The hierarchization of competing logics in psychiatric care in Sweden

• Co-existence of two competing institutional logics in psychiatry: managerial and professional.
• Actor-to-actor strategies to handle competition through hierarchization.
• Hierarchization resulted in inequal co-existence, different from previous studies.
• Managerial logic dominated gaining legitimacy from quantifications of performance.
• Quantification is legitimate in society through trust that is placed in numbers.

SummaryIn many healthcare organizations, the managerial institutional logic co-exists and competes with the professional institutional logic in the day-to-day work of managers and professionals. In its examination of the relationship between these two institutional logics at three psychiatric care units for children and adolescents, this study contributes to our understanding of the theoretical concepts and their practical implications for the actor-to-actor approaches to competing institutional healthcare logics. Many earlier studies use theoretical concepts to describe this co-existence as a relatively equal relationship between the competing logics. This study, using data from interviews, observations and shadowing, reveals the existence of a process we label “hierarchization”. In this process, the managerial logic dominates the professional logic although the latter logic still co-exists and competes, albeit in a subordinate role. The study also reveals that quantification of primarily patient throughput is used to legitimize the dominant managerial logic. Such use of quantification supports the meta-trend of placing trust in numbers.