Conceptual framework: institutional logics

Initially introduced by Friedland, institutional logics suggests that institutions are guided by dominant belief systems, termed ‘logics’ [8]. These logics encompass more than just operational guidelines; they represent the fundamental narratives that shape an organization’s ethos, decision-making processes, and behaviors. In healthcare, there are four main logics: public management, market, medical professional, and care professional or partnership (Table 1) [9,10]. These logics provide a structured way to understand a hospital’s motivations and actions.

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Table 1. The four healthcare logics.

https://doi.org/10.1371/journal.pone.0344582.t001

Institutional logics guide organizational behavior and shape the culture and sustainability of organizations [11]. In healthcare, PE is a vital component of health service design and delivery, particularly in hospitals [12]. MVV statements and strategic plans potentially embody an organization’s commitment to integrating PE into operations. This study focuses on the meanings embedded within the professed and perceived PE goals of an urban academic hospital as interpreted through the four healthcare logics. The research questions were: How does a hospital understand and describe its goals? What do hospital documents reveal about the hospital’s goals for PE? How do staff and patient and family partners understand and describe the hospital’s goals for PE? Exploring the diverse interpretations of PE goals among different participants through institutional logics can contribute to understanding the nature of translating and operationalizing PE goals in complex hospital systems. By examining how PE goals are articulated and interpreted across different groups within a hospital, this study will extend current understanding of how organizational and cultural mechanisms enable or constrain person-centred transformation.

Approach

This study adopted Stake’s instrumental embedded case study methodology [13] to explore how PE goals are conveyed in organizational documents and understood and perceived by staff and partners. In instrumental case studies, cases are not examined for their own sake but rather as a means to gain a broader understanding of a particular phenomenon or to find a theoretical explanation [13]. This approach was chosen for its usefulness in closely examining complex organizational structures and dynamics [10] and allowing for an in-depth exploration of the hospital’s strategic objectives. Including diverse participant groups—executives, directors, clinicians, managers, and patient and family partners—was crucial to capturing a broad spectrum of perspectives, experiences and interpretations of health and healthcare at the hospital. Patient and family partners or advisors are formal roles within health service organizations (sometimes paid, but typically volunteer-based) who provide first-hand experiences of health service delivery when engaging with clinicians and managers in activities intended to improve the quality of care for other patients [14].

Case selection

Using the instrumental embedded case study methodology, two embedded cases were selected within one hospital system as the study site. Being one of the largest multi-site hospitals in Canada, with a comprehensive scope of services and broad demographic reach, the site provided a resource-rich environment to conduct this study. Furthermore, the hospital’s reputation and commitment to PE initiatives presented a unique opportunity to explore how institutional logics manifest in and influence PE goals and practices within a complex hospital ecosystem. At the time of the study, the hospital was in the process of shifting its PE model from department-specific Patient and Family Advisory Committees (PFACs) – committees of patients and families that regularly meet to discuss health service design and improvement – to a corporate-wide roster model. The roster model focuses on having a list of patient and family partners with various medical conditions, experiences, and interests; partners provide their perspectives on healthcare activities through a vetting and matchmaking process with teams and clinical programs.

Within the hospital, two departments/clinical programs were selected as the embedded cases. The first program was identified as an exemplar of PE practices by executives and directors. The selection of the second program as the second case presented a contrasting narrative to the first program, particularly in response to the challenges during the COVID-19 pandemic. While both programs faced clinical capacity challenges during the pandemic, their approaches to PE differed markedly. The second program reallocated most of the PE resources to address immediate clinical needs, whereas the first program continued to engage patients and families in healthcare activities, as well as sustain their PFAC.

This investigation focused on the perceptions and articulations of the hospital’s goals for PE by both staff and patient and family partners as part of a broader case study that looked at how hospital goals for PE are -or are not – translated to practices. Purposefully selecting two distinct clinical programs as embedded units of analysis not only broadened the pool of directors, clinicians, managers, and partners available for interview but also created an analytic vantage point from which institutional logics could be compared. Programs seldom align with organizational mandates in identical ways: each is shaped by its own unique mix of clinical priorities, resource constraints, professional cultures, and histories of engagement. By holding these two programs in deliberate analytic tension, the study could ask whether a shared logic of PE permeates the hospital or whether locally situated logics inflect the interpretation and enactment of PE goals, producing patterns of convergence or points of divergence. Thus, the comparative design was not merely a methodological convenience; it was a deliberate strategy to expose the depth, diversity, and potential contestation of meanings that different groups ascribe to the hospital’s PE goals.

Recruitment

Patient and family partners, clinicians, and managers were recruited to garner diverse perspectives on the hospital’s PE goals and practices from October 2022 to October 2023. A purposive, snowball sampling method was employed, where initial participants were requested to refer patient and family partners, clinicians, or managers they had worked with closely who had been involved in PE processes or initiatives at the hospital. This recruitment strategy ensured participants could share their understanding of the practical implementation of PE-related hospital objectives.

Sampling

The study aimed to achieve data crystallization and conceptual depth by engaging participants from multiple groups with different perspectives on the topic. Rather than seeking theoretical saturation, which emphasizes consistency and convergence, the study adopted crystallization as an interpretive strategy that values multiplicity, contradiction, and complexity [15]. Through iterative cycles of data collection and analysis, this approach enabled exploration of the diverse and sometimes competing perspectives embedded in hospital goals and PE practices. Crystallization enabled a more holistic, layered understanding of how mission, vision, and value statements, strategic plans, and PE initiatives reflect the coexistence of multiple institutional logics within healthcare organizations.

Ethics statement

The University of Toronto Research Ethics Board and Research Ethics Board of the health system where the study was conducted approved this study. Written and verbal consent was obtained before scheduling the interview and again at the start of the interview.

Data collection

Data analysis

To delve into the meaning and intention of goals from different perspectives (i.e., between participant groups and between embedded cases), this study employed critical discourse analysis (CDA) for strategic management research [18]. CDA critically examines how discourse, defined as language use within social contexts, is influenced by and influences social structures [18]. Central to this approach is the understanding of strategy as discourse, which moves beyond viewing strategy merely as plans or decisions, framing it instead as a formative language element that actively shapes organizational realities [18]. In this light, strategic narratives and texts are descriptive and constitutive of organizational goals, values, and attitudes. In this research, CDA was a tool for understanding how language and discourse shape hospital PE goals [18].

CDA was used to explore how logics were linguistically expressed and prioritized within the hospital’s organizational documents. This document analysis provided an initial understanding of how the hospital describes its goals. CDA was also used to analyze participant interpretations of the hospital’s goals, and this was compared between the two embedded cases. Comparing perspectives from interviews with diverse participant groups, between documents and interviews, and between the two embedded cases highlighted the differences and commonalities in the language used that reflect the organizational culture and PE priorities.

Analysis involved line-by-line coding using the pattern-inducing approach for studying institutional logics [19] on documents and interviews. This analytic approach highlighted how participants perceived, described, and understood the hospital’s goals in relation to the four healthcare logics. By employing this method, this study was able to delve into the intricacies of how participants’ values and beliefs about PE shape their understanding of the hospital’s goals.

Document analysis

The following documents were analyzed: MVV statements, the strategic plan, the declaration of respect, and the patient declaration of values. Based on the descriptions of the four healthcare logics shown in Table 1, the strategic plan and MVV statements emphasized a community focus, reflecting the public management logic (i.e., benefit to society, community, and societal well-being). The strategic plan also highlighted the market logic (i.e., healthcare efficiency and cost containment) in mentioning the sustainability of health services as a goal. The medical professional logic (i.e., optimizing care quality) was evident across the strategic plan, MVV statements, and, notably, the declaration of respect. The declaration of respect primarily focuses on interactions among staff and team members, underlining a commitment to medical professionalism. Finally, concepts related to the care professional (e.g., patient well-being) and partnership logics (i.e., partnership with patients and families in activities) were embedded throughout all organizational documents, and commonly mentioned in the strategic plan, MVV statements, and the patient declaration of values. The widespread incorporation of care professional and partnership logic across documents underscores a holistic approach to healthcare that values patient-centeredness and partnership at its core.

Interview findings

Expanding the medical professional logic: staff roles and responsibilities

The original conceptualization of the medical professional logic focuses on care quality [9]. However, the medical professional logic in this study was found to be more about roles and responsibilities, which may or may not include activities directly related to improving care quality. Broadening how the medical professional logic is understood beyond activities focused on care quality (e.g., using clinical tools) to encompass diverse aspects of clinician and manager responsibilities can help us understand how different healthcare logics interact in a hospital environment. Having an accurate understanding of how logics are connected to practices from the perspectives of staff and partners allows for a more precise exploration of how different logics coordinate, cooperate, and influence the realization of hospital goals for PE. In this case at least, perhaps logics attunely represented aspirations rather than realities of PE in practice.

For patient and family partners, the distinction between care as a personal experience (care professional logic) and high-quality care (medical professional logic) is often indistinguishable. According to the literature, patient and family narratives intertwine emotional support, empathy, and clinical excellence, illustrating a holistic view of healthcare where patient well-being and clinical quality are seamlessly integrated [20–22]. This perspective suggests high-quality care inherently encompasses emotional and physical health, challenging the traditional dichotomy between these aspects. This overlap is consistent with our understanding of care quality; the Institute of Medicine’s conceptualization of quality of care includes patient-centeredness as a dimension of quality [23].

The literature reveals persistent tensions between the medical and care professional logics, particularly in balancing patient preferences for compassionate care with clinician perceptions of best practices that tend to focus on a narrower conceptualization of care quality [24,25]. Clinicians may prioritize a treatment based on clinical guidelines, while patients might value quality of life considerations that lead to different preferences. For example, there is no shortage of studies showing a difference in how treatment decisions are made, with providers more often thinking decisions are shared and patients believing that their providers made the final decision [26–29]. In the present study, this difference may potentially reflect a gap between a commitment to PE – which both programs and staff clearly stated – and the meaningful engagement of patients and families that PE implies. To accurately discern whether such a gap exists would require investigating PE processes and activities.

These reflections potentially suggest advancing the original conceptualization of the medical professional logic focusing on care quality to a nuanced conceptualization that includes diverse activities integral to clinician roles and responsibilities, such as using clinical tools, patient satisfaction surveys, and engaging patients and families in program operations. As Martimianakis et al. stated: “compassionate organizations must strive to recognize the goals and values of patients and families in physical, mental, emotional, and spiritual domains of well-being in every encounter” [30:176]. This nuanced conceptualization potentially facilitates incorporating PE and person-centered care within the medical professional logic. Given that these aspects are inherent to the roles of clinicians, their inclusion within the medical professional logic is not only logical but essential and aligns closely with contemporary healthcare imperatives focused on holistic and integrated person- and people-centered care.

Viewing hospital goals through roles and responsibilities

Clinicians and managers in this study delineated their roles and responsibilities when describing how they understood hospital PE goals. Some roles and responsibilities were directly aimed at enhancing care quality, and others potentially not, and this signifies how some staff might delineate between the medical and care professional logics. Logics are not designed to be mutually exclusive, but in practice, clinicians and managers in this study often separated their work on quality of care and their work on PE. Addressing tensions between staff roles and PE practices requires an attitudinal nudge to understand both of these in one and the same perspectives, perhaps through a clarified understanding of compassionate care. In practice, compassionate care usually does not require a lot of time or resources [30]. The first principle of compassionate healthcare organizations is to provide person-centered, holistic, and compassionate care. However, this is one piece of the picture because compassionate organizations should also promote compassionate leadership at all levels, a safe and health-promoting environment, well-being and self-care among providers, caring practices, health equity and diversity, an organizational culture of compassion, patient and family engagement, and transparency and accountability when it comes to building a compassionate care system [29]. Compassionate care has the potential to bridge the medical and care professional logics where the act of caring extends beyond clinical interventions to include the psychological and spiritual well-being of patients and families.

Integrating PE in hospital reform and management

Prior research on patient-centred reform emphasizes the importance of embedding patient voices in governance, quality improvement, and performance evaluation [31–33]. However, scholars have noted that participation efforts often remain symbolic or fragmented when they are not integrated into the institutional logics that shape professional practice [34,35]. This study extends that work by demonstrating how patient engagement (PE) can become meaningful when aligned with the medical and care professional logics that guide hospital staff’s everyday activities and sensemaking.

Conceptually, these findings speak to the broader literature on institutional logics [36,37] and professional identity in healthcare [38]. Expanding the boundaries of the medical professional logic to include the relational and experiential dimensions of care reframes expertise as co-constructed, bridging the gap between clinical knowledge and patients’ lived experience [39,40]. This resonates with theories of co-production and relational professionalism, which view patients as epistemic partners rather than data sources [41,42].

From a managerial perspective, aligning different logics offers a framework for embedding PE into organizational systems. Leaders can operationalize PE values through strategic design (e.g., integrating patient insights into quality indicators), accountability structures (e.g., shared decision-making committees), and professional development (e.g., reflective practices that value experiential knowledge). Such practices echo findings from studies on organizational learning and culture change in healthcare [43,44].

At the policy level, aligning institutional logics with PE supports governance reforms that emphasize transparency, equity, and responsiveness to diverse patient populations [2,6]. By embedding the patient voice within the dominant professional framework rather than juxtaposing it against it, this approach offers a pathway for sustainable, system-level cultural change that institutionalize participatory values and promote enduring cultural change across the health system.

Implications

The findings of this study have important implications for advancing person-centred care at both theoretical and practical levels. By revealing how institutional logics shape the articulation and understanding of PE goals, this research deepens our understanding of the organizational factors that sustain or hinder meaningful PE in hospitals. It extends person-centred care scholarship by leveraging institutional logics as a framework to explain why PE activities often remain confined within professional boundaries rather than evolving into a shared governance or co-leadership model with patients and families, and other hospital staff. The study also highlights the need for hospital leaders to critically examine the dominance of medical and care professional logics and intentionally cultivate structures that balance these with public management and market logics. Fostering this balance can help build more trustworthy, inclusive, and resilient health systems where patient and family voices inform and shape hospital priorities and decision-making.

Strengths and limitations of this study

A notable limitation of this study lies at the intersection of methodology constraints, interpretive subjectivity, and the scope of document analysis. While CDA can provide insight into language use and social dynamics within an organizational context, its application in this research might not wholly encapsulate the multifaceted nature of participant perspectives. Certain nuances or contradictory viewpoints could have been underrepresented or overlooked. For example, this study found that the conceptualization of PE goals between managers and clinicians did not differ considerably. However, the difference may lie in how PE goals are operationalized and practiced. The day-to-day realities of hospital operations, coupled with the diverse professional backgrounds of clinicians and managers, likely influence the manifestation of PE goals in nuanced and potentially divergent ways. Although not captured in the current study, such potential differences in practice offer a fertile ground for further investigation. Exploring these differences in practice will not only elucidate the dynamic interplay between diverse roles within the hospital but also provide deeper insights into the operational challenges and opportunities for enhancing PE. The findings from this analysis should be considered within these interpretive limitations, acknowledging that they represent a particular interpretation of how the hospital’s PE goals are understood and articulated but not necessarily practiced.

The study’s reliance on publicly available organizational documents to understand institutional logics might have provided a constrained view. This approach was chosen because these documents represent overt, public statements that outline the identity and ambition of the organization [16,17]. Due to the overt nature of these statements and their regular inclusion in hospital communications, they are more readily accessible than other documents. As such, these public documents may better represent how an organization wants to convey its goals and values to communities and the broader public.

However, such documents might not entirely reflect the broad spectrum of operational strategies or the diverse institutional logics at play within the hospital. Analyzing internal documents might have provided additional insights into the logics at play behind the scenes. However, given the extensive scope and resources required for this analysis, it was not feasible within the constraints of the current study.

This study was conducted when the COVID-19 pandemic officially ended, and the hospital had started post-pandemic recovery activities. Furthermore, interviews from the first program were done immediately before accreditation. The pandemic’s profound impact on healthcare systems and PE practices [45] likely elicited atypical responses and scenarios, and the anticipation of accreditation probably elicited “corporate speak” in some cases. Both situations may not represent the hospital’s standard operational conditions or long-term strategies. Furthermore, the dynamic and rapidly changing landscape of healthcare—characterized by shifts in policies, technological advancements, and evolving societal attitudes—means that perspectives and experiences about the hospital’s goals and priorities could quickly evolve. This limitation suggests that the analysis presented here, while valuable, should be contextualized within the specific period in which the data were collected.

However, this timing can also be viewed as an advantage. While the study may not reflect the hospital’s standard operations, it captures a critical transitional phase in the hospital’s journey. This period is marked by an intensified focus on reevaluating and strengthening patient, family, and community engagement strategies. In delving deeply into the logics at play, this research provides valuable insights into the hospital’s PE goals from diverse perspectives. It is a unique opportunity to understand how different groups’ views can be integrated to work cohesively toward the organization’s overarching objectives. In this context, the study offers a window into the hospital’s evolving strategies and priorities, making a significant contribution to understanding how healthcare organizations can adapt and align their PE goals in response to unprecedented challenges.