The co-optation of managerialism: Professionals’ responses to accountability pressures

The struggle between bureaucracy and professionalism has been described repeatedly during the last 50 years. Their opposing logics are at the heart of this struggle. Bureaucracy focuses on administrative hierarchies of formal authority, subordination and control, while professionalism focuses on professional autonomy. Since professionals joined organizations, their professional autonomy has decreased while bureaucracy emerged as the more powerful force, especially when administrators renamed themselves as managers. Managerialism is both evasive and direct in its attempts to control professionalism. This is especially evident in public healthcare in the everyday work of the most powerful of the medical professionals – the physician. Theory provides two archetypical explanations of the outcomes of these control attempts: managerialism will have no influence on professional work (e.g., decoupling) or managerialism will intervene in professional work imposing bureaucratic control (e.g., colonization, resistance). These two explanations mainly describe how one of these conflicting logics “triumphs” over the other, but they fail to describe the cooperative or interactive efforts. In this paper we focus on such an interactive order and how different techniques influence the negotiated order that emerges. One technique that we especially highlight has received limited attention in organizational research: co-optation. Co-optation means absorbing new elements as a means of averting threats to stability or existence, and where the absorbing part could be an organization, or, as in our case, professionals. Since co-optation means real influence for the co-opted party, the strategy tends to lead to unintended consequences where both parties are influenced in unforeseen ways. This paper illustrates co-optation processes through a qualitative study of outcare units in child and adolescent psychiatric care (CAP) in Sweden. These units are organized in multiprofessional teams including psychiatrist, psychologists, social welfare counsellors and nurses, and are led by a unit manager. The study shows that professionals co-opt managerial logics and managerial techniques that drive their professional interests. Psychiatrists co-opt budget and resource arguments by avoiding patients who are high-risk in terms of medical failure and by enabling a strict focus on psychiatric patients and refinements in patient