Summary

For social movements, is an institutionally accommodating approach more or less likely to affect societal change than more disruptive activities? And if both approaches serve different purposes toward a common goal, how can they most fruitfully be combined? We tackle these vital questions in a context where a small patient movement advocating for patient-centric technology innovation has tackled highly entrenched institutions. We trace how this movement succeeded in affecting change through three different pathways – breaching, bridging and bonding – by distributing and intertwining relational, material and discursive social-symbolic work over time.

Pushing for patient-centric innovation

Our recent paper published in the Journal of Management Studies uncovers how heterogeneous and distributed forms of social-symbolic work combine over time to yield synergistic relationships that precipitate institutional change. We studied a group of patients and parents of children with Type 1 diabetes (T1D) who started to challenge the technological and regulatory standards of T1D healthcare. Under the hashtag #WeAreNotWaiting, the community set out to foster interoperability in T1D technology, to ‘close the loop’ between separate medical devices, and more broadly to show industry and regulators that they had to innovate alongside patients.

Radical Flank effects and Social-Symbolic work

In the social movement literature, one long-standing conundrum has been to establish whether and in what contexts radical and moderate collective action can combine to change a societal status quo. On the one hand, change needs to be acceptable to institutional incumbents or it may be quashed, so too much disruption might be counterproductive. On the other hand, if the disruption can easily be absorbed or ignored by institutional incumbents, real change may never happen. In some cases, the use of radical approaches by challengers may help the overall cause by making the moderate voices more palatable to incumbents; a phenomenon that social movement theory has termed the ‘radical flank effect’. However, research in this area has had less to say about how more or less radical practices might intertwine over time in realizing these positive effects. For this reason, we combine insights from the radical flank theory with literature on social-symbolic work to shed light on the interweaving repertoires of action that different movement actors pursue in institutional change projects over time.

Interweaving pathways of change

Our longitudinal analysis of Twitter data, interviews and observations reveals three broad social-symbolic work ‘pathways’, which proved highly complementary over time and which contributed to technological and regulatory change in T1D healthcare. The ‘breaching’ pathway included activities that disrupted industry incumbents and regulators and created pressure on them through material breach work and discursive breach work – in our case, ‘hacking’ commercial T1D technology, risking legal persecution and challenging existing regulations through broadcasting and explaining the motives behind this material work. Those who engaged in the ‘bridging’ pathway seized on this institutional breach but pursued a more moderate pathway to change; this pathway saw members collaborating with industry incumbents and regulators to co-develop T1D technology through material and relational bridge work. Situated between these two pathways and keeping them aligned around shared goals, the ‘bonding’ pathway included values work and amplification work, which corralled the community and helped sustain the collective effort.

Maintaining the pressure and accommodating incumbents

With our processual framework, we propose that this success in paving the way for patient-centric technology innovation in T1D care is because of how more radical and more moderate work types were sequenced, aligned, and integrated across the breaching, bridging and bonding pathways. In our case, this led to a change that was revolutionary in pace but developmental in scope – Micelotta et al. (2017) have termed this type of change ‘institutional accommodation’. We found that where the radical ‘breaching’ work provides impetus for change and maintains the pace and pressure for change to happen, work in the moderate ‘bridging’ pathway continually reinserts this change into institutional givens, preventing it from becoming too institutionally disruptive. We highlight the importance of the ‘bonding’ pathway as an important social glue that prevents these pathways from drifting apart over time. Overall, we draw attention to the fact that institutional change projects require multifaceted collective material, discursive, and relational work, which may often emerge organically, but which needs to be carefully aligned to affect change. Studying change in the area of patient-driven technology innovation, our case lends itself particularly well to moving beyond an emphasis on discursive change strategies by emphasizing the importance of material breach work to trigger institutional change. We define material breach work as the illicit altering of material artifacts that are central to an institution’s or organization’s practices. At the same time, we highlight how this work needs to be framed by other types of work to achieve its intended effects.

Small movements can achieve change

Our study contributes fine-grained processual insights into the radical flank and social-symbolic work literatures. But we also offer contributions beyond the academic setting by demonstrating how relatively small and resource-poor movements can impact societal challenges. We recommend that social movement actors carefully reflect on how they might distribute and sequence different types of social-symbolic work, particularly in traditionally change-resistant contexts such as healthcare. This might mean focusing on more radical breaching work first, to gain momentum, and then activating a bifurcated approach, where radical and moderate work proceeds in parallel but is tightly aligned. Bonding work is vital throughout to remind all actors of the social movement’s core values. Overall, we argue that it matters less who does what type of work (that is, whether in one social movement one is in the ‘radical’ or in the ‘moderate’ camp); what matters is that all types of work – breaching, bridging, and bonding – are pursued for change to take place.