Theoretical framework for explaining willingness to implement new policies
23
4.3
DTC policy: policy content and discretion
To increase the understanding of the case studied, we will now some qualitative data regarding the DTC policy. This provides an additional perspective on the interplay between discretion, policy content and organizational context. First, we note that the DTC policy can impose change with respect to discretion. Professionals have to work in a more 'evidence-based' way, and are required to account for their cost declarations in terms of the mental health DSM (Diagnostic Statistical Manual) classification system. As a result, it becomes harder to use practices that are difficult to standardize and evaluate, such as psychodynamic treatments. Some professionals perceive this as a reduction in their discretion. As Van Sambeek et al. (2011, p. 50) argue: 'Although the DSM and evidence-based guidelines are developed mostly by professionals, they can generate resistance when becoming mandatory [?]. When their use has become obligatory, professionals feel limited in their clinical autonomy'. Discretion regarding the length of treatment is arguably also increasingly limited. Whereas, in the former system, each medical action resulted in a payment, under the DTC policy a standard rate is determined for each disorder. This means that it has become more difficult to adjust the treatment to the specific needs of a patient. As one professional argued (unless stated otherwise, quotations are drawn from open answers from the survey):
'Patients receive a 'label' from a classification system [?] Sometimes a patient fits into a 'depression' but really needs something more than a neat 'Cognitive Behavioural Therapy protocol of ten sessions'. If time and number of sessions rather than content start leading, it becomes impossible to provide patient-centred care.'
As a result, many professionals felt a loss of discretion (also evidenced by the relatively low average score of 4.6). Two illustrative quotes from professionals are 'the profession is reduced to mere procedures' and 'the DTC policy is a straightjacket'. This means that the 24
possibility of there being high discretion (positively affecting change willingness, but eventually negatively influencing policy performance) did not occur in the case studied. Contrary to this, there was relatively low discretion, which negatively influenced willingness to change, but could nevertheless be fruitful for policy performance, as implementers had less possibility to shirk or sabotage the policy. When examining the meaningfulness of the policy, we see that the mean score is quite high (7.7): many professionals do not have the feeling that societal goals are being achieved (i.e. a high societal meaninglessness). This is mainly due to the characteristics of the DTC policy. For instance, when considering the efficiency goal, we see that the DTC policy can have financially perverse incentives. An example can clarify this. The DTC time allocation for treating a personality disorder is between 800 minutes and 1800 minutes. An implication of this is that the treatment yields the same amount of money for the professional regardless of the time spent on the treatment. This provides an incentive to complete the treatment at 800 minutes. Furthermore, it provides an incentive to classify a patient in a higher diagnosis group (the so-called 'up-coding'). As a result, the efficiency goal is unlikely to be reached through the DTC policy. We also conclude that many professionals felt that the DTC policy is not very meaningful for their own patients (average score 7.7 on client meaninglessness). For instance, one requirement of the DTC policy is that professionals have to provide patient information to a national DTC Information System. This patient information, such as details of the disorder, used to be fully protected under the duty of professional confidentiality but, now, many professionals feel that the patients' privacy is insufficiently protected. Many thought this was not beneficial for their patients. When studying personal meaninglessness (average score 6.6), we first found that, following the introduction of the DRG policy, the revenues of professionals (especially freelancers) often declined, but that later many professionals experienced positive financial consequences. Quotes that illustrate this are: 'After a miserable time of major financial 25
problems, it is going well at the moment' and 'I think I earn more money because of the DTC policy, that's nice'. Second, and related to client meaninglessness, many professionals felt that their professional confidentiality was being impinged upon. As one professional put it: 'I consider the delivery of a diagnosis to health insurers contrary to my professional confidentiality'. Third, many professionals felt that the DTC policy resulted in an increased administrative workload, something which was not welcomed. In our survey, 90% (fully) agreed with the statement 'As a result of the policy, I have to do more administrative work'. To summarize, in terms of personal meaninglessness, the DRG policy affected in particular the professionals' income, professional confidentiality and administrative workload. This section has highlighted the policy content and organizational context behind the statistical data, as such providing some background to interpret the results of this study (for more information, see Palm et al. 2008, van Sambeek, Tonkens & Bröer 2011).
5 Conclusions
Our main goal was to examine factors that might influence the willingness, or reluctance, of public professionals to implement new policies. Based on literature from public administration, change management and applied psychology fields, a theoretical model was constructed. This model was tested in a survey of 1,317 mental healthcare professionals implementing a new reimbursement policy. It works adequately in that the factors included in the model explain 47% of the variance in change willingness. The high internal consistency values (Cronbach alphas ranging from .71 to .96) and the meeting of regression criteria strengthens the reliability and validity of the study. As such, we can conclude that our quantitative, interdisciplinary approach adds to the literature concerning the attitudes of professionals towards public policies. The results show that policy content is the most important factor in explaining this willingness. However, the organizational context and the personality characteristics of the implementers are also influential and should be taken into account if one is to properly study 26
the attitudes of professionals towards public policies. Alongside these general conclusions, we can draw three more-specific conclusions. Firstly, the three meaninglessness factors (societal, client and personal) have the strongest influences on willingness to change. When professionals do not see benefits for themselves they were less willing to implement it. Although this is influential, even after controlling for this factor, societal meaninglessness remained the most influential. When professionals feel that a policy does not contribute to societal goals, such as transparency or increasing patient choice, they are far less willing to implement it. These findings show how important the perceived benefit of a policy is to professionals. Despite this, the current debate on policy implementation is primarily focused on the influence and discretion of the implementers. Our study shows that while influence and discretion are important, taking account of the perceived meaninglessness (or its counterpart meaningfulness) of a policy is vital, and should be included in further research. Secondly, we can see that the subjective norm of especially professional colleagues in an organization is an important factor in explaining the willingness of public professionals to implement new policies. This is a relevant observation given the current debate on pressured public professionals (Freidson 2001). It has been stated that public professionals nowadays feel pressure from many sides due to the emancipation of their clients, the demands of politicians and the (ir)rationalities of their managers. Although we will not deny that many professionals do indeed feel such pressure, the created discourse, of feeling pressured, also seems to influence professionals who would not otherwise sense such pressure. Thirdly, this study is one of the first policy implementation studies that explicitly considers the personality characteristics of the implementers. Our research shows that these are important. For instance, the more rebellious professionals were less willing to implement the DTC policy, irrespective of the content and the organizational context. Elaborating on Judge et al. (1999), we note that there is a real possibility that successfully coping with a new policy is determined by the psychological predispositions of professionals. 27
As with all studies, this study has limitations. First, we examined factors influencing the willingness to implement public policies. However, willingness or alternatively resistance to implementation may not always predict behaviour (Ajzen 1991). In the theoretical framework we noted the important role of discretion during implementation in the policy behaviour of professionals. High discretion can enhance policy performance as it can increase the willingness to implement, with implementers being given the opportunity to adapt the policy to the situations of their clients. However, if professionals do not agree with the policy, they can use this high discretion to shirk or sabotage. In the present study, we analysed only the influence of discretion on the willingness to implement policies. Future studies could go deeper into the relationship between discretion, willingness to implement policies and policy performance. For instance, one could explore the conditions under which a high level of discretion positively influences both willingness to implement new policies and policy performance, and under what conditions a high level of discretion stimulates willingness to implement new policies, but negatively influences performance. Second, the results of this study, and the implications outlined, should be interpreted in light of the study's context, sample and response rate. Although the study's generalizability is improved by the fact that the sample included a large number of public professionals, working in different occupations, positions and places, one should be cautious in generalising this to other public-sector policies or domains. Another area for further research would therefore be to test the proposed model using other types of policies in a range of public domains. A third limitation was that we did not include all the possible factors that might influence willingness to implement. In future research, scholars could, for instance, examine the influence of other organizational factors such as the level of trust between professionals and management, or the level of organizational identification. Further, other personality characteristics could be taken into account, such as optimism.
28
Concluding, we see that the three factors - related to policy content, organizational context and personality characteristics - are all important in explaining the willingness of professionals to implement public policies. This indicates the complexity and multidimensional character of policy implementation. It suggests that, to increase the understanding of public policy implementation, researchers and practitioners should move beyond taking single factors into consideration, and try to include multiple factors for explaining the willingness or otherwise resistance of public professionals to implement policies. This would add to the understanding of the attitudes of professionals towards governmental policies, which could ultimately lead to policy implementation being more effective.
References
Ajzen, I. 1991, "The theory of planned behavior", Organizational behavior and human decision processes, vol. 50, no. 2, pp. 179-211. Bekkers, V.J.J.M., Edwards, A., Fenger, M. & Dijkstra, G. 2007, Governance and the democratic deficit, Assessing the legitimacy of governance practices, Ashgate, Aldershot. Brehm, J. & Gates, S. 1999, Working, shirking, and sabotage: Bureaucratic response to a democratic public, University of Michigan Press, Michigan. Clague, C. 2003, "Rule obedience, organizational loyalty, and economic development" in Democracy, Governance & Growth, ed. S. Knack, University of Michigan Press, Michigan, pp. 227-251. DeVellis, R.F. 2003, Scale development: Theory and applications, Sage, Thousand Oaks. Dowd, E.T. & Wallbrown, F. 1993, "Motivational components of client reactance", Journal of Counseling and Development, vol. 71, pp. 533-538. Ewalt, J.A.G. & Jennings, E.T. 2004, "Administration, governance, and policy tools in welfare policy implementation", Public administration Review, vol. 64, no. 4, pp. 449-462. Freidson, E. 2001, Professionalism: The third logic, Cambridge University Press, Cambridge.
29
Herold, D.M., Fedor, D.B. & Caldwell, S.D. 2007, "Beyond change management: A multilevel investigation of contextual and personal influences on employees' commitment to change", Journal of Applied Psychology, vol. 92, no. 4, pp. 942-951. Higgs, M. & Rowland, D. 2005, "All changes great and small: exploring approaches to change and its leadership", Journal of Change Management, vol. 5, no. 2, pp. 121-151. Hill, M. & Hupe, P. 2009, Implementing public policy, 2nd edn, Sage, Thousand Oaks. Hogwood, B.W. & Gunn, L.A. 1984, Policy analysis for the real world, Oxford University Press, Oxford. Holt, D.T., Armenakis, A.A., Feild, H.S. & Harris, S.G. 2007, "Readiness for organizational change: The systematic development of a scale", The Journal of applied behavioral science, vol. 43, no. 2, pp. 232-255. Judge, T.A., Thoresen, C.J., Pucik, V. & Welbourne, T.M. 1999, "Managerial coping with organizational change: A dispositional perspective", Journal of Applied Psychology, vol. 84, no. 1, pp. 107-122. Judson, A.S. 1991, Changing Behavior in Organization: Minimizing Resistance to Change, Basil Blackwell, Cambridge, MA. Lawrence, P.R. & Lorsch, J.W. 2006, Organization and environment, Harvard University, Boston. Lewin, K. 1951, Field theory in social science, New York: Harper. Lipsky, M. 1980, Street-Level Bureaucracy, Russell Sage Foundation, New York. Marinetto, M. 2011, "A Lipskian analysis of child protection failures from Victoria Climbié to 'Baby P': a street?level re?evaluation of joined-up governance", Public Administration, vol. 89, no. 3, pp. 1164-1181. Matland, R.E. 1995, "Synthesizing the implementation literature: The ambiguity-conflict model of policy implementation", Journal of Public Administration Research and Theory, vol. 5, no. 2, pp. 145-174. May, P.J. & Winter, S.C. 2009, "Politicians, Managers, and Street-Level Bureaucrats: Influences on Policy Implementation", Journal of Public Administration Research and Theory, vol. 19, no. 3, pp. 453. Metselaar, E.E. 1997, Assessing the willingness to change: Construction and validation of the DINAMO, Free University of Amsterdam. Meyers, M.K. & Vorsanger, S. 2003, "Street-level bureaucrats and the implementation of public policy" in Handbook of public administration, eds. B. Guy Peters & J. Pierre, Sage, London, pp. 245-254. 30
O'Toole, L.J. 2000, "Research on policy implementation: Assessment and prospects", Journal of public administration research and theory, vol. 10, no. 2, pp. 263-288. Palm, I., Leffers, F., Emons, T., Van Egmond, V. & Zeegers, S. 2008, De GGz ontwricht: Een praktijkonderzoek naar de gevolgen van het nieuwe zorgstelsel in de geestelijke gezondheidszorg, SP, Den Haag. Palumbo, D.J., Maynard-Moody, S. & Wright, P. 1984, "Measuring degrees of successful implementation", Evaluation review, vol. 8, no. 1, pp. 45-74. Pressman, J. & Wildavsky, A. 1984, Implementation, 3rd edn, University of California press, Berkeley, CA. Riccucci, N.M. 2005, "Street-level bureaucrats and intrastate variation in the implementation of temporary assistance for needy families policies", Journal of Public Administration Research and Theory, vol. 15, no. 1, pp. 89-111. Shen, L. & Dillard, J.P. 2005, "Psychometric properties of the Hong psychological reactance scale", Journal of personality assessment, vol. 85, no. 1, pp. 74-81. Smith, M.J., Richards, D., Geddes, A. & Mathers, H. 2011, "Analysing policy delivery in the United Kingdom: the case of street crime and anti-social behaviour", Public Administration, vol. 89, no. 3, pp. 975-1000. Tummers, L.G. forthcoming 2012, "Policy alienation of public professionals: The construct and its measurement", Public Administration Review, . Tummers, L.G., Bekkers, V.J.J.M. & Steijn, A.J. 2009, "Policy alienation of public professionals: Application in a New Public Management context", Public Management Review, vol. 11, no. 5, pp. 685-706. Van Meter, D.S. & Van Horn, C.E. 1975, "The Policy Implementation Process: A Conceptual Framework", Administration & Society, vol. 6, no. 4, pp. 445-488. van Sambeek, N., Tonkens, E. & Bröer, C. 2011, "Sluipend kwaliteitsverlies in de geestelijke gezondheidszorg", Beleid en Maatschappij, vol. 38, pp. 47-64. Wanberg, C.R. & Banas, J.T. 2000, "Predictors and outcomes of openness to changes in a reorganizing workplace", Journal of Applied Psychology, vol. 85, no. 1, pp. 132-142. Weick, K.E. 2000, "Emergent change as a universal in organizations" in Breaking the code of change, eds. M. Beer & N. Nohria, Harvard Business School Press, Boston, pp. 223-241. Winter, S.C. 2003, "Implementation perspectives: Status and reconsideration" in Handbook of Public Administration, eds. B. Guy Peters & J. Pierre, Sage, London, pp. 213-222.
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Appendix: Questionnaire
Background questions 1. What is your gender? 2. What is your year of birth? 3. What is your highest completed education? Male/female ______________
? Vocational training ? University ? Post-doctoral University ?
Other: ______________ Y/N
4. Do you have a managerial function? 5. What is your institutional setting?
? Working independently ? Working partly independently, partly in
institution
? Working in institution ? Other: ______________
[Unless stated otherwise, all measures were formatted using five-point Likert scales. As indicated in the main text, we used templates to specify the change. Templates allow the researcher to specify an item by replacing general phrases with more specific ones that better fit the research context. Template words are underlined. The templates are in this case: Policy: DTC-policy Goal: (1) increasing transparency in costs and quality of mental healthcare, (2) increasing efficiency and (3) increasing patient choice among mental healthcare providers Patients Clients: Professionals: Healthcare professionals Organization: Institution]
Policy content and discretion
Societal meaninglessness
1. I think that the policy, in the long term, will lead to goal 2. I think that the policy, in the short term, will lead to goal 3. I think that the policy has already led to goal 4. Overall, I think that the policy leads to goal
Client meaninglessness
1. 2. 3. 4. 5.
The policy is harmful for my clients privacy With the policy I can better solve the problems of my clients The policy is contributing to the welfare of my clients Because of the policy, I can help clients more efficiently than before I think that the policy is ultimately favourable for my clients 32
Personal meaninglessness
1. 2. 3. 4. 5. 6. 7.
As a result of the policy, I experience positive financial consequences On the long term, the policy is beneficial for me I have won little as a result of the introduction of the policy My future in this job will be limited because of the policy I am worried I have lost some of my status due to the introduction of the policy As a result of the policy, I have to do more administrative work The policy erodes my duty of professional confidentiality
Discretion
1. 2. 3. 4. 5. 6.
I have freedom to decide how to use the policy While working with the policy, I can be in keeping with the client's needs Working with the policy feels like a harness in which I cannot easily move When I work with the policy, I have to adhere to tight procedures While working with the policy, I cannot sufficiently tailor it to the needs of my clients While working with the policy, I can make my own judgments
Organizational context
Influence during organizational implementation
1. In my organisation, especially professionals could decide how the policy was being implemented 2. In my organisation, professionals have - by means of working groups or meetings - taken part in decisions on the execution of the policy 3. The management of my organisation should have involved the professionals far more in the execution of the policy 4. Professionals were not listened to over the introduction of the policy in my organisation 5. In my organisation, professionals could take part in conversations regarding the execution of the policy 6. I and my fellow professionals were completely powerless in the introduction of the policy in my organisation
Subjective norm
Please indicate how the following people feel about the DTC policy (5-point scale, from very negative to very positive): 1. My board of directors [group: managers] 2. My manager [group: managers] 3. My professional colleagues [group: professionals] 4. My subordinates [group: professionals] 5. Others in my organization unit [group: professionals] Personality characteristics
Rebelliousness
1. 2. 3. 4.
I become frustrated when I am unable to make free and independent decisions It irritates me when someone points out things which are obvious to me I become angry when my freedom of choice is restricted Regulations trigger a sense of resistance in me 33
5. I find contradicting others stimulating 6. When something is prohibited, I usually think, "That's exactly what I am going to do." 7. I am contented only when I am acting of my own free will. 8. I resist the attempts of others to influence me. 9. It makes me angry when another person is held up as a role model for me to follow 10. When someone forces me to do something, I feel like doing the opposite 11. I consider advice from others to be an intrusion 12. Advice and recommendations usually induce me to do just the opposite
Rule compliance
1. A good citizen always complies with the rules and laws 2. You always have to strictly abide by the law, even it that means that good opportunities will be lost as a result 3. Occasionally it is acceptable to ignore the law to do what you want 4. A good citizen lives on the rules and laws 5. The law must always be respected, regardless of the circumstances
Effect Willingness to implement 1. I intend to try to convince employees of the benefits the policy will bring 2. I intend to put effort into achieving the goals of the policy 3. I intend to reduce resistance among employees regarding the policy 4. I intend to make time to implement the policy 5. I intend to put effort in order to implement the policy successfully
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