How the interplay between institutional logics and managers' actions shapes management in a hospital in Sweden during the COVID-19 pandemic

Managers' occupy an essential role within health care organisations (HCOs) as their formal authority and positional power enable them to influence organisational processes and outcomes through the ways they act and how they shape management practices (Northouse, 2025; Yukl and Gardner, 2020). However, managers' are also embedded within the organisational structure which is shaped by different institutional logics and thus has a strong influence on how management can be performed (Ocasio et al., 2017). This article focuses on how the interplay between institutional logics and managerial actions shape management in an HCO during the COVID-19 pandemic.

Previous research on the health care sector has identified managerial logic and professional logic as the two main institutional logics (van den Broek et al., 2014; Gadolin, 2018; Arman et al., 2014). Professional logic was dominant in the public sector until the 1990s, when there was a shift to managerial logic and New Public Management (NPM) (Hood, 1995). However, professional logic was still a central part of HCOs, which made these organisations much more complex (Høiland and Klemsdal, 2022).

A sustainable body of research shows that managerial logics in terms of NPM generally have dominated the public sector and shaped management in recent decades, with managers' largely reproducing the logics in which they are embedded (Pollitt and Bouckaert, 2017). However, during a major crisis such as the COVID-19 pandemic, the interplay between managerial and professional logics seems to have been transformed. For example, several studies show how traditional hospital management was ineffective and that management subsequently underwent transformation (Ghahramani et al., 2025; Abdi et al., 2022; Leonelli et al., 2024) and that managers' roles changed from management in line with NPM to more focus on clinical work in line with professional logic (Kagan et al., 2021; Bentzen and Torfing, 2023; Vázquez-Calatayud et al., 2022).

Management during the COVID-19 pandemic was characterised by several distinct features, including an unprecedented systemic scale, prolonged uncertainty, high demand for advanced care, indecision regarding treatment, unclear guidance on protective equipment, resource shortages, repeated waves of infection, high sickness absence and skill gaps (SOU, 2022:10, Jacobsson et al., 2022). These features therefore extend and partially challenge prevailing assumptions in crisis management research, which suggest that crises give rise to conditions characterised by acute time pressure, heightened uncertainty and increased complexity (Hannah et al., 2009; Larsson et al., 2025). It further indicates that managers must adopt new work practices, rapidly reconfigure priorities, reallocate resources and make high-stakes decisions while meeting increased stakeholder expectations (Boin and Hart, 2003; Boin et al., 2013; Hannah et al., 2009; Wu et al., 2021). At the same time, management during the COVID-19 pandemic broadly aligned with crisis management research, while also exhibiting distinct features, thereby contributing to a more nuanced theoretical understanding of how crisis characteristics shape managerial practice in temporally extended events. Moreover, crisis management research still offers limited insight into how managerial transitions occur across different stages of a major crisis (Hannah et al., 2009; Wu et al., 2021).

Despite scholarly attention to institutional logics and management in HCOs during COVID-19 pandemic, empirical research on shifts in institutional logics and management remains fragmented. In particular, limited attention has been paid to how the interplay between institutional logics and managerial actions unfolds over time and how this interplay shapes both stability and changes within management in HCOs. Further, how the contextual conditions under which this interplay occurs and whether management in HCOs emerges, evolves or remains stable.

This article offers an understanding how the interplay between institutional logics and managers' actions creates both constraints and opportunities for generating organisational change or stability. Theoretically, the starting point is that managerial actions are neither fully determined by the institutional context nor entirely autonomous, but rather shaped through the interplay between the institutional context and managerial agency (Barley and Tolbert, 1997; Stones, 2005; Kennedy et al., 2021). To capture this dynamic, the article draws on strong structuration theory (SST) (Stones, 2005), in conjunction with institutional theory (Ocasio et al., 2017; Powell and DiMaggio, 1991). By linking these theories and empirically exploring the interplay between institutional logics and agency at different time points (before, during and after the COVID-19 pandemic), this article contributes with a detailed and empirically grounded understanding of stability and changes within management in HCOs.

By using interviews with managers' at different hierarchical levels in a regional hospital, the aim of this study is to contribute to an understanding of how the interplay between institutional logics and managers' actions shape management and creates both constraints and opportunities for generating organisational change or stability in a Swedish hospital before, during, and after the COVID-19 pandemic.

The article is structured as follows: The next section (Section 2) discusses the theoretical aspects of the interplay between institutional logics and managers' actions. This section also discusses how institutional theory and SST can be used as analytical tools to explore change and stability within HCOs. Section 3 describes the material and the method used for the study. Section 4 presents the empirical results and is divided into three parts: before, during and after the COVID-19 pandemic. Each part begins with the findings, which are then analysed. The final section discusses the findings of the study and outlines directions for future research, as well as the conclusions.

An institutional logic can be defined as socially constructed patterns of identities, interests, rules, norms, values, tasks and working methods which are embedded in practices and structures within an organisation. These are adopted by most of the organisations within a sector in society, so-called isomorphism (Powell and DiMaggio, 1991; Scott, 2014; DiMaggio and Powell, 1983; Ocasio et al., 2017). In institutional theory, two main logics have been identified for public management: managerial logic and professional logic (Gadolin, 2018; van den Broek et al., 2014).

Managerial logic has been described as bureaucratic with a focus on managerial control, coordination and standardisation (Ackroyd, 1996; Mannion and Exworthy, 2017; Dellve and Jendeby, 2022). Studies have also shown that it is characterised as business-like health care (Reay and Hinings, 2009), which prioritises financial accountability, efficiency and cost savings (Llewellyn, 2001; Witman et al., 2011) with a focus on quantifications (Currie and Spyridonidis, 2016). Professional logic has, in previous studies, been characterised in terms of autonomy and self-governance (Blomqvist and Winblad, 2022; Kitchener, 2002; Reay and Hinings, 2009), professional knowledge and experience (Witman et al., 2011; Høiland and Klemsdal, 2022), and need, client and relationship oriented (Arman et al., 2014; Mannion and Exworthy, 2017).

Even though institutional theory to some extent claims that institutional logics are reproduced and produced by actors within organisations (Thornton and Ocasio, 2008; Ocasio et al., 2017), it is argued that institutional theory often underestimates the role of individual actors within organisations by neglecting how actors actively respond to and sometimes resist institutional pressures (Hirsch and Lounsbury, 1997; Barley and Tolbert, 1997; Stones, 2005). Institutional theory tends to emphasise stability and continuity, which can make it less effective when trying to explain rapid management changes where organisations and managers' appear as passive entities, shaped more by external forces than by internal decision-making processes (Ocasio et al., 2017). Thus, literature based on institutional theory does not shed light on agency and conditions which shape management within organisational contexts.

Linking the theory of institutional logics (Ocasio et al., 2017; Powell and DiMaggio, 1991) and structuration theory (Giddens, 1984; Stones, 2005), and empirically exploring the interplay between logics and managerial agency within different time points (before, during and after the COVID-19 pandemic), the shaping of management within organisational contexts is made visible. Structuration theory explores the dynamic relationship between individual actions (human agency) and social structures such as rules, norms and resources (Giddens, 1984). The theory argues that social structures both shape and are shaped by individual actions. However, while institutional theory has been criticised for rendering agency insufficiently visible, structuration theory has, in contrast, been criticised for placing excessive emphasis on individual actors and so potentially underestimating the constraining power of institutionalised structures and external forces (Barley and Tolbert, 1997; Stones, 2005; Kennedy et al., 2021).

Furthermore, the abstract level of structuration theory has made empirical application challenging and made its empirical application rare as concepts such as “duality of structure” can be difficult to operationalise, leading to ambiguity in research applications (Barley and Tolbert, 1997; Stones, 2005; Kennedy et al., 2021). Consequently, the relation between structure (e.g. managerial and professionalism logics) and actors has been widely discussed theoretically, but there are few empirical studies illustrating how the interplay between the institutional context and actors has been perceived and described in real organisational settings (Kennedy et al., 2021; Barley and Tolbert, 1997; Stones, 2005).

To address the challenge of empirical application, this article draws on Stones' (2005) SST, which tries to clarify the structuration concepts for practical use in empirical settings by analytically distinguishing between external structures, internal structures, active agency and outcomes (the Method section describes how this is used as an analytic tool in this study). SST is an approach which seeks to retain structuration theory's critical insights while making it accessible for case study research and has been used in a few empirical studies within the health care sector. For example, the implementation of digital patient-clinician interplay (Assing Hvidt et al., 2021), investigating integrated care for older people and those with chronic conditions (Hughes et al., 2022), and bridging the macro–micro divide in health care governance as a theoretical example (Bodolica et al., 2016).

To summarise this section, in this article social structures, in terms of managerial and professional institutional logics, are seen to be reproduced by managers' actions within the organisation and are a prerequisite for the logics to continue to exist and prevail (Thornton and Ocasio, 2008; Greenwood et al., 2011). Drawing on Stones' (2005) SST, the study seeks to provide an understanding of how managerial and professional logics interplay with managers' interpretation and actions; and, further, how the interplay constitute management within public sector. Thus, by analysing at different time points, the focus is on how the interplay between institutional logics and managers' agency permits management to emerge, change or remain stable (Barley and Tolbert, 1997; Stones, 2005).

The Swedish healthcare sector is characterised by a decentralised governance structure comprising 21 politically independent regions that are responsible for the provision of healthcare services, including hospital and primary care. At the national level, authorities primarily exert influence through financial incentives, regulatory guidance, expert recommendations and supervisory mechanisms. During the COVID-19 pandemic, healthcare organisations established crisis management structures at national, regional and local levels. However, these arrangements did not fundamentally displace existing governance logics. Rather, they resulted in a hybrid form of crisis governance in which certain functions – particularly coordination, information sharing and resource allocation – were temporarily centralised at the national and regional levels, while operational and clinical decision-making largely remained the responsibility of organisational managers and healthcare professionals (Saunes et al., 2022; SOU, 2022:10).

In this study, a major hospital in one region, which was at the centre for organising and providing care and treatment for COVID-19 patients, was selected. At the hospital, there were four managerial levels: closest to core operations were first-line managers' (FLM), second-line managers' (SLM) led separate units, third-line managers' (TLM) headed several units clustered as divisions, and at the top there was the director who was directly accountable to the politicians.

As stated above, empirical research on shifts in institutional logics and management remains fragmented, with limited attention to how the interplay between institutional logics and managerial actions unfolds over time and how this interplay shapes both stability and changes within public management. To explore and illustrate how this interplay shaped management across different time periods, the study is structured around three stages of the COVID-19 pandemic: before, during and after.

This study consists of 15 interviews with 9 FLM, 4 SLM and 2 TLM. The respondents were chosen because they were all involved and responsible for building up or reorganising existing wards in the hospital to receive and treat all COVID-19 patients coming from the geographic region during the pandemic. Managers' from all levels in the hospital were selected to ensure a broad spectrum of perspectives and experiences, and to gain a deeper and more thorough understanding of how the respondents perceived the management within the organisation. For reasons of integrity, the highest director in the region was excluded.

This article is based on a qualitative study, with data collection inspired by narrative in-depth interviews (Anderson and Kirkpatrick, 2016). This approach was chosen for its capacity to capture a detailed understanding of complex phenomena, such as decision-making outcomes and how these shape managerial action, by foregrounding participants' own voices and experiences.

All interviews were conducted in 2023 and accomplished within 4 months, with each interview embracing all the stages of the COVID-19 pandemic. Ethical approval of the study was not required when conducting the interviews. However, the data collection followed common ethical approach standard. The interviews were semi-structured, lasted between one and two hours, and were recorded. At the beginning of each interview, ethical considerations were highlighted, which included providing information about the study's objectives, how confidentiality would be assured, and affirming that the participant knew of their right to withdraw from the research.

Several studies have examined how decision-making processes changed during the COVID-19 pandemic, highlighting, for example, the use of different decision-making models and the ways in which actors' interests were articulated and negotiated in formal meetings (Romiti et al., 2025; Liem et al., 2025; Johnson et al., 2023). In these studies, analytical attention is primarily directed towards the decision-making processes themselves. The present study adopts a different perspective. Rather than focusing on how decisions were reached, this article examines the outcomes of decision-making and how these outcomes shaped managerial action. In this respect, the study aligns more closely with earlier organisational research that emphasises the consequences of decisions for organisational practices (Yukl and Gardner, 2020; Ocasio et al., 2017; Stones, 2005), rather than the procedural dynamics leading up to them.

The interviews were designed to explore how the managers' at different levels within the organisation perceived management in formal arenas and how this shaped their own management and actions. To illustrate the distinct periods, each interview was divided into three parts – before, during and after the COVID-19 pandemic. At each stage, the managers' described which arenas they were participating in within the organisation, what issues were included within these arenas and how these influenced their own management and actions. This revealed the manager's perception of the institutional logics at hand and how this interplayed with the manager's actions in shaping the organisational management.

By using semi-structured analytic interviews, there was flexibility in questioning which permitted adaption of the interview guide based on participants' responses and so enabled exploration of emerging themes, clarification of responses, follow-up on interesting leads and the exploration of unexpected avenues of inquiry (Mason, 2018). This also provided the opportunity to seek clarification or elaboration on participants' responses, ensuring a more comprehensive interpretation of the data and thus reduce ambiguity.

The study's reliance on self-reported data and retrospective accounts may introduce biases and limitations inherent to this type of research (Julie Wolfram and Hassard, 2007). The sample size may not fully capture the breadth of perspectives within the population of interest. At the same time, all the respondents were involved in the work to reorganise the organisation and establish COVID units in the hospital. Moreover, the interviews showed there was an overwhelming similarity in the answers both within and between the groups of FLM, SLM and TLM, which can strengthen the perception of the majority of the managers'. Furthermore, the findings in this study are context-dependent, which may limit generalisation to other health care settings.

This study draws on Stones' (2005) SST by analytically distinguishing between external structures, internal structures, active agency and outcomes. The external structures are conditions for action and are defined by two types of structural forces. The independent casual is entirely beyond an actor's influence, to resist or control, in any meaningful way. The second force, the irresistible causal, is when actors have some capacity to resist or influence but must be in a position and have adequate power, knowledge and critical distance in order to act. In this study, the irresistible force is the managerial and professional logic described in the institutional theory.

The internal structures are what managers' (agency) know and perceive about the situations and the position relations they have in the organisation, as well as the norms and rules embedded in their position. These internal structures are shown in the interviews. Furthermore, the interviews investigated the focus on formal arenas, and how this shaped organisational management, particularly the interplay between the institutional logics and the managers'. The results of the interviews were thematised (see below) to reveal what logic was at hand: more focus on financial aspects and bureaucracy indicated managerial logic, while emphasis on autonomy and self-governing implied more professional logic.

Active agency is how managers' perceive how the structures and their position relations can either facilitate or constrain their possibilities and purposes to act (Stones, 2005). Further, it also encompasses whether the outcomes are about both the short term, affecting the immediate situation, and the long term, where structures will be reproduced and stability maintained or transformed and so create change within an organisation (Stones, 2005). Hence, SST combined with institutional theory is used to analyse the empirical data.

This study employed a thematic and abductive analysis across the entire dataset, as well as an analysis of the different stages of the COVID-19 pandemic. By structuring the results around these stages – one of the aims of the study – the analysis provides a comprehensive description of the characteristics of each period and visualises the contrasts between the three phases of the crisis, thereby illustrating how organisational change and stability unfolded over time.

The thematic and abductive analysis began with a thorough reading of the transcribed interview material to gain a comprehensive understanding of its contents. Following these readings, coding was initiated using a method influenced by thematic analysis (Braun and Clarke, 2021). Subsequently, a more targeted approach was adopted where passages were extracted and compiled into a separate document which illustrated which institutional logics (structure) were at hand and how these interacted with managers' actions (agency) and, thus, how this shaped the organisational management. The components were then organised into subcategories, serving as the foundation for further analysis. By using abductive analysis, there was iterative cycle moving back and forth between empirical data and the theoretical framework in order to generate the most plausible explanations for the observed phenomena (Dubois and Gadde, 2014; Alvesson and Kärreman, 2011). The subsequent phase involved refining these categories into broader conceptualisations. Here, attention focused on category names and corresponding passages, which were grouped into distinct themes.

Furthermore, to provide interpretative richness and enable a nuanced exploration of participants' perspectives and meanings, this study employs extended empirical quotations, which serve as thick descriptions (Geertz, 2025) illuminating managers' perceptions of key issues within formal arenas and demonstrating how decision-making outcomes shaped their managerial actions.

Subsequently, the qualitative research design was chosen to be able to detect and analyse managers' perceptions of how the interplay between institutional logics and managerial actions unfolds over time and how this interplay shapes both stability and changes within HCSs. The selected quotes in the study are representative of the managers' perceptions and illustrate the basic findings of the material; it should be noted that there was an overwhelming similarity among the managers' responses.

By using three distinct periods, this study identified shifts in management over time and demonstrated how the interplay between structure and actors varied across these periods and so illustrated how management emerges, changes or remains stable. The findings capture managers' perceptions with focus on formal arenas and how these shaped organisational management. The results were thematised and revealed which institutional logics dominated at different stages of the crisis. To offer a detailed understanding of what these shifts display, the findings are divided into three parts: before, during and after the COVID-19 pandemic. Each part begins with the findings, which are then analysed.

Regarding the managers' perception of how management was shaped by the interplay between institutional logics and managers' actions, the findings indicated that managerial logic was reproduced within the organisation. The findings have been categorised into the following themes: (1) focus on financial aspects, production and information and (2) hierarchical organisation and weak coordination.

All respondents described that in formal arenas where higher and lower managerial levels meet, usually once a month, there were generally the same focal points on the agenda. The quote below illustrates this.

The managers' emphasised that there was a strong focus on financial aspects, production and information distribution. Further, the managers' at all levels described that they had almost the same content and structure when they distributed information down through the organisation in their own formal arenas.

The SLM and TLM had more focus on financial aspects, production, and varying information from the technostructure, such as the finance and HR departments, within their formal arenas. However, the FLM described that they mainly had two different arenas within their own unit and which focused on different issues. First, when they met all the personnel, this meeting followed the same basic structure as the SLM arena, i.e. mainly focused on information sharing, financial aspects and production. However, in the second arena, which included different professional groups such as nurses or assistant nurses, the focus was on improvements, care and treatment, patient safety and the working environment.

The respondents at all levels described how information, which mainly included financial aspects, production and general information, was passed from one managerial level to the next vertically down through the organisation. The managers' also said that the information and bottom-up communication followed the same linear path; FLM reported to SLM who reported to TLM and so on. The quote below illustrates this.

Thus, the managers' perceived that all information flow was linear and was strictly organised vertically among the different managerial levels. Furthermore, the respondents at all levels described that the budget, production and other major issues were decided high up in the hierarchy. The respondents emphasised that it was generally not possible for lower managerial levels to affect decisions about finance or production.

Particularly, the FLM mentioned that they did not have the authority to take decisions for their own unit if it had any negative effect on the finances, e.g. hiring personnel. In this case, they had to go to their manager to obtain both approval and a formal decision. At the same time, the respondents said that they could act relatively freely within the budget assigned to their unit, although the manager on the next level down perceived this as limited, stating that there was no possibility of influencing it.

However, on occasion, the respondents described that there were meetings with managers' from several levels at the same time in the same arena. These, however, were usually only once or twice a year when, for example, the organisation was facing summer vacation with critical personnel planning, there were not enough personnel, units needed to be closed, etc.

This study showed that respondents perceived a strong focus on production, financial aspects and information distribution within the formal arenas at all levels. These findings align with managerial logic characteristics which have been described as business-like health care (Reay and Hinings, 2009) prioritising financial accountability, efficiency (Kitchener, 2002; Llewellyn, 2001; Witman et al., 2011) and focusing on quantifications (Currie and Spyridonidis, 2016). This indicates that overall managerial logic shaped the organisational management with some exceptions for the FLM who worked in arenas with the professions and acted in line with professional logic.

The study also showed that the organisation was seen as hierarchical and operating in a linear manner in line with the managerial logic ideas of bureaucracy and focus on control (Mannion and Exworthy, 2017; Dellve and Jendeby, 2022). This not only shaped management actions but also conditioned and constrained managers' possibility to act in areas such as finance, production and information. Furthermore, the main issues were predominantly controlled by top management, which managers' felt limited the possibility to influence which would have effect at their management level.

The findings in this study indicate that the TLM ostensibly occupied a position which gave them more requisite power, knowledge and critical distance to challenge or transform prevailing managerial logics, yet they did not do so. However, the SLM and FLM did possess adequate knowledge and sufficient critical distance to act, but they did not seem to perceive such action as either possible or within their scope of authority, given that their position was embedded within a hierarchical organisational structure shaped by managerial logic.

At the same time, there appeared to be little explicit reflection among managers' about alternatives to managerial logic. One explanation for this lack of reflection may be that the managerial structure has become deeply internalised across all managerial levels, to the extent that it was perceived as self-evident and unquestioned. As a result, alternative approaches to management were neither actively considered nor problematised. Instead, this study indicates that managerial logic was experienced as routine and conventional practice, normalised through longstanding use and tacitly accepted by managers'.

Consequently, this study's findings indicate that the structure in terms of managerial logics was dominant and shaped the managers' actions and organisational management. This constrained managers' possibilities to act in significant fields and so created stability of the organisational structure.

Regarding the managers' perceptions of how management was shaped through the interplay between institutional logics and managers' actions, the findings indicated a change to professional logic within the organisation. The findings have been categorised into the following themes: (1) decentralisation with autonomy and focus on professional knowledge and (2) horizontal and vertical arenas for cooperation. This section will, however, first begin with a brief description of the characteristics of the COVID-19 pandemic.

The COVID-19 pandemic placed health care services in a completely new situation in several respects, and the organisation had to deal with a situation never faced before (Jacobsson et al., 2022). What was unique for the COVID-19 pandemic was the number of patients who needed advanced care, the uncertain knowledge of how covid patients should be treated and for how long, what protective equipment should be used, a lack of operationally critical material, a protracted process in several waves over a longer period of time, extensive sickness rates among healthcare staff and a lack of competence, as well as changed material distribution and prioritisation within the organisation (SOU, 2022, p. 10).

The respondents emphasised that when the COVID-19 pandemic broke out, the entire situation for the HCO changed rapidly and was basically reorganised to build up capacity to receive the great numbers of COVID-19 patients coming into the hospital. The FLM and SLM described how they were responsible for building up that capacity in a very short time. The FLM emphasised that they had great freedom to act, there were few restrictions, and they had almost a full mandate and responsibility to reorganise or start new COVID units.

The FLM strongly emphasised that they were trusted by superior managers', and were self-governing, i.e. they could act freely to take action, not having to seek managerial approval for the majority of their decisions. The SLM said they supported the FLM and the professions to act freely. Furthermore, the FLM said that when they needed a decision, the organisation was characterised by short paths and quick responses. The respondents, particularly the FLM, said that they had confidence in each other and the priorities which were made, and that the professions were also given full responsibility, trust, and a mandate regarding how to treat and care for the covid patients. However, a few FLM expressed some dissatisfaction and disappointment that they were left alone with the bulk of the work.

The respondents described that two new arenas were organised to handle the new situation.

One arena was organised horizontally, initiated and managed by the FLM where they met almost daily during the first wave of the pandemic.

In the arena where the FLM met, they said they shared information and tried to create a common understanding of the situation day by day. The FLM also said they tried to coordinate and cooperate with, different issues, forming consensus regarding different tasks and problems they were facing, such as guidelines, how they should organise covid patient treatment and care, what protective equipment personnel should wear, staffing, planning and so on. The FLM also highlighted the importance of this arena to support each other and to share thoughts and feelings about the totally new situation they had to deal with. They described their collaboration as close, communicative and informative.

After a while a vertical arena was organised where managers' from different levels of the organisation met regularly with the main focus being on sharing information, creating a common understanding of the current situation and coordinating the overall concerns and issues in order to make significant priorities and direct quick decisions. This meant that the vertical structure was basically intact but was organised in a different manner.

During the COVID-19 pandemic, in terms of external structure, the independent casual force (Stones, 2005) was entirely beyond the actors' influence in any meaningful way and they had to accept the challenges it brought to both society and the organisation.

At the beginning of the COVID-19 pandemic, the managers' said they did not really know how to manage the new, uncertain and fast changing situation, and it seemed as though management, in line with managerial logic was insufficient for managers' to act quickly in an appropriate way to meet the challenges and rapid change. To handle the situation, the top managers' gave the SLM and, in particular, the FLM mandate, trust, responsibility, a high degree of autonomy and minimal restrictions to act and so relied largely on their and the professions' expertise to handle the change. These characteristics are also in line with how professional logic has been characterised in terms of autonomy and self-governance (Blomqvist and Winblad, 2022; Kitchener, 2002) and professional knowledge and experience (Witman et al., 2011; Høiland and Klemsdal, 2022). Hence, this study indicates that the perceived organisational management during the COVID-19 pandemic can largely be described in terms of professional logic.

Furthermore, the new logic not only facilitated and enabled the FLM to take actions and create conditions for new ways of organising their units but also led to the development of new arenas to enable organisational collaboration, coordination and collegiality, which was perceived as close, communicative, and informative. The new arenas were described as efficient, providing a shared understanding of the situation with short communication paths and rapid responses across all organisational levels. Even though the most important decisions were always made in the line organisation, these were mainly in arenas where several managerial levels were present at the same time.

In addition, managers' at all levels accepted the change from managerial to professional logic, which both created the conditions for and enabled the FLM and the professions to handle the pandemic. Managers' at all levels had the knowledge and critical distance to act, although the power to change came from the top and was distributed down to the FLM and the professions.

Consequently, the interplay between the structure and agency indicates that the external structure (COVID-19 pandemic) influenced and formed the base for the actors to act differently and exchanged managerial logic for professional logic, which created a change in the organisation, i.e. a new structure.

Regarding the managers' perception of how management was shaped by the interplay between institutional logics and managers' actions, the findings here are categorised using the same themes as those in the “before the COVID-19 pandemic” section.

The respondents said that after the COVID-19 pandemic, almost everything went back to how it was before the crisis. They described how the organisation reverted to a hierarchical and centralised structure with centralised and vertical thinking, a strong focus on financial aspects and production, and started to operate in distinctive silos again. One respondent emphasised that during the COVID-19 pandemic:

The respondents described how the HCO reorganised back to its broad health care mission to provide a vast range of different treatments and patient care in parallel processes in the same way as before the COVID-19 pandemic. The managers' also said that there was a huge backlog of cancelled treatments which the organisation had to deal with while, at the same time, handling new patients. There was also a lack of personnel, which increased both the workload and created stress. Furthermore, the respondents said that the new arenas which had been created during the pandemic, where different levels of management met to share information and communicate, faded away. The vertical arena, when FLM, SLM and TLM meet together generally only for issues such as summer and winter vacation staffing, did however still exist.

This section is, in general, identical to the analysis of managers' perceptions of management before the COVID-19 pandemic. These aspects have been described and analysed in depth above and, thus, a short analysis of the results in this section will suffice.

All respondents described that the organisation went back to being hierarchical with a focus on financial aspects, production and characterised by weak intra-organisational cooperation which aligns with how managerial logic has been described in previous research. This study indicates that the perceived organisational management can, largely, be described in terms of managerial logic.

The study showed how this logic shaped management actions and both conditioned and constrained managers' capacity to act in areas such as finance, production and decision-making. Furthermore, the key issues were predominantly controlled by top management, which lower level managers' meant limited their possibility to act in their own units.

The results indicate that top management made a conscious decision to regain control and power by reinstating a managerial logic. At the same time, pressure from citizens and wider society – and consequently from politicians – to address the large number of patients whose treatments had been postponed during the COVID-19 pandemic also contributed to a shift back towards familiar, previously established organisational structures.

Although the FLM and SLM managers had sufficient knowledge and critical distance, they did not perceive themselves as having the power to act. In additional, FLM were reluctant to revert to a managerial logic as it would limit their capacity to influence the key issues. However, managers' at all levels showed little reflection on why they reverted to, and acted within the perceived constraints of, managerial logic. The structure before the COVID-19 pandemic appeared deeply internalised and as a conventional and unquestioned approach to handle a complex HCO, and was again widely accepted by managers' despite their experiences during the COVID-19 pandemic.

Consequently, this study shows that after the COVID-19 pandemic, managerial logic came back and replaced professional logic. Hence, the interplay between the structure and actors shows that the actors changed the structures and reinstalled the old managerial logic. This organisational change illustrates the return of the old organisation.

A comparative Table 1 summarising the main findings across the three analysed periods is presented below.

The aim of this study is to contribute to an understanding of how the interplay between institutional logics and managers' actions shape management and creates both constraints and opportunities for generating organisational change or stability in a Swedish hospital before, during, and after the COVID-19 pandemic.

The findings of this study reveal a sequential shift in institutional logics during the stages of the COVID-19 pandemic. The first stage was dominated by managerial logic, which was reproduced by managers' although it constrained their actions and led to stability in the organisation. This is basically in line with institutional theory and how structures create stability over time in organisations (Thornton and Ocasio, 2008; Ocasio et al., 2017). However, during the COVID-19 pandemic, the managers' replaced managerial logic with professional logic, which enabled the managers' to act and so create change within the organisation. This aligns with structuration theory, which holds that managers, as actors, exercise their agency and can reshape the structure (Stones, 2005; Giddens, 1984). After the COVID-19 pandemic, the managers' changed the logic with managerial logic being reinstalled which, once again, constrained managers' ability to act and, ultimately, led to the return of the old organisation. These shifts in management illustrate how structures and actors are mutually constitutive (Giddens, 1984; Stones, 2005) and how the relative strength of institutional logics and agents varies across different conditions in each phase of the crisis.

This study also contributes to an understanding of how the conditions present in different stages of a crisis shaped management. The findings indicate that, before the COVID-19 pandemic, the conditions that maintained stability were rooted in a long-standing dominant logic: hierarchy, centralised and formal decision-making, and working in silos had been internalised by managers'. No alternative management logic was discussed, and both the internal and external environments were relatively stable.

During the COVID-19 pandemic, the results indicate that the conditions generating change were driven by the new and uncertain situation with one goal, rapid change and the urge to act fast. This together with unlimited financial resources but limited access to equipment and materials and having to build up capacity quickly, proved that prevailing managerial logic was insufficient to handle the new situation and that the characteristics of professional logics were more appropriate.

The period following the COVID-19 pandemic saw the organisation reverting to the handling of multiple assignments and having to cope with a huge backlog of patients. At this time, there was no direct reflection or ambition for alternative management or organisation as the characteristics of managerial logic were so deeply internalised for the work within a complex HCO and, so, it was easy to revert back to that logic.

Theoretically, the crisis is an example on how continuity and change in public management emerge from the interplay between institutionalised logics and situated managerial action. Rather than viewing organisational change as either the outcome of strategic choice or structural constraint, the analysis thus shows how moments of crisis temporarily widen the scope for agency, while post-crisis conditions tend to reinforce established institutional arrangements.

The findings from the periods before and after the COVID-19 pandemic align closely with the principles of NPM, which has been the dominant public sector management paradigm since the 1990s (Pollitt and Bouckaert, 2017). The fact that top managers actively reinstated this logic after the pandemic further illustrates its enduring influence and institutional strength. This persistence may help explain why it has been challenging for public sector organisations to complement or shift away from NPM-oriented practices. At the same time, the management practices that emerged during the pandemic resonate with ongoing debates about the limitations of NPM and the increasing efforts within the public sector to move towards more trust-based forms of governance (Elmersjö and Sundin, 2021; Bentzen, 2019). The present study identifies several conditions that enabled such a shift during the crisis, suggesting that alternative management ideals may gain traction when institutional constraints are temporarily loosened. These factors merit further investigation, as they may provide important insights into how more trust-based and professionally grounded management approaches can be developed and sustained beyond crisis contexts.

Regarding the interplay between structure and agency, future research could further investigate the conditions under which structural forces exert greater influence than actors in shaping organisational stability and change across diverse contexts, while investigating which conditions actors possess for greater influence and the ability to modify existing structures. Comparative studies across organisational settings and crisis types would be particularly valuable to understand when actors can override structural constraints and where structure constrains actions in public organisations and other complex institutional contexts.

Moreover, this study has shown that structure is not only institutional logics, but also the position practice relations managers' have within the organisational structure (Stones, 2005; Abdelnour et al., 2017). During the COVID-19 pandemic, the top management was dependent on the FLM and professions to handle the situation. During the pandemic, the findings showed a substantial redistribution of power from upper management to FLM and the professions, but this power was largely re-consolidated back at the top management level after the pandemic. One interpretation for this change can be that, after the pandemic, top management used managerial logic to consolidate their power in relation to the FLM and professions who had more power during the pandemic. The perception of reverting to managerial logic after the pandemic varied depending on the manager's position within the organisational hierarchy. In particular, the FLM were not so keen to go back to managerial logic as it would weaken their power to influence decision-making. Thus, this study indicates that structure is not only institutional logics but also organisational structure where the actors' hierarchical positions can take away other actors' possibilities to act. Consequently, future research could examine how managers' hierarchical positions and management practices constrain the adoption of alternative management forms, such as professional logic and trust-based management, and how this reinforces their authority in relation to FLM and professional groups.

This study was conducted within a regional hospital in Sweden, employing a qualitative research design. Consequently, the generalisability of the findings cannot be established. Nevertheless, the findings of this study should be regarded as a partial contribution to the wider body of knowledge and serve as a foundation for further inquiry. The selection of the region and respondents may affect the scope and interpretation of the findings, and one limitation of the study is that the highest director was not interviewed. As some of the literature indicates, during crises managers often centralise decision-making – either due to their management style or in order to respond rapidly to emerging demands – thereby limiting the vertical chain of command and affecting the work of line managers (Romiti et al., 2025). In contrast, in the present study all TLM consistently emphasised the formal decision-making arenas involving the highest director, which aligns with the overall findings indicating a shift from centralisation to decentralisation and back again. These shifts were also perceived by all managers' within the organisation.

The practical implications in this study highlights for example trust-based management, use of knowledge from the professions and the emergence of new arenas for shared understanding of situation during the crisis as potential levers for improving organisational efficiency if integrated into non-crisis contexts. The study also offers practical insights into how management and organisations evolve, change or remain stable over time, and contributes to a greater awareness of strategies that can enhance organisational capacity to prepare for and respond to uncertain, demanding and complex situations.

The study also contributes theoretically by integrating SST with institutional theory to enable and visualise a sequential analysis of institutional logics. It further demonstrates how this combined theoretical approach can be applied within management research in the healthcare sector. This study also refines crisis management theory by showing how a combination of factors fostered resilience during a major crisis characterised by an unprecedented systemic scale, prolonged uncertainty, high demand for advanced care, unclear guidance on protective equipment, resource shortages and repeated waves of infection thereby extending existing frameworks that predominantly assume more temporally bounded crisis contexts. Central to this resilience was trust in FLM to manage rapid changes in core processes, establish new horizontal and vertical arenas for the immediate sharing of information, and facilitate rapid, coordinated decision-making and action. This highlights how decision-making authority and coordination mechanisms may shift in scope and significance under pandemic conditions compared with more conventional crises.

The authors want to thank the colleagues at Department for Work Science at Dalarna University for their insights and valuable comments on the manuscript and the major Hospital in a Region in Sweden that made it possible to carry out the study.