management control system research paper

A Taxonomy of Management Controls in Management Control Systems Research

28 Pages Posted: 8 Nov 2019

Hitotsubashi University Business school

Date Written: October 29, 2018

Research on management control systems has recognized that multiple management controls operate together in business practices. Also, some frameworks that combine various management controls together have been developed to capture business practices. However, research dealing with a combination of management controls, which explicitly explains each management control and how they are combined, is lacking. In this paper, a review of several recent-year-developed works that deal with constructing management control systems frameworks will be presented to highlight these shortcomings, specifically: (1) unclear explanations about the concept of management controls and management control systems, (2) ambiguous relationships between management controls, and (3) not considering management controls comprehensively in a framework. Also, considering that various definitions for management controls and management control systems exist, a single definition will be proposed as a premise of this paper. A list of 40 management controls will be made, followed by a taxonomy of management controls, based on methods used to capture business practices in the existing research. Management controls will be classified into six variables: environment, technology, organizational structure, use of management control systems, culture, and MAS. Relationships between management controls, relationships between variables and management controls, and treatment of some special management controls, will be discussed. Finally, how this paper overcomes the shortcomings of existing work and how it refines existing control frameworks and theory will be noted.

Keywords: management controls; management control systems; taxonomy; framework; theoretical research

JEL Classification: M40, M41

Suggested Citation: Suggested Citation

Zhe Shang (Contact Author)

Hitotsubashi university business school ( email ).

2-1 Naka Kunitachi-shi Tokyo 186-8601 Japan

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Management control systems and innovation: a case study grounded in institutional theory

• Original Paper
• Open access
• Published: 18 February 2023
• Volume 34 , pages 109–133, ( 2023 )

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• Rúben Silva Barros   ORCID: orcid.org/0000-0002-1170-3356 1 &
• Ana Maria Dias Simões da Costa Ferreira 1  

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Drawing on the growing literature that has addressed the role of Management Control Systems in innovation and the literature on institutional theory, this study explores the case of Amorim Cork Composites to analyse how the situated rationalities within the company get reflected in the management control practices in use, and then how these practices are used to communicate and provide guidance when innovation is part of the strategy. The study uses a single case study approach at an innovative company, collecting data from 32 interviews, direct observations, and documentation of the company. Based on that data, this study is able to perceive the existence of a rationality that is constructed around the importance of innovation, which becomes a paramount part of the defined strategy and leaves signs on to the internal control practices of the company. After that, through a mix of strategic objectives, well-defined cascaded process of these objectives, values, mottos, objectives related to that situated rationality within the company, and with the commitment created within the “signing” of objectives contracts, managers are able to communicate strategically and provide guidance to the collaborators, driving them to action that makes them more aware.

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1 Introduction

The conceptual approach of institutional theory has provided a focal point in many accounting studies as it is considered helpful for understanding a phenomenon, taking into consideration the social-cultural contexts (Moll et al., 2018 ; Ribeiro & Scapens, 2006 ; Lounsbury, 2008 ). Recently, ter Bogt and Scapens ( 2019 ) revisited Burns and Scapens’ ( 2000 ) framework, and extended it. One of the alterations is the introduction of the notion of situated rationality, which essentially constitutes the way actors think and rationalize what they are supposed to do in a given situation (ter Bogt and Scapens, 2019 ). Situated rationalities are expected to shape the rules and routines of the company (ter Bogt and Scapens, 2019 ), and by analogy the Management Control Systems (MCS) in use within the company. As it is a concept that is still little explored in the literature, Bertz and Quinn ( 2022 ) suggest that the situated rationalities need to be considered in greater depth.

Notwithstanding, the acknowledgement and recognition that these systems are shaped by the situated rationalities has been quite absent from the literature on MCS and innovation, as well as the recognition of the influences of institutions in an innovation driven context. Furthermore, MCS are by definition routines to maintain patterns (Simons, 1995 ), to coordinate (Müller-Stewens et al., 2020 ; Pagliarussi & Leme, 2020 ), convey information for decision making (Simons, 2014 ), and are able to frame cognitive models and communication patterns (Davila, 2005 ; Davila et al., 2009b ). Nevertheless, how strategic communication and guidance is provided when innovation is paramount in strategic terms is very much an unexplored domain. In response to this lack of investigation this study merges the two research literatures and explores the case of Amorim Cork Composites (ACC), a developer and manufacturer of cork-material products. ACC’s case allows us to analyse how the situated rationalities within the company become reflected in the management control practices and how these practices are used to strategically communicate and provide guidance when innovation is part of the strategy.

An in-depth, intensive, and interpretative case study on ACC was undertaken to allow a grounded and fine-grained assessment of their MCS and surroundings in a real-life context, with all the specificities and rich descriptions that are inherent to this research approach (Ryan et al., 2002 ). ACC is the innovative arm of a large Portuguese industrial group employing a solid use of management control practices. Besides having a strong history and culture regarding innovation, ACC has implemented the Balanced Scorecard (BSC) methodology since 2003. Since then, this methodology has been used by its managers as a tool to implement and revise strategy over time. With the stability thus gained, it has been possible to ensure an advanced state of institutionalization of these practices. Data for the study were collected from several sources: interviews, documents, observations of meetings, and visits to the company. Of these, the main source of data was the 32 interviews with various employees from different hierarchical levels. Thirty-one of these interviews were recorded and transcribed, which allowed further analysis with the qualitative software MAXQDA.

Also, for all purposes, this case study borrows ACC’s understanding of innovation. Innovation at the case company is perceived as the creation of a new product in which cork can provide additional value, a different application for an existing product or an existing application of cork, a transfer of products between segments, or simply the development of a new product for the portfolio. In broad strokes, the main form of innovation experienced in ACC is product innovation.

Based on this background, the results of the present study allow us to make contributions to both practitioners and the two bodies of literature here presented. First, perceived at the case company is a situated rationality, that is termed “innovation”, concerned with having a sustainable delivery of value through the development of new products creating opportunities and value for the raw material cork. Our results also allow us to contribute to the literature on MCS and innovation, by highlighting the important role that MCS may play in communicating and providing guidance to the organizational members’ actions relating to innovation. As mentioned above, the manner(s) in which strategic communication and guidance are conducted is quite absent from this body of literature, and the case of ACC provides valuable insight and evidence in this area. It is shown that through the inclusion of strategic objectives that are subsequently cascaded in a well-defined structure, values, mottos, and objectives related to the situated rationality identified within the company, managers are able to communicate strategically. With these characteristics of the cascading process and the commitment from the “objectives contracts” managers imprint guidance on the awareness and accountability of the collaborators.

Indeed, with these points it is possible to contribute to calls in the management accounting and control literatures to further explore matters related to control and innovation (e.g., Chenhall & Moers 2015 ; Moll, 2015 ; Fried, 2017 ; Major et al., 2018 ; Barros & Ferreira, 2019 ) and to calls to address these matters with qualitative research methods (Henri, 2006 ; Barros & Ferreira, 2019 ).

In a more modest way the study also contributes to the literature on institutional theory and on the ter Bogt and Scapens framework by showing how the identified situated rationality of “innovation” is reflected in the MCS. Also, exploring the unique solutions that the managers at the company adopted, it is argued that these systems are able to work in maintaining an existing rationality within the company. Maintenance is also promoted by the strategic communication and guidance that these systems provide. In other words, maintenance also strengthens the commitment to innovation of the collaborators within the company.

This study can also be of interest to practitioners in the sense that it reveals some details of the control practices used and how they incorporate the strategic imperative of innovation.

The rest of the paper has five more sections. The next (Sect.  2 ) reviews the institutional theory literature and the earlier literature on the role of MCS on innovation. Section  3 explains the research methods, the data collection process, and how the data were analysed. Section  4 presents the case company and the results of the study. It identifies the situated rationality, discusses how that rationality is reflected in the management control practices adopted and how they are used to communicate and provide guidance. Section  5 has a discussion about the case. Section  6 provides the conclusions, limitations, and some possibilities for future research.

2 Theoretical background and literature review

2.1 institutional theory: from burns and scapens ( 2000 ) to ter bogt and scapens ( 2019 ).

Institutional theory has been a dominant approach for understanding organizations (Greenwood et al., 2008 ). According to institutional theory, organizational behaviours or individual thoughts and actions are influenced by institutions (DiMaggio & Powell, 1991 ; Ribeiro & Scapens, 2006 ), with rationality being constrained by institutionalization (DiMaggio & Powell, 1991 ). Certainly, an institutionalist considers that action must be perceived as constituted by institutional rules and beliefs (Lounsbury, 2008 ), and that the current actions of individuals are the result of past actions (Wickramasinghe & Alawattage, 2007 ).

When introduced to the field, institutional theory was thus a way to help understand how and why individuals respond in a particular way to management accounting and control practices (Scapens, 1994 ; Burns & Scapens, 2000 ; Wickramasinghe & Alawattage, 2007 ). One of the first streams mentioned in the literature is old institutional economics (OIE), with its strength in explaining the constraining of practices by structures like institutions, rules, and routines (Oliveira & Quinn, 2015 ), or why and how certain behaviours emerged, are sustained, and change (Moll et al., 2018 ). Based on this stream, and to help developing the understanding on how management accounting practices change, Burns and Scapens ( 2000 ) introduced a framework to describe these processes. In that framework, through encoding, enacting, and the reproduction of rules and routines, practices become institutionalized (Burns & Scapens, 2000 ).

In the proposed framework, Burns and Scapens ( 2000 ) highlight that institutions shape action, and that action is produced and reproduced over time. In their graphic representation of the framework, at the top we have the institutional realm connected to the realm of action by rules and routines. Rules and routines first encode the institutional principles. These rules and routines are then enacted at a second moment by actors, typically as a result of tacit knowledge and reflexive monitoring. At a third moment, routines are repeated and may be changed in a conscious or unconscious manner. Finally, institutionalization of the rules and routines that were reproduced by individuals is achieved. Through institutionalization the authors explain that management accounting has the potential “ to underpin the ‘taken-for-granted’ ways of thinking and doing in a particular organization ” (Burns & Scapens, 2000 : 5). In this framework, as observed by Bertz and Quinn ( 2022 ), management accounting has the potential to change in an organization over the long term, in slow motion, and in an evolutionary way.

However, with time researchers have identified issues with the framework. Some further studies have developed the model or some of its concepts even further (Quinn, 2011 ; Oliveira & Quinn, 2015 ; ter Bogt and Scapens, 2019 ). Recognizing the existence of issues with B&S, ter Bogt and Scapens ( 2019 ) improved the original framework, bringing it up to date with the more recent streams of institutional theory. The authors account for issues regarding the role of broader institutions and the tensions that arise between institutions and the organization, and at a broader level issues regarding trust, power, and agency in accommodating change. In improving the framework, the two core realms of the original version are maintained (Fig.  1 ) but the newer version allows that there are institutions located both inside and outside the organization. Broader institutions will shape the local institutions (without a hierarchical way of thinking) that are also shaped by the past experiences and history of the organization, groups, and individuals. Together these institutions shape the situated forms of rationality (a new concept) within the organization. Then, institutions and the situated rationalities affect routines. Also included in the framework are the generalized forms of practice that have the potential to also affect routines in the mimicking of practices – but more likely they affect rules. This is represented by the arrows in the model connecting all these boxes with the concepts. In the end it is the interaction between situated rationalities, rules, and routines that shapes action, which in this line of reasoning is also shaped by both the local and external institutions.

Extended ter Bogt and Scapens ( 2019 : 1810) framework

In developing the concept of situated rationalities the authors start by explaining that the reproduction of institutionalized behaviour may still involve some form of deliberation (ter Bogt and Scapens, 2019 ). The agents are likely to deliberate about the most appropriate routines in cases of routines/habits that conflict, in complex situations, and even when a particular routine is appropriate an understanding of the appropriateness is still necessary. That deliberation is supported by the logic of the situation where an individual is, allowing him to rationalize his choices and providing him the means by which the abstract institutions influence their deliberations over rules and routines (ter Bogt and Scapens, 2019 ). That situated logic is termed situated rationality by ter Bogt and Scapens. In the authors’ words, situated rationality could be perceived as “ the taken-for-granted ways of thinking which actors adopt when taking actions in a specific situation ” (ter Bogt and Scapens, 2019 : 1804). Thus, situated rationalities represent a form of rationality applied by individuals or specific groups regarding what they should do in a given situation (ter Bogt and Scapens, 2019 ), helping them to define their choices, actions, and how they think (ter Bogt and Scapens, 2019 ; Pagliarussi & Leme, 2020 ). The nature of the concept can also be captured in the dilemma posited by the actor deliberating what he/she is expected to do in a given situation. In so doing, the actors will apply a form of rationality that will be shaped by the institutions, and therefore the situated rationalities within the organizations will be shaped by the multiplicity of the rationalities embedded in both the local and broader institutions (ter Bogt and Scapens, 2019 ). As forms of rationality, within an organization we will probably find multiple and different situated rationalities simultaneously, either by the existence of different professional groups or forms of rationalities concerning the history or experience of the particular organization (ter Bogt and Scapens, 2019 ). Also, Bertz and Quinn ( 2022 ) report on a situated rationality that a manager brought to a public organization based on his finance training and leadership.

Although not stated by ter Bogt and Scapens ( 2019 ), the same reasoning could be applied to situations other than those in which management accounting routines should be chosen. Actors must also deliberate which paths to follow and that decision is subsumed within the situated rationality regarding what lies in front of the actors. In a similar vein, Cardinale ( 2018 ) argues that a structure not only “ open[s] up possibilities for action, but also that it actively encourages actors to settle upon some of those possibilities rather than others ” (Cardinale, 2018 : 17). In this way, Cardinale ( 2018 ) builds the case that structures constrain, enable, and imprint dispositions that orient action. On the one hand, institutions constrain actions by making some possibilities impracticable and, on the other hand, they enable actions by making alternatives feasible. But institutions also orient actors to choose some worthwhile possibilities instead of other viable possibilities. Ultimately, this has some implications on the way structure affects action, since actors are pushed toward some courses of action instead of others (Cardinale, 2018 ).

From previous research it is also known that MCS employed in the organizational field can be seen as routines (Quinn, 2011 ; Oliveira & Quinn, 2015 ; Pagliarussi & Leme, 2020 ), playing a key role in the coordination of organizational actors’ actions (Pagliarussi & Leme, 2020 ). Moreover, by following the teachings of the previous analysis, as situated rationalities are able to influence rules and routines, MCS are also shaped by them and influence behaviour. This should also be conveyed when looking at the influences of these systems on action, decision making, and on how these practices are used regarding different realities. However, in parallel, the literature that explores the role of MCS on innovation has progressed without this acknowledgment. Indeed, that line of research of control on innovation, to the best of our knowledge, has progressed without even considering the teachings of institutional theory. An exception is the work of Biswas et al. ( 2022 ), who studied MCS influence on micro-level practices during product innovation through the lens of institutional theory.

2.2 Research in MCS and innovation

In the last 40 years MCS have evolved into controls that are more complex and open (Chenhall & Moers, 2015 ). New features have added strategic aspects and concerns to the control solutions (Barros & Ferreira, 2019 ). Likewise, remarkably, Simons introduced the framework about the levers of control, and his identification of the interactive use of MCS recognized the role of these systems in exploring strategic uncertainties (Simons, 1995 ; Davila et al., 2009a ). This acknowledgement opens the door for management control practices to accept the necessary variation, and with that, the acceptance of innovation as well (Davila et al., 2009a ). As Chenhall and Moers ( 2015 ) explain, when the importance of environmental uncertainty was accepted, organizations were forced to organize their structures to help achieve innovation in a way that allowed them to acquire competitive advantages.

Researchers have started to pay attention to the role of MCS in innovation and much ground has been covered to date. Scholars have analysed different configurations of controls in product development (Bellora-Bienengräber, 2019 ), the use of accounting information across different stages of product developments (Jorgensen and Messner, 2010 ; Feeney & Pierce 2018 ), MCS use regarding different types of innovation (e.g., Curtis & Sweeney 2017 ; Aaltola, 2018 ; Guo et al., 2019 ), the use of control systems across different innovation modes (Bisbe and Malgueño, 2009 ), the combined used of controls and tensions in different settings (e.g., Curtis & Sweeney 2017 ; Zarzycka et al., 2019 ; Barros & Ferreira 2022 ), and even the use of MCS in driving organizations committed to open innovation (Biswas & Akroyd, 2022 ).

In this line of the combined used of controls, Fagerlin and Lövstål ( 2020 ) also report on the use of informal controls. Many of these studies have in common the idea that has been in the management control literature for quite a while, of analysing controls not in isolation, but in combination (e.g., Malmi & Brown 2008 ; Grabner & Moers, 2013 ). In this sense, the Levers of control (LOC) framework has been a background that researchers have relied on (e.g., Bedford 2015 ; Bisbe and Malgueño, 2015 ; Lopez-Valeiras et al., 2016 ; Healy et al., 2018 ; Müller-Stewens et al., 2020 ; Barros & Ferreira, 2022 ), as it allows for the consideration of multiple controls and the ways they are used (Chenhall & Moers, 2015 ). Resorting to the LOC framework, scholars have found significant links between MCS and innovation at an organizational level (Moll, 2015 ). Interactive use of systems is seen to aid in generating and disseminating knowledge, fostering collaboration (Henri, 2006 ), and promoting internal and external information flows (Lopez-Valeiras et al., 2016 ).

Undoubtedly, this line of research has witnessed considerable evolution and it is clear that there is a positive association between MCS and innovation (Guo et al., 2019 ). However, the need for further research to learn how MCS dovetail with innovation remains (Chenhall & Moers, 2015 ; Moll, 2015 ; Major et al., 2018 ). Following Simons definition, “[MCS] are the formal, information-based routines and procedures managers use to maintain or alter patterns in organizational activities” (Simons, 1995 : 5) Footnote 1 . By this it is understood that MCS have inherent characteristics that allow them to orient behaviours and to increase the likelihood of achieving the organizational goals. Relating specifically to innovation (broadly speaking), Jorgensen and Messner ( 2010 ) provide evidence showing that accounting frames the strategizing process, and that both act as a general understanding to help the meeting of conflicting ends in new development projects. Also, it is known that the information carried in these systems is used for decision making at different stages of product development (Feeney & Pierce, 2018 ), and very recently Müller-Stewens et al. ( 2020 ) hypothesized that diagnostic and interactive use of systems permit effective coordination processes, finding evidence of it related to product newness in highly turbulent technological environments. Davila et al. ( 2009b ; Davila, ( 2005 )) also mention that MCS are stable and provide a frame for cognition, mental models, and actions. Indeed, as Simons ( 2014 ) points out regarding the definition of MCS, control systems carry information able to influence decision making and action. Nevertheless, the way that information is embedded, and how the importance of innovation is transmitted throughout the organization are areas that need further research. If internally the company has identified innovation as paramount, this should be reflected in these practices in order to communicate and align the internal behaviours. However, the literature fails to provide deep analysis on it.

2.3 Research purpose

Given this background, the study merges the two bodies of literature exploring the case of ACC, which with its specificities allows us to focus on both the concept of situated rationality and the role of MCS in innovation. More specifically, this study brings the developments made by ter Bogt and Scapens ( 2019 ) to the literature on the role of MCS and innovation, exploring how, at the case company, the situated rationality is reflected in the MCS practices, and how the management control practices in place are used to communicate and provide guidance to the organizational members when innovation is a critical part of the strategy.

Institutional theory is an interesting theoretical background in the sense that, with the acknowledgment that MCS are structures embedded in situated rationalities of the organizations that cannot be taken out of the equation, institutional theory is able to provide an explanation and better understanding of the findings.

3 Research method

The research purpose outlined earlier is addressed through a qualitative methodology using a case study approach. Case studies are considered the best way to gain deeper and holistic insights on complex organizational processes (Ryan et al., 2002 ; Eisenhardt & Graebner, 2007 ; Adams et al., 2018 ), and as institutional theory gives us as a core tenet that management accounting should be understood in its context, a case study is an ideal choice for the current study (Moll et al., 2018 ). Also, as Adams et al. ( 2018 ) highlight, an intensive case study in the interpretative tradition can allow a broader and richer understanding of management accounting practices. With this in mind, a single and interpretative case study was conducted, allowing for a greater focus and a more detailed analysis, offering richer descriptions and a contextualization of the phenomenon under study (Ahrens & Dent, 1998 ).

3.1 Case selection

The case company analysed in this study is Amorim Cork Composites , a Portuguese company working in the cork industry and integrated within a larger economic group. In a preliminary meeting the company demonstrated its availability to host the research and at the same time brought together two features considered as essential for the study’s proposes: a strong orientation toward innovation and a set of formal management control practices in use to achieve the intended strategy. In fact, the history, culture, and posture of the company toward innovation are all features that make it appropriate for this study. Its strategy was built around innovation as a central element and it has a track record of continuously developing new products and new cork applications. Also, since 2003 ACC has implemented a system based on a Balanced Scorecard methodology and more recently has implemented an innovation system to help in the management of the innovation projects.

3.2 Data collection

Data collection progressed in two phases between November 2015 and September 2016, including interviews, observations (See Tables  1 and 2 in appendix for a list of the interviewees and observations), and the company’s internal and external documentation information. The first phase comprehended a pilot case study to ensure the company’s availability, suitability for the purposes of the research, and investigation of the practices in place. In this phase, six interviews were conducted, there were two visits to the company facilities, participation in an internal meeting, and diverse internal documentation was collected. The pilot case study allowed the researchers to ensure that ACC met the criteria for selection and to obtain a clear picture of the full range of employees available to interview.

In the second phase – the main case study – the primary data source consisted of an additional 26 interviews. Individuals from various levels within the company were interviewed to obtain multiple perspectives and maximize the depth of the analysis. At the same time, this strategy ensured the triangulation of information (Yin, 2018 ). More specifically, interviews were held with all the heads of the departments except one, and in the major departments two additional employees were interviewed. Here, as Eisenhardt and Graebner ( 2007 ) put it, the strategy was to choose numerous and highly knowledgeable informants. In the production department, which involves most of the company’s employees, all the second line managers were interviewed.

In the course of the interviews, although a guide with a set of questions was prepared in advance, the conversation evolved into a more informal and unstructured dialogue form. This allowed the interviewer to simultaneously adapt the interview to the expertise of the interviewee and to gain flexibility to pursue new issues and themes as they arose in the conversation (Scapens, 2008 ).

Throughout these two phases, a total of 32 interviews were conducted and 2 visits to the facilities and showroom were held. Also, a researcher attended a meeting for all employees who are involved in the control system at which the results of the previous year were discussed and the objectives for the following year were presented. The interviews had an average duration of one hour and were all tape recorded (except the first one, during which only logistic aspects of the research were treated) and transcribed verbatim thereafter. Since recording was not feasible in the visits, detailed reports were written immediately thereafter, on the same day.

A variety of documents were also requested, gathered, and addressed in the interviews. This allowed for the triangulation of information between different sources, building stronger interpretations (Yin, 2018 ). We had access to documents related to the MCS and the innovation processes, such as internal reports, organizational charts, PowerPoint presentations, information about the goals and evaluation measures, and examples of monthly reports of results from both employees and the senior managers.

3.3 Data analysis

Concerning the analysis of the data, all the files with the transcribed interviews and the visit reports were imported into MAXQDA, a qualitative data analysis software. Then, the analysis was started through the highlighting of sentences and passages that were interesting for the goal of the study. Notes in the form of memos were made to register observations or raise questions that arose during the analysis.

Throughout the analysis, it was perceived that some lines of reasoning echoed, and it emerged that at least one form of rationality was in place at the company. This was in line with ter Bogt and Scapens’ concept of situated rationality. As the authors have pointed out, situated rationality is a theoretical concept that exists in the minds of the individuals but easier to identify than the institutions (ter Bogt and Scapens, 2019 ). To assert situated rationalities, we have kept in mind the concept developed by the authors and that they are shaped by the history of the company. With this we have sought to identify the logical way of thinking in order to perceive the lines of rationality applied. Therefore, we have looked at the history of ACC, the current strategy of the company, and the referential by which the internal collaborators think. Helpful in determining the situated rationality were also the examples provided by the works of ter Bogt and Scapens ( 2019 ) and Bertz and Quinn ( 2022 ).

4 Case background and results

4.1 the case company and the situated rationality of “innovation”.

ACC is very oriented toward innovation. ACC’s historical background can be traced to the industrial unit that was created to take advantage of the cork waste generated from the manufacturing of cork bottle stoppers. The goal was to transform this waste into cork granulates and those granulates into valuable agglomerates. The creation of this company was, by itself, an innovation in the sense that it came about as a way to create more value for a specific material. Today, ACC is a result of the merging of this activity with another business unit (BU) of the group that added the production of agglomerates of cork with rubber to the original production lines. As a result, the case company’s main activities today are the production of granulates, agglomerates of cork, and agglomerates of cork with rubber.

These materials are later used by ACC in a wide range of applications that are subsequently commercialized around the world. ACC takes advantage of the acoustic, sealant, thermal, resistance, resilience, and even aesthetic characteristics of its cork granulates and agglomerates to later produce solutions with different characteristics. Their products range from sealing applications for diverse machinery to anti-vibrators for trains, and even components of footwear. The case company works for the aerospace, automotive, construction, and furnishing industries (among others). Because of the variety of properties of its raw materials and applications, from the very beginning of its existence the company felt the need to invest in research and development. With it the company has achieved the position of the most innovative business unit of the group, as can be seen in the passages below, collected from different sources:

The launch of new products on the market and the development of new applications, two central goals of the BU’s strategy, also made an important contribution to sales growth as well as helping to create value in the market. (2015 annual report and accounts of the holding) ACC, from a generic point of view, has always been quite innovative, is one of the companies within the group, not demeaning anyone, but always with a high index of innovation and new products. (Industry global segment manager)

From the passages above it is clear that innovation is a key component of ACC’s business, and that there is a determinant role for innovation in its future. This is clearly perceived and reinforced in the following comment of the CEO and excerpt from an external document:

I would say that in strategic terms in the company, the most important objective is linked to innovation. Even if it is not the one that has more weight in what is the result but, I think it is the one that is more strategic. In the sense that it is the one that guarantees future … future sustainability. (…) Because we know that in this area selling the same products to the same customers is not the topic. Therefore, the issue of innovation is something that we realize that the more innovation the greater the increase of value. (CEO) The central goal of growth in these markets [speaking about the markets in which ACC is present] will be supported by a number of initiatives specifically designed for this purpose and which should also result in the introduction of new products and gaining new customers… (2016 annual report and accounts of the holding).

Therefore, creating value from cork and the products of the company is a high priority within the group and particularly at ACC. This emphasis makes innovation a concern of the day-to-day job of most of the employees:

This is a company with many years, and there is the constant concern of all business areas in having new processes, new materials, new applications for our raw material. Or, otherwise we will easily stagnate. (Retail segment manager) Composite cork is made from granulated cork bound together using different binding agents or incorporating other components (…) Today, as a result of technological advances and an unparalleled investment in R&D and Innovation, these different materials leverage cork’s unique properties (…). (company document)

Given this historical path, strategic positioning of the company, and clear way of seeing the future, a well-defined rationale came to light. Certainly, inside this organization exists a strong conviction that the future sustainability of the business and the creation of value resides in innovation, and more particularly product innovation. Or, in another way, there is a rationality in which the message conveyed is to think about being innovative. This is an idea clearly perceived by the message conveyed the first comment of the CEO (see above) and, also, in the passage below:

Nobody has a contract that says that you must come up, you know, with one good idea (…) Trying to grow sales is a large aspect of my contract and of my team, and we realize that new business or a new product line will help that dramatically. (Retail segment manager)

Therefore, we argue that internally the existence of a situated logic or form of rationality that encourages the individuals to the need and importance of innovation is perceived. It is a means to an end. In light of ter Bogt and Scapens ( 2019 ), there exists a situated rationality that will be termed “rationality of innovation”. This form of rationality is concerned with the development of the raw material (cork), with finding new opportunities, new ways to create value for the cork exploring its unique properties, and to go beyond the traditional portfolio of products. This identified situated rationality also has impacts on the internal management control practices and ACC’s day-to-day activities with characteristics that resonate with it.

4.2 The situated rationality of “innovation” and the management control practices

The rationality of “innovation” therefore leaves its marks in the internal management control practices that are in place within the company. The case company has adopted two models well known in the literature: a BSC, and an innovation model based on a stage gate approach. In light of ter Bogt and Scapen’s (2019) framework, both BSC and the stage gate approach may represent generalized practices that influence the internal rules and routines within the company.

Specifically, the system based on the stage gate model approach, implemented more recently, is intended to manage the developments of new products. At its core this system is an application and legitimization of this situated rationality of “innovation”. A practice implemented to manage the innovation projects and at the same time to improve the process. It is a signal for the achievement and support of product innovation. The solution implemented starts with a funnel of ideas with grids to evaluate, and to select the best value propositions. Innovation in ACC is very market-oriented and the value propositions come mainly from salespeople or segment managers. The propositions that arrive to this stage then pass through the funnel; after an evaluation of the business potential they pass through a series of milestones until they arrive to the industrialization phase.

The case company also has used a BSC methodology since approximately 2003 that outlines very clear routines to be followed throughout the whole year. Being less strongminded in the management of new product developments, the routines and procedures promoted by this practice affect a larger population. In this way, BSC and the strategy map are the most visible features of the management control practices within the company. The strategy map is defined annually, and is a double entry matrix with four perspectives (financial objectives, clients, processes, and infrastructures) and three strategic guidelines that represent the pillars of the whole strategy (growth, value, efficiency). For the year 2016 there were a total of 23 objectives divided by the various perspectives and guidelines. Once the strategy map is defined, a strategic scorecard is delineated that incorporates the goals and indicators for each objective, as well as the set of initiatives that must be put in place that year, identifying the employees responsible for each, the milestones, and the resources needed.

As with the BSC of most of private institutions, the top objective that appears on the strategy map is related to financial purposes, stating: “Deliver sustained remuneration for capital employed”. However, since internally there is a rationality associated with the importance of innovation to achieve both sustainability and financial return, innovation is further represented – objectively perceived through the inclusion of three very specific and broad objectives. The first, which is more structural, is included in the perspective of infrastructure and is specifically for the year 2016. It relates to the operationalization of an innovation network, which is understood as strategic to the company.

The second objective appears within the market perspective in the strategy map and simply states “Develop new products”. Measured by the sales of products that have not yet left the development stage, this objective aims to ensure that developments completed before the end of the previous year record sales. To a certain extent, the idea is to guarantee the acceptance of these new products in the market.

The third objective is broader in the sense that it is not assigned to the innovation department, and it is integrated in the guideline of value and in the market perspective. Again, it is a financial objective measured by the sales of all the portfolio of new products and applications in absolute value. Different from the second objective, this one focuses on sales of products that have left the development stage. Also, it is an objective that has become more stable over the years, appearing in various strategy maps. For example, for the year 2015 the same objective appears, defining a percentage of whole sales volume that has to come from the sale of new products.

Then, these objectives, whether related to innovation or not, are cascaded for the whole organization by objectives’ contracts that are carried out in the top-down direction through some limited negotiation between manager and employee, and that are called individual objectives contracts.

In sum, the features explained in this section allow for a perception of how the situated rationality of “innovation” imprints on the management control practices within the company. The practices go along with the “ways of thinking” for the value creation through innovation. Also, in parallel, the processes of communication and guidance occur.

4.3 MCS as communicators

First, the importance of communication for the holding company and the BUs of the group is clearly recognized:

Internal communication has been a strategic focus of the holding for many years. As a group that experiences countless changes, restructurings, business alterations, and an intense level of recruitment, it is fundamental that different groups of employees are informed about and aligned with its short-, medium-, and long-term objectives. (2016 annual report and accounts of the holding)

From the above excerpt from the annual report, one sees that managers attribute an important role to communication, whether because of the continuous changes or the turnover of employees. Some of the mechanisms used to guarantee a continual flow of communication are, as expected, the control practices in place that inform all involved in the system of the organization strategy. The practices inherent to the BSC are used by managers to communicate the strategy as well as the situated rationality of “innovation”. At the case company there are several procedures that guarantee a constant communication about their prevailing importance for the development of activities inside the company. This communication stance of the MCS comes in different ways and from different procedures. ACC presented the core value of innovation in their belief systems and mission statements related to innovation. That core value is presented both in the list of values of the company, and in presentations for various internal publics. Some mottos also appear such as: “Together towards innovation” (taken from an internal presentation).

Despite that, the most prominent mechanism for communication stems from the inclusion of innovative goals in the final set of objectives:

(…) If the goals are all business as usual, this promotes doing the business as usual, and doing nothing else. So once again, if we want innovation, it is good that this is clear in the objectives. (CEO)

Nevertheless, simply including innovative goals does not necessarily mean that the attention to innovation will reach all employees. The cascading process made from the strategy map to the individual contracts of objectives represents a clear signal through the inclusion of objectives connected to sales of new products. Although many of the contracts of objectives do not specify goals of value propositions that everyone should bring in, this objective ends up passing on the perspective of searching the market for new opportunities. Some comments point exactly to this:

[When asked about the objective of sales of new products] New products, yes. They all have [The sales team]. (…) But what, in fact, probably, they have more difficulty and, is less in focus, is that after that they have to go looking for them, right? (Head of Asia sales department) People are encouraged to sell what is new and what is different and not just follow the traditional product portfolio. Therefore, and all people, as a rule, have goals of selling new products. It means that if they exist, they have to sell them; if they do not exist, they must create them. Or, give ideas so that they are created. (Head of Human Resources department)

Also, an aspect that was evident and common to various interviews was the degree of understanding of a mutual reinforcement between innovation and growing sales (another important objective in the case company). In a very ingrained way, this constitutes another important reference to the communication of the need for the sales teams and segment managers to be aware and engage with the search for opportunities in the market and to bring proposals of new products to the company.

Besides the cascading process, there are other mechanisms at managers’ disposal to put emphasis on innovation. One of the first opportunities is the meetings that seek to mobilize the internal employees to the goals that have been defined at the top management level. These meetings – internally called alignment sessions – happen twice per year Footnote 2 . The first occurs as soon as the strategic orientations and the strategic map are defined for the following year, providing a follow up of the strategic scorecard and a first contact with the orientations for the next year. The second meeting takes place at the beginning of the year after the closing of the strategic scorecards and all the individual contracts of objectives.

Throughout the alignment session the objectives regarding innovation were also reviewed and the CEO had the opportunity to remind the individuals regarding the importance of these objectives for accomplishing the strategy. As it is paramount to the company, the importance of innovation is also transmitted and emphasized. In addition to the communication at these meetings, the strategy map also plays an important role as an element of day-to-day dissemination of the importance of innovation. This map is able to provide a comprehensive idea of what the intended value-creating activities will be, and in the case company innovation is the core of these activities. As it is literally a sheet of paper that offers a graphic representation of the objectives and their causal relationships, it makes the relationship between the renewal of the product portfolio and the return of invested capital easily identifiable.

In short, MCS are used by the managers, apart from other purposes, to communicate and disseminate the previous identified rationality of “innovation”. Some of the initiatives pointed out here also allow for the collaborators to obtain guidance on the intended purpose of innovation.

4.4 MCS as guides

The MCS described above also work in the company as a way to provide guidance. They imprint in the minds of the organizational members some direction. Indeed, letting the collaborators know the overall scheme of objectives of the organization represents just the beginning of the intrinsic and complex processes of MCS in innovation. The characteristics of the systems in use ensure that employees know the importance of all the objectives necessary to achieve the main goals of the BU. Then, the existing tools work by orienting the individuals to behaviours that guarantee that all the employees are moving in the same way.

The cascading process of the overall objectives, through the contracts of objectives, represent the first alignment tool of all the internal levels of the company. As it has served to communicate and reinforce the importance of innovation, it also represents a way to guide employees to the activities that managers perceive as more valuable. The main objective is the delivery of value but the contracts also present the most viable course of action: selling new products and creating new opportunities. In this regard, the objectives of selling new products reach the key elements in the context of innovation through the cascading process. Sales teams, the innovation team, and segment managers end up with innovation objectives that impose upon them, in a very discrete way, the need to search for new opportunities in the market. These kinds of financial measures regarding sales of new products impress the sales teams with the importance of their awareness:

Moments ago I was talking and trying to set goals… X millions of sales of new products for 2018. (…) If you ask me, but what products? I have no idea. (...) And, therefore, if we don’t have pipeline for that, what do we have to do? (…) Cause opportunities with sales teams, global segment management, in internal meetings, with partners, with customers, because we must immediately provoke the market to come up with new ideas to develop them. (CEO) If we have as one of our goals to have x% of sales volume in new products, necessarily there is a permanent concern: add products to the portfolio, create new products, find new products for new applications. (Head of business development and global segment management)

In this way, the practices and processes of control encourage the employees to follow a course of action, which in this case is to engage in activities and postures that help in product innovation. This encouragement is further reinforced by the commitment that is created with the “signing” of individual contracts of objectives and by the prioritization of innovation. Individual contracts result in a personal commitment created between the employee and the company, similar to the commitment seen by Davila ( 2000 ) in one of the research projects analysed. Although there is a small negotiating margin on the part of the employees, the process ends with the definition of the contract of objectives and respective weightings of each objective for the awarding of a bonus at the end of the year.

Financial measures related to innovation are included in these contracts creating accountability for meeting these goals. The commitment created by this symbolic act of signing the contract then encourages the employee to focus on the areas covered by it. The employees end up showing a greater awareness for those areas, prioritizing the themes underlying the objectives they must achieve:

An objective also has a way of indicating where you want to go, and of helping us clearly realize that if I have this, it is because this is a priority. (Project Manager 1)

As the above comments show, employees become focused on those objectives in which innovation is also measured, giving, to some extent, the guarantee of their prioritization. Thus, the commitment and focus promoted by these contracts end up fostering the path. They provide a way forward, serving as a guideline for the allocation of employees’ attention. Focusing on some strategic points, these contracts make innovation appear as a point of arrival, guiding the behaviours. These ideas are conveyed in the following comments:

[The BSC] is also a model that, and for me this is very important, that is not only about the “what” but the “how”. (…) The direction is also part, it is not only the speed and the point of arrival. (CEO) It is not because it is linked to the contract of objective that there is a desire to be innovative. Okay, if you have a goal whose relative weight represents 30, 40% of the objective it’s obvious. So, in a way, we are forcing the team to devote more attention to innovation. (...) It is obvious that the contracts or the objectives can influence or push the direction of innovation . (Retail segment manager)

Briefly, the analysis made earlier provided an understanding of how the communication and guidance inherent in the management control methodology is used in the case company.

5 Discussion

Up to this point this study has sought to explore the situated rationalities of ACC. More specifically, we explored how this rationality translates into the management control practices that the company has in place, and how these practices are used at the macro level of the company to communicate and provide guidance for the organizational members.

First, inside ACC there is a clear rationality of “innovation” that crosses all the hierarchical levels from the top managers to the lowest levels included in the performance practices. This rationality relates to a settled way of thinking that attributes to innovation a place of relevance to the future of the company in terms of results and other success measures. In other words, advancing the rational or presented way of thinking is to guarantee a constant flow of innovation for sustainability of the business. In broad stokes, the rationality that attributes importance to innovation becomes a significant component of the strategy, is interpreted as a way to achieve future success, and is incorporated in the management control routines. This is not far from the works of Revellino and Mouritsen ( 2015 ) and Davila ( 2005 ), in which they highlight the role of accounting in providing background so that innovation can occur within the bounds of the defined strategies.

What was seen in terms of practices is that the most visible is the BSC, and more recently the company implemented a system similar to a stage gate approach. This latter one is a clear sign of innovation as a means to an end. These two, according to ter Bogt and Scapens’ ( 2019 ) extended framework, are two generalized practices that influence the internal control systems applied. ACC has implemented for quite some time a set of performance measurement practices based on the BSC model (since 2003), with a strategy map, a cascading process of objectives well implemented. In fact, today ACC’s BSC model is clearly a set of routines that are institutionalized at the organizational level. These practices have been in place for many years and have been maintained despite the rotation of employees over time and the internal changes that the company has gone through. Furthermore, BSC-associated practices strongly determine the internal routines that are used by the managers and reached a state of natural enactment. A set of strategic objectives that the management team defined is found in the strategy map, and some of them are directly related to innovation.

Relating to the features perceived in ACC’s rationality of “innovation”, as presented in the previous section, they were not adopted specifically as a strategic guideline for innovation. Instead, a main goal similar to the ones that are common amongst private companies is delineated and the underlying rationality is marked by the inclusion of some objectives directly related to it. Looking at the set of strategic objectives and the strategy map, the management team has defined an array of three objectives directly related to innovation. The main goal still is the delivery of sustained results and, undeniably the inclusion of the rhetoric associated with the rationality provides the way to achieve that sustainability or the interpretation on the path that should be pursued. In other words, the findings indicate that these three specific strategic objectives in combination with the rest made the systems and practices lead the organizational members to the specific rationality within the company. The most powerful element in this – the financial measures related to innovation – end up being included in the individual contracts of objectives, and thus, as in the study of Curtis and Sweeney ( 2017 ), accountability is created for meeting these goals. Furthermore, as in Jorgensen and Messner ( 2010 ), the stage gate process also provides a formal structure that reminds persons of the importance of the profitability.

This dressing given to the prevailing rationality and the further signs of it within the internal control practices, in its core, is consistent with the arguments of Cardinale ( 2018 ), in the sense that MCS give to employees a frame of reference with the viable alternatives when faced with the eventualities of the day-to-day activities.

In fact, the objectives of sales of new products have never failed, thereby indirectly showing the power of the management control routines in the orientation aspect. A further important aspect is the stability achieved by the institutionalization of these practices. As Thornton et al. ( 2012 ) report, the stability of institutions and organizational practices allow for the activation of the schemes embedded in the logics of the organization as a default of actors’ cognitive processes. MCS are developed to help managers achieve the intended strategies, assisting decision making and representing the situated rationalities of the organization. They could be understood as top-down schemas providing actors with cognitive structures to shape their attention, help with problem solving, and guide their decisions.

This idea of schemas, as Thornton et al. ( 2012 ) further explain, highlights how actors understand, remember, and act upon complex information by relying on knowledge about the working mode of the world. Moreover, the authors also explain that the capacity to allocate cognitive resources from individuals is scarce, which means that organizations tend to develop structures and processes to shape individuals’ focus of attention (Thornton et al., 2012 ). In the case company this is what happens with their MCS. First, through the long-time routinization of the practices, and the time over which they have been enacted, they achieved a state of stability and a state of importance within the daily life of the employees. Simultaneously, as some authors have mentioned, MCS are capable of framing cognitive models, actions, and communication patterns (Davila, 2005 ; Davila et al., 2009b ).

Also, as a result, the BSC internal practices represent a way for managers to maintain and sustain the situated rationality. This complements the findings of Bertz and Quinn ( 2022 ). They attribute to the generalized practice of the BSC a role in the change of the situated rationality. Complementing it, our findings suggest that these generalize practice when already encoded in the rules and routines (or, an institutionalized practice) within the company and is also a way to maintain it in the existing situated rationality. Graphically, this reinforces the double-headed arrows from the situated rationalities to routines presented in ter Bogt and Scapens’ ( 2019 ) framework (Fig.  1 ). The stability and the routinization of the BSC allows sustaining the situated rationality of innovation. It is also possible to argue that the maintenance of this rationality could be influenced by the constant and important use of the practices as instruments of communication and guidance of the collaborators. As reported by Bertz and Quinn ( 2022 ) for the BSC, the MCS allowed the managers to communicate to lower levels in a strategic way. They provide newly entered collaborators and “old” collaborators with knowledge of the way things should work. The core values, mission statements, and objectives cascaded through various collaborators work with an active attitude of constant reminder about the situated rationality. Also, exposing strategy maps in meetings, for example, represents a way to communicate the strategy and its principles. The messages passed from institutional communications and presentations, values that are shared, and the cascading process of the objectives contracts all come as a way of communication and guide the action of the collaborators. Then, again, the cascading process of the objectives and the commitment from the signing of these contracts increases commercial awareness and accountability.

With this, the actors’ inclination to search for new proposals and opportunities in the markets is increased. At the bottom line, this is similar to what Curtis and Sweeney ( 2017 ) perceive in their case study at Caseco about the role of MCS as increasing the commercial awareness to market opportunities of future developments. Interestingly, following this logic, the study shows that in part it is possible to contradict Bisbe and Otley’s ( 2004 ) and Bedford’s ( 2015 ) views that MCS do not increase the propensity of the company to experiment with new products.

6 Concluding remarks

Relying on developments made by ter Bogt and Scapens ( 2019 ) to the Burns and Scapens ( 2000 ) framework, this study reports on an in-depth case study at ACC, an acknowledged innovative company in the cork industry. Specifically, the study departs from most institutional theory studies in the sense that it does not analyse the process of change and the role of management accounting in it, isomorphism, or even the institutionalization of practices. It addresses the terminology developed by ter Bogt and Scapens ( 2019 ) to explore ACC’s case and characteristics that allow us to observe: how the situated rationality of innovation within the case company is imprinted on the management control practices implemented; and, how these practices communicate and provide guidance to the organizational members in relation to innovation.

With very robust and institutionalized management control practices, the findings obtained through the case of ACC permit us to make contributions to the literature on the MCS and Innovation, and, in a more modest way, to the literature on institutional theory. Regarding the first body of research, although this study is not the first case study that seeks to provide deeper understandings of the relationship between MCS and innovation, our findings highlight the important role that these systems may play in communicating and guiding organizational members to behaviours and actions more related to innovation. The literature that seeks to connect MCS and innovation has taken a light approach on how strategic communication and guidance is provided to the collaborators of the company. Looking at it in a macro-organizational way, the results show that through the inclusion of values, mottos, objectives that underpin the situated rationality, the cascading process of some of these objectives, and the use of objectives contracts, the managers are able to strategically communicate and provide guidance. With this, the study also responds to the calls to dig further into this line of research (e.g., Chenhall & Moers 2015 ; Moll, 2015 ; Fried, 2017 ; Major et al., 2018 ; Barros & Ferreira, 2019 ), especially by resorting to qualitative research methods such as the case study (Henri, 2006 ; Barros & Ferreira, 2019 ).

To the literature on the extended B&S framework, we are able to address the call of Bertz and Quinn ( 2022 : 97) that the situated rationalities “ need to be considered in more fine grained detail …” . A situated rationality, termed rationality of “innovation”, within the company was identified and our results lead us to assert that the MCS, as practices established long ago and institutionalized, are able to maintain the situated rationalities within the company. MCS also help in achieving the constant strategic communication and guidance that are inherent to these practices and have been enacted on a continuous basis.

Lastly, there are also more general contributions to both practitioners and the literature in exposing and detailing the solution implemented at ACC and how a set of combined control practices can make a flourishing habitat that includes innovation.

Aside from these contributions, from the research choices made there are also some limitations that should be acknowledged. First, the results presented should be considered carefully. The use of a single case study means that although this study has provided a very in-depth analysis of the role of MCS on innovation at ACC, this represents the situation of only the case company. Different companies in different sectors with different contexts and with different management control protocols may choose to use other tools to represent the innovation. It should not be neglected that management accounting is a situated practice (e.g., ter Bogt and Scapens, 2019 ).

At the same time, the analysis conducted using the institutional theory perspective was very focused on the sphere of organization, underplaying the institutions within and outside the company, their influence, and even their impacts and tensions.

Nevertheless, there are also future research opportunities. When it is considered that innovation at ACC is very market driven, it is possible to ask if other postures regarding the origins of novel ideas could require different approaches and different controls. In this regard, Revellino and Mouritsen’s ( 2009 ) study acknowledges that the development process of new products entails a multiplicity of controls, which could also be the case of managing different forms of innovation.

Data availability

The data generated and analysed during the current study are not available due to confidentiality issues.

This would be the general definition followed in this study. However, the study still recognizes the more recent trends in which MCS are seen not as systems that operate in isolation but as a collection or package of controls that incorporate the whole strategic process from formulation to implementation (Malmi & Brown, 2008 ; Grabner & Moers, 2013 ).

One of these meetings was observed (see Table  2 of the appendix).

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The authors would like to thank the editor, Professor Frank Verbeeten and the two anonymous reviewers for their helpful comments and suggestions. Also, we gratefully acknowledge comments and suggestions from Luís Pimentel, Rui Vieira, Ricardo Barradas and the participants of the BRU Research Seminar Series, XVIII Encuentro Internacional AECA, ENROAC & MCA Conference, XVIII International Congress of Accounting and Auditing (CICA), XXI Grudis Conference & Doctoral Colloquium, 44th EAA Annual Congress. Rúben Silva Barros gratefully acknowledge the financial support of Fundação para a Ciência e Tecnologia under the doctoral grant SFRH/BD/104181/2014. The authors are also grateful for the financial support of this institution under the grant UIDB/00315/2020.

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Barros, R.S., Ferreira, A. Management control systems and innovation: a case study grounded in institutional theory. J Manag Control 34 , 109–133 (2023). https://doi.org/10.1007/s00187-023-00351-4

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• DOI: 10.1108/AAAJ-11-2013-1531
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Management control systems and research management in universities

• Gloria Agyemang , J. Broadbent
• Published 15 September 2015
• Business, Education
• Accounting, Auditing & Accountability Journal

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Accounting, Auditing & Accountability Journal

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Article publication date: 21 September 2015

The purpose of this paper is to examine the management control systems developed by universities and groups within them, to manage research within UK University Business and Management Schools. Specifically, the paper analyses how universities develop their internal management control systems in response to an externally imposed regulatory system. It also provides an agenda for future research.

Design/methodology/approach

The paper uses a middle range approach to consider the UK Research Excellence Framework (REF) and the previous Research Assessment Exercises. It uses the language provided by a number of conceptual frames to analyse insights from the lived experience, and builds on previous literature that has recognised the perverse outcomes of such performance measurement systems.

The study finds that the internal management control systems developed by academics themselves amplify the controls imposed by the REF. These internal control systems are accepted by some academics although they encourage a movement away from previously held academic values.

Originality/value

This study contributes to debates about the dysfunctional impacts of the use of performance measures to manage research. Its originality lies in explaining that the management control systems developed to resist the imposition of external performance measurement systems may lead to symbolic violence where participants become involved with their own subjugation.

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Agyemang, G. and Broadbent, J. (2015), "Management control systems and research management in universities: An empirical and conceptual exploration", Accounting, Auditing & Accountability Journal , Vol. 28 No. 7, pp. 1018-1046. https://doi.org/10.1108/AAAJ-11-2013-1531

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Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial

• Tim Luckett 1 ,
• Jane Phillips 2 ,
• Meera Agar 1 , 3 ,
• Linda Richards 4 ,
• Najwa Reynolds 5 ,
• Maja Garcia 1 ,
• Patricia Davidson 6 ,
• Tim Shaw 7 ,
• David Currow 6 ,
• Frances Boyle 8 , 9 ,
• Lawrence Lam 10 ,
• Nikki McCaffrey 11 &
• Melanie Lovell 5 , 9  

BMC Health Services Research volume  24 , Article number:  969 ( 2024 ) Cite this article

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The Stop Cancer PAIN Trial was a phase III pragmatic stepped wedge cluster randomised controlled trial which compared effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six Australian outpatient comprehensive cancer centres ( n  = 688). A system for pain screening was introduced before observation of a ‘control’ phase. Implementation strategies introduced in the ‘intervention’ phase included: (1) audit of adherence to guideline recommendations, with feedback to clinical teams; (2) health professional education via an email-administered ‘spaced education’ module; and (3) a patient education booklet and self-management resource. Selection of strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model (Michie et al., 2011) and evidence for each strategy’s stand-alone effectiveness. A consultant physician at each centre supported the intervention as a ‘clinical champion’. However, fidelity to the intervention was limited, and the Trial did not demonstrate effectiveness. This paper reports a sub-study of the Trial which aimed to identify factors inhibiting or enabling fidelity to inform future guideline implementation initiatives.

The qualitative sub-study enabled in-depth exploration of factors from the perspectives of personnel at each centre. Clinical champions, clinicians and clinic receptionists were invited to participate in semi-structured interviews. Analysis used a framework method and a largely deductive approach based on the COM-B Model.

Twenty-four people participated, including 15 physicians, 8 nurses and 1 clinic receptionist. Coding against the COM-B Model identified ‘capability’ to be the most influential component, with ‘opportunity’ and ‘motivation’ playing largely subsidiary roles. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention’s value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians’ scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.

Conclusions

Future guideline implementation interventions may require a ‘meta-implementation’ approach based on complex systems theory to successfully integrate multiple strategies.

Trial registration

Registry: Australian New Zealand Clinical Trials Registry; number: ACTRN 12615000064505; data: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspxid=367236&isReview=true .

Peer Review reports

Pain is a common and burdensome symptom in people with cancer [ 1 ]. Barriers to pain care occur at all ‘levels’, including the patient and family (e.g., misconceptions regarding opioids), clinician (e.g. lack of expertise), service (e.g. inadequate referral processes) and healthcare system (e.g. lack of coordination) [ 2 , 3 , 4 , 5 , 6 , 7 , 8 ]. A recent systematic review suggests that around 40% of cancer patients with pain may not receive adequate management [ 9 ]. Research has demonstrated that routine screening and implementation of evidence-based guidelines has potential to improve quality of cancer pain care and outcomes [ 10 , 11 , 12 , 13 , 14 ]. However, experience suggests that clinicians are unlikely to utilise screening results or follow guidelines unless these are supported by targeted strategies [ 15 , 16 ].

The Stop Cancer PAIN Trial (ACTRN 12615000064505) was a phase III pragmatic stepped wedge cluster randomised controlled trial conducted between 2014 and 2019 which compared the effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six outpatient comprehensive cancer centres in Australia ( n  = 688) [ 17 , 18 ]. A pen/paper system to screen for pain using 0–10 numerical rating scales (NRS) for worst and average intensity over the past 24 h was introduced to each centre prior to observation of a ‘control’ phase, in which clinicians were also made aware of the Australian Cancer Pain Management in Adults guidelines [ 19 ]. At the beginning of the training phase, trial investigators presented at staff meetings on the importance of better managing pain and the rationale and evidence base for the intervention components. Implementation strategies (collectively termed the ‘intervention’) were then introduced in a ‘training’ phase and maintained during an ‘intervention’ phase as follows: (1) audit of adherence to key guideline recommendations [ 19 ] and feedback delivered to clinical teams in one or two cycles; (2) health professional education via a ‘Qstream’ email-administered ‘spaced education’ module [ 20 ]; and (3) a patient education booklet and self-management resource for completion together with a clinician that included goal setting, a pain diary and pain management plan [ 21 , 22 ]. Selection of these strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model of behaviour change [ 23 ], and evidence that each strategy had been separately effective for supporting guideline implementation for other health conditions. The intervention was supported at each centre by a consultant physician who agreed to be a ‘clinical champion’ [ 24 ].

As reported previously [ 18 ], the Stop Cancer PAIN Trial found no significant differences between the intervention and the control phases on the trial’s primary outcome - the proportion of patients with moderate-severe worst pain intensity who reported a 30% decrease at 1-week follow-up. Fidelity to the intervention was lower than anticipated and variable between centres: only 2/6 centres had two audit cycles rather than one; completion rates for the health professional spaced education varied from 12% to 74% between centres; and the proportion of patients reporting receipt of written information of any kind rose to an average of only 30% (20-44%) versus 22% (2-30%) in the control phase. Unexpectedly, secondary measures of mean, worst and average pain over a 4-week follow-up period improved by 0.5 standard deviation during control as well as intervention phases. However, the lack of a comparison group with no screening system made it difficult to conclude whether improvement in the control phase was due to effects from screening, a Hawthorne effect, or some other explanation.

The current paper reports a sub-study of the Stop Cancer PAIN Trial which aimed to identify factors influencing fidelity to the intervention that might warrant consideration by similar initiatives in the future.

The intervention, methods and results of the Stop Cancer PAIN trial have been described in previous open-access articles [ 17 , 18 ]. The sub-study used a qualitative approach with pragmatic orientation to enable in-depth exploration of factors influencing success from the perspectives of clinicians at each participating centre [ 25 ]. Clinician views canvassed at interview were considered the most efficient means of identifying barriers and enablers among complex contextual factors at each centre, including personnel’s knowledge, attitudes and beliefs towards pain care and the intervention.

The sub-study was approved by the Southwestern Sydney Local Health District Human Research Ethics Committee (HREC/14/LPOOL/479) as part of the overall trial. All participants gave written informed consent to participate.

Reporting adheres to the consolidated criteria for reporting qualitative research (COREQ) [ 26 ].

Participants

Participants were eligible if they were employed on a permanent basis either full- or part-time at a participating centre in a role that provided clinical care to cancer patients or patient-focused administrative support. The clinical champion at each centre was invited to participate by the research team. Other personnel were invited by means of email circulars and verbal invitations during meetings. Given the diverse range of roles at each centre, no limit was set on sample size to canvass as many perspectives as possible.

Data collection

Data were collected by means of semi-structured interviews conducted by one of two researchers, a female pharmacist with experience of medical education for pain management (LR), and a male social scientist with a doctorate (TL). Both interviewers had prior experience in qualitative research and knew some participants through their project roles.

Participants were fully aware of the study purpose before consenting. Interviews were conducted face-to-face or by telephone, with the participant and interviewer being the only people present. Interviews began with open questions about ‘what worked’ and ‘didn’t work’ across the intervention before focusing on each implementation strategy in more detail and important contextual factors at their centre (see Table  1 for a topic guide, which was developed specifically for this study). Interviewers explicitly invited criticism, expressing a tone of open enquiry and neutrality throughout. Prompts were used as necessary to explore factors identified by participants in more detail. Factors identified at previous interviews were raised at subsequent ones for verification, inviting participants to disagree or agree as they felt appropriate. No requests were received to return transcripts to participants for comment. Interviews were audio-recorded and transcribed verbatim.

Analysis used the framework method [ 27 ] and a largely deductive approach based on the same theoretical framework used during intervention design - the COM-B Model [ 23 ]. Based on a systematic review, the COM-B Model posits that behaviour change requires three conditions, namely ‘capability’ (including both psychological and physical capacity), ‘opportunity’ (all the factors that lie outside the individual that make the behaviour possible or prompt it) and ‘motivation’ (including habitual processes, emotional responding, as well as analytical decision-making). Initial line-by-line coding categorized data against these conditions according to which best described relationships between factors and behaviours within and across implementation strategies and the levels of patient, clinician and centre. While the COM-B model originally focused directly on human behaviour, it became clear during coding that behaviour was substantially influenced by centre, specialty and disciplinary factors, so these were also considered appropriate foci for coding against COM conditions. To enhance credibility, the same data were coded in different ways where multiple interpretations seemed plausible until coding of further interviews identified consistencies to help with disambiguation. Charting of codes for data within and between centres enabled mapping between the relative contributions made by each condition, summarised as lessons learned for guiding similar initiatives in the future. Dependability was increased by ensuring coding was conducted by two members of the research team (NR, MG) who had no previous involvement in the project but were experienced in qualitative research. Review and discussion with two team members who were involved in the project throughout (TL and ML) was intended to balance ‘outsider’ and ‘insider’ perspectives to guard against bias from preconceived interpretations whilst also referencing contextual understanding. Both Excel 2019 (Microsoft) and NVivo V12 (QSR) software were used to help manage different stages of the analytic process.

Twenty-four people participated across the six centres, ranging from one to six participants. Fifteen were physicians (of whom six were clinical champions), eight were nurses, and one was a clinic receptionist. This response rate ranged from 2 to 27% of eligible personnel at each centre. See Table  2 for a more detailed summary of participant roles at each centre. Interviews were a median of 20 min long, with an inter-quartile range of 13 to 28 min.

Capability, opportunity and motivation

Coding against the COM-B Model identified ‘capability’ to be the component having most influence over intervention success, with ‘opportunity’ and ‘motivation’ playing largely subsidiary roles.

Capabilities: Pertinent capabilities were reported to include: a pre-existing, centre-level culture of continuous improvement, communication pathways between senior management and other personnel, established roles and responsibilities for pain care among disciplines and specialties, systems and processes that could readily accommodate the intervention, and a culture of involving patients as partners in care. These capabilities influenced the degree to which personnel and patients had the opportunity and motivation to fully engage with the intervention.

Opportunity and motivation: These elements were most frequently discussed by participants in terms of ‘time’ that personnel could commit to pain care relative to other responsibilities. Clinical champions were perceived to play a critical role in supporting intervention success but were under-resourced at every centre and challenged by turnover in the role at two. In addition to more systemic drivers, individual personnel’s motivation was influenced by the degree to which they accepted the intervention’s value proposition at the outset and perceived this to be demonstrated over time.

Interactions between capability, opportunity and motivation are explored below in terms of their implications for similar future initiatives. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention’s value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians’ scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.

Consider centres’ readiness for change

The degree to which centres had a pre-existing culture of continuous improvement was considered important in providing a fertile context for the intervention. At Centre 5, there was a consensus that change of any kind was difficult to instigate, even according to the head of department: “… because it’s new - because we’re so entrenched in our ways ” (C5P04 [Centre 5, participant 04] medical oncologist, head of department and clinical champion). At another, the complex centre-level nature of the intervention was perceived to pose particular challenges compared to oncology drug trials with which they were more familiar: “ we haven’t been a principal site [in a trial of this kind] previously and I think that’s sort of opened up some gaps in knowledge for us and some opportunities for learning in the future … what kind of support we’d need to come with that trial to help it be a success in this culture ” (C3P02 palliative care physician and clinical champion).

Articulate and deliver on the intervention’s value proposition

Interviews highlighted the importance of articulating the intervention’s value proposition to every member of the workforce and maintaining engagement by demonstrating benefits over time. At Centre 5, some participants perceived that the intervention had been imposed by management rather than generated from clinical priorities: “…senior staff say [to researchers] ‘come to our clinics, but we expect everyone else to do the work’ ” (C5P05 radiation oncologist). This was compounded by a perceived lack of communication about the project, which limited personnels’ opportunity to take a more active role even when they were motivated to do so: “ I would have facilitated [the intervention] … but I didn’t know about it ” (C5P01 nurse practitioner). Eliciting and maintaining engagement was said to be additionally challenged at this centre by high staff turnover, especially among junior medical officers on rotation: “ it was very accepted by the junior medical staff [but] I think, unfortunately, when there’s a relatively high turnover of staff … ” (C5P07 radiation oncology trainee). At two other centres, turnover among personnel required a transition in the role of clinical champion, interrupting support for the intervention while the new incumbents familiarised themselves with the role.

Across centres, participants reported reservations among some of their colleagues regarding the project’s fundamental premises, including the assumption that pain care needed improving at their centre (“ they actually felt this trial was a little bit insulting for their clinical skills. There was a bit of eye rolling and ‘of course we do that already!’ ” (C3P02 palliative care physician and clinical champion)) or that pain warranted a specific focus rather than symptoms more generally: “ I find it more useful when more than one symptom is targeted ” (C5P06 palliative care physician).

More specific criticism was also levelled at each of the intervention strategies as follows.

Pain screening

In the case of screening, two participants questioned the validity of a 0–10 numerical rating scale (NRS) for different reasons: “ sometimes getting the numbers breaks the flow of the narrative” (C6P04 medical oncologist); “they [patients] would say, ‘no, I’m not in pain but I have a lot of discomfort when I swallow’ - it was in the wording ” C5P02 registered nurse). Even one of the clinical champions felt that screening was redundant where pain was very severe: “ if someone is clearly in a pain crisis, you don’t need to be asking … you kind of know what number - they might tell you it’s 15 [out of 10] ” (C6P02 palliative care physician and clinical champion). Perceptions of the value of screening were also influenced by the degree to which it led to demonstrable improvements in pain care, which was undermined by problems with establishing an efficient process at some centres: “ I think I’ve still probably got stray [pain screening] forms on my desk ” (C3P06 palliative care physician). A lack of understanding among personnel and patients about how screening might lead to better pain outcomes was said to result in “ fatigue ” (C5P03 clinical nurse consultant [clinical nurse consultant]; C1P01 palliative care physician and clinical champion), manifest as a downward spiral of effort in, and value from, screening.

Audit and feedback

The audit and feedback strategy attracted limited attention from personnel at most centres: “ I don’t think that the audit and feedback were terribly noticeable ” (C4P01 medical oncologist and clinical champion). At the centre where only the palliative care department participated, one participant perceived baseline audit results to be acceptable and therefore demotivating for change: “[ the audit results showed] we were doing a good job even ahead of time … it did sort of make you think – ‘well where do we go from here?’ ” (C6P04 pain medicine physician). At another centre, motivation among personnel to improve on less favourable audit findings was perceived to depend on whether they prioritised pain care to start with: “ people have come up to me and said, ‘Gee, we really did very badly didn’t we?’ … but they’re not necessarily the people who don’t treat pain well - that’s the problem ” (C1P01 palliative care physician and clinical champion).

Spaced education for health professionals

Participants’ opinion on the value of the online spaced education depended on discipline and seniority, with nurses and junior medical officers reporting benefits “( it gave me a bit more confidence that I was on the right track” (C5P01 nurse practitioner)) but consultant physicians perceiving the knowledge level too “basic” (C6P04 pain medicine physician) or questioning advice from online spaced education that their responses were ‘wrong’: “…some of the multiple answers could have been equally valid” (C504 medical oncologist and clinical champion). Where consultants remained engaged, motivation was said to rely on cultivating “ competition” between colleagues (C602 palliative care physician and clinical champion). Inevitably, the voluntary nature of online spaced education also meant that only motivated personnel engaged to begin with.

Patient self-management resource

All participants who had used the patient self-management resource perceived at least some value. However, its use was limited by barriers relating to role and process considered below.

Define roles and responsibilities

Among the most commonly voiced barriers was a lack of clarity about which specialties and disciplines should be responsible for pain screening, patient education and management. This was usually described in terms of a ‘lack of time’ for pain care relative to other duties afforded greater priority within their scope of practice. Perspectives on roles and responsibilities are considered separately for each aspect of pain care as follows.

While most centres allocated the clinical task of pain screening to clinic receptionists, there was widespread reflection that this had been suboptimal. The only participating clinic receptionist felt that pain screening fell outside her area of responsibility: “but I’m an administrative person - I don’t have anything to do with pain management ” (C2P03 clinic receptionist). Clinician participants across disciplines similarly perceived that pain screening required clinical expertise to assist patients with reporting their pain and triage for urgent follow-up: “ you need somebody talking to the patients, rather than just handing the form, say ‘fill this in’ ” (C2P04 clinical nurse consultant). One centre that recognised this early on reallocated screening from an administrative to a nursing role, leading to substantial improvements in the completeness and quality of data: “ it made a big difference and certainly improved our ability to recognise people who had pain and allowed access for those people who were in severe pain to medications or at least an assessment … implementation through the clerical staff was not a long-term strategy ” (C1P01 palliative care physician and clinical champion).

Patient education

There was little consensus on which disciplines should be responsible for supporting patients to use the self-management resource, with medical personnel deferring to nurses and vice-versa. Role allocation was challenged by the diverse components within the resource, with each perceived to fall within a different scope of practice: “ pain is something I always do as an assessment … [but] … I’m not managing the pain … I’ll review and make recommendations and talk about the pain diaries and discussing their diary with their palliative care doctor or their general practitioner. And I would encourage that process. [But] I wouldn’t be the one that’s setting the goals on their daily activities and stuff ” (C5P01 nurse practitioner). Some oncology nursing roles were perceived to focus on chemo- or radiotherapy protocols to the exclusion of supportive care unless symptoms arose from, or impeded, treatment. Meanwhile, oncologists tended to interpret their role as solely focused on prescribing rather than also encompassing patient education: “ junior doctors only [have] 15 minutes to take a history and everything. [They] could enter in meds [into the patient resource] if everything else is done by someone else … part of me knows it’s [patient resource] important, but the other part of me - I just - when will I have time in my clinical practice to do it? ” (C5P05 radiation oncologist).

Pain management

Some oncologists viewed even pharmacological pain management as peripheral to their scope of practice when consultation time was short, prioritising cancer treatment instead. These participants viewed their role as limited to referring to palliative medicine or pain specialists, especially where pain was believed to have causes other than cancer: “ if the pain is a complex pain where the patient doesn’t have evidence of cancer, and it may be treatment-related, then in those scenarios we tend to divert to the chronic pain team ” (C5P07 radiation oncology advanced trainee). While participants from palliative care and pain medicine welcomed referrals for complex cases, they felt that oncologists sometimes referred for pain they could have easily managed themselves: “ what about some regular paracetamol? … These are things that you’d expect any junior doctors, never mind consultants [to have provided advice on] ” (C5P06 palliative care physician).

Integrate within existing systems and processes

Participants from several centres expressed a view that the intervention’s complex nature had proven overwhelming for systems and processes at their centres. At two centres, integration was especially challenged by broader infrastructure shifts and process failures that limited receptiveness to further changes. Participants at several centres emphasised the process-driven nature of oncology services and the challenge of changing established processes: “ they have got a pro forma that they use for chemo-immunotherapy review, and pain is not part of it, and that perhaps needs more of an organisational nuance … why doesn’t pain feature as a clinical outcome as part of the chemotherapy, immunotherapy review?” (C6P01 clinical nurse consultant). Participants emphasised the need to integrate pain care into existing processes to help personnel understand what was expected of them: “…nursing staff were getting them [screening forms] in the patient’s files and going, ‘what am I supposed to do with this?’ ” (C2P04 clinical nurse consultant). Moreover, centres’ focus on cancer treatment meant that pain care struggled to gain traction even when a process could be instituted: “ unless pain is the presenting complaint and is at the forefront it goes into those, sorts of, you know, the ‘other details’ ” (C5P06 palliative care physician). For the palliative care centre, where pain care was already prioritised, there were doubts about how the proposed process improved on those already in place: “ I generally ask pretty detailed questions about pain anyway [so don’t need patients to be screened in the waiting room] ” (C6P04 pain medicine physician).

Suggestions for better integrating the intervention included “in-building” (C3P04 medical oncologist) responsibility for the strategies within new staff roles or introducing the strategies gradually by means of a “ multistep process” (C5P04 medical oncologist, head of department and clinical champion). Features of two strategies were singled out as having positive potential for supporting existing processes of care. The patient resource was said to “ facilitate communication between the oncology teams and the palliative care team ” (C5P05 radiation oncologist) and serve as a “ visual cue ” (C3P02 medical oncologist) to cover educational topics that “ they might have otherwise forgotten ” (C2P01 palliative care physician and clinical champion). Participants also found the spaced education email administration, spacing and repetition “ easy to manage ” (C2P01 palliative care physician and clinical champion) within their daily routines.

Promote patient-clinician partnership on pain care

Several participants expressed surprise at the prevalence of moderate-severe pain in screening results, and acknowledged that this revealed under-reporting of pain in usual care. Under-reporting was perceived to stem partly from patient expectations that pain from cancer was “ normal ” (C4P03 nurse practitioner) and to be especially common in the context of certain generational or cultural attitudes towards pain and opioids (“ I certainly think there’s a cultural element but there’s also your elderly patients who you know have been through the war and they’re just used to coping with things and you just suck it up … it’s like a badge of honour to be able to say ‘I’m not one of these pill-takers ’” (C3P03 registered nurse [RN])) or when patients were concerned that reporting pain might reduce their fitness for anti-cancer treatment: “[ patients might think that] if I tell them honestly how crappy I am with other symptoms and pain and everything, then they might stop my chemo” (C3P02 palliative care physician). Several participants perceived that under-reporting was also due to patients taking an overly passive role in consultations: “[clinicians assume that] if the patient doesn’t bring it up, it’s not a problem for them and … then the patient [is] thinking ‘the doctor will only talk about important things that are important for me and I won’t mention it because obviously it’s not important’ ” (C3P02 palliative care physician and clinical champion).

The screening component of the intervention was considered to address under-reporting by “ normal[ising] ” pain care, thus encouraging disclosure. The patient resource was also considered helpful for building patient capability to partner with clinicians on pain management by “ encouraging self-efficacy ” (C2P01 palliative care physician and clinical champion) through the tools it provided and its positive message that “ you can get control of your pain ” (C3P02 palliative care physician and clinical champion). It was also perceived to help patients “ keep a record ” (C5P03 clinical nurse consultant) of breakthrough pain and analgesia to discuss in their consultation. However, some participants delineated patient groups who might be less able to use the resource, including those with lower educational levels who struggled to set goals and identify an ‘acceptable’ level of pain balanced against side-effects from pharmacological management. For these patients, it was suggested that too many resources could be overwhelming rather than supportive: “ it’s almost like, the more resources they have, the less resourced there are ” (C5P06 RN). At one centre with an especially diverse demographic, patients were said to require substantial support even to understand the purpose and process of pain screening: “ most [patients] look at you going ‘oh, do I have to do anything?’ … They don’t want to read the [instruction] page which is relatively simple ” (C2P03 clinic receptionist).

Invest in clinical champions

All participants perceived the role of clinical champion to be pivotal to the intervention’s success. Champions were perceived to have two major responsibilities: advocating for the intervention among colleagues to boost motivation and providing practical support to build capability.

To be effective advocates, champions were perceived to need support from senior management ( “[leadership of change] it’s got to happen from the top ” (C5P02 RN)) as well as established, cordial relationships with colleagues they could leverage to motivate engagement: “ it also relies on the champion’s personal relationship with the staff which you’re asking to perform these roles and trying to change their management ” (C1P01 palliative care physician and clinical champion). Where champions felt under-supported by management, they relied on moral support from the project team to sustain their advocacy work: “ being the champion, and sometimes being the nagging champion, it actually felt quite nice to have the back-up of other people ” (C1P01 palliative care physician and clinical champion). Both physicians and nurses perceived the champion role might better suit the scope of practice of a junior doctor or senior nurse rather than consultants, based on their willingness to engage and approachability: “ realistically, you’re probably always going to get more engagement with registrars compared to consultants, unless it’s their own trial ” (C5P07 radiation oncologist); “ just give it [the role] to the CNCs [clinical nurse consultants] because as a general rule they’re the best at everything and have the best relationships with the patient ” (C3P04 medical oncologist).

From a practical perspective, clinical champions were expected to provide human resources for establishing and supporting pain screening and patient education: “ you need a body ” (C2P04 clinical nurse consultant). Unfortunately, however, champions across centres reported having limited time protected for the role within their usual duties: “ there just wasn’t the manpower to do that here ” (C3P02 palliative care physician and clinical champion). One suggestion for boosting capacity was to narrow the focus to one clinic and delegate practical tasks to less senior delegates than required for advocacy to render the time commitment more cost-effective: “[ it] might have been better to focus on one clinic and have full-time … junior nurse ” (C5P05 radiation oncologist). This presented an opportunity to train more than one clinical champion to provide better coverage across shifts and safeguard against the risk of losing champions to staff turnover.

Increasing pain awareness is the first step: Plan for slow incremental change rather than rapid uptake

While the barriers above meant only modest practice changes could be achieved, champions at half the centres perceived incremental progress had been made through increasing awareness among personnel regarding pain care as a focus for improvement: “ I think just trying to make pain something that people think about was probably one of the better strategies ” (C1P01 palliative care physician and clinical champion); it’s more at the top of our minds to remember, to screen the pain at every visit ” (C2P01 palliative care physician and clinical champion); “ I think it has highlighted those issues for us and we now need to take this on ” (C5P04 medical oncologist, head of department and clinical champion). Both nursing and medical participants at Centre 5 emphasized the need to be persistent in striving for continuous improvement: “ I think to get practice change, even for well-motivated people, I think it just needs to be pushed … they’ve done similar things with hand washing for doctors and it’s finally getting through ” (C504 medical oncologist and clinical champion); “ it would take more than just one of these kind of programs to get people to change ” (C5P03 clinical nurse consultant). Encouragingly, participants at this and one other centre expected some clinicians to continue using the patient education booklet and resource after the project ended: “ I’d just love to continue using these booklets ” (C5P02 RN); “[the] patient-held resource has been useful and has been taken up by people and I think they will continue to use those ” (C6P02 palliative care physician and clinical champion).

This qualitative sub-study of a cluster randomized controlled trial identified centre-level capabilities to be the most influential factors impeding or facilitating guideline implementation strategies for improving pain care for outpatients with cancer. Findings suggest that future initiatives of this kind should: consider centre readiness for change; articulate and deliver on the intervention’s value proposition; define clinician roles and responsibilities; integrate the intervention within existing systems and processes; promote patient partnership; invest in the clinical champion role, drawing from senior nurses and junior doctors, with support from medical leaders and management; and design the initiative around slow incremental change rather than rapid uptake.

Our findings are largely consistent with those from an ethnographic study exploring factors influencing implementation of cancer pain guidelines in Korean hospital cancer units, which identified a ‘lack of receptivity for change’ to be a key barrier [ 28 ]. However, observations from the Korean study suggested that a lack of centre leadership and cultural norms regarding nursing hierarchy were the most important underlying factors, whereas our Australian sample focused more on constraints imposed by centre systems and processes and a lack of clarity regarding disciplinary roles. These factors were consistently emphasized regardless of participants’ discipline and seniority, including by one centre’s head of department. Consistent with these findings, a recent Australian qualitative sub-study of anxiety/depression guideline implementation in oncology centres found greater role flexibility to be a key factor underpinning organisational readiness for change [ 29 ]. This team also provided quantitative evidence consistent with our finding that centres’ readiness for change is associated with personnel’s perception of benefit from guideline implementation [ 30 ]. Future initiatives should work harder to persuade clinicians of the intervention’s rationale and evidence base prior to commencement, given that perceptions of coherence and effectiveness are key dimensions of acceptability required for clinicians to invest time and effort [ 31 ]. Since our Trial was conducted, evidence has emerged for an impact from cancer symptom screening on survival that could be used persuasively [ 32 ]. Furthermore, the spaced education module might be more acceptable if made adjustable to the knowledge levels of a broader range of clinicians.

Other studies on implementation of cancer pain guidelines [ 11 , 13 ] suggest that structured approaches to process change tend to be more successful than less prescriptive approaches of the kind taken in the Stop Cancer PAIN Trial. We provided centres with guideline implementation strategies but no clear guidance on how to integrate these within existing contexts - i.e. implementation of the implementation, or ‘meta-implementation’. It was wrongly assumed that clinical champions could support integration with centre processes based on their knowledge of local context, but this turned out to be unreasonable given champions’ limited time for the role and lack of training in change management. Like most research to date [ 33 , 34 ], our trial focused largely on the advocacy role played by clinical champions, neglecting more practical and time consuming aspects that our interviews identified to be just as important. We join others in calling for more research on the mechanisms by which clinical champions can optimally facilitate change and ways to maximize their efficacy through training and support [ 24 ]. This should include exploration of optimal models by which different aspects of the champion role might be shared between more than one person where no-one is available with all the necessary attributes, as well as ways to ensure sustainability after support from the project team is withdrawn.

Theory-based research suggests that adding complex interventions to complex healthcare systems creates dynamic interplay and feedback loops, making consequences hard to predict [ 35 ]. In the current trial, this was likely exacerbated by our attempt to combine multiple strategies targeting patient, clinician and centre levels. We chose each strategy based on evidence for its stand-alone efficacy, and combined strategies rather than used them singly with the intent of leveraging complementary mechanisms, as recommended by the COM-B Model and US Institute of Medicine [ 36 ]. However, findings from our interviews suggest that interactions between the strategies and local processes separated their spheres of influence, precluding intended synergies. The Stop Cancer PAIN Trial is not alone in having over-estimated the value of combining guideline implementation strategies; a recent systematic review found that 8 other multi-component interventions similarly demonstrated limited effects on guideline adherence and patient outcomes [ 37 ]. Collectively, these findings suggest that future attempts at combining strategies should consider complex systems theory as well as behaviour change frameworks at each of a number of stages [ 38 ]. Alternatively, a more manageable approach for most cancer centres might be to focus on just one component at a time, periodically reviewing progress against SMART goals and, depending on results, supplementing with additional components using plan-do-study cycles [ 39 ].

Given the challenges with integrating screening into centre processes, it seems unlikely that improvements in pain scores during the control phase reported in our primary results article were due to the spontaneous use of screening data in consultations [ 18 ]. Indeed, while routine use of patient-reported outcome measures (PROMs) in oncology has been researched for more than a quarter-century [ 40 ], benefits to patient outcomes have only recently been demonstrated in the context of electronically-administered PROMs (ePROMs) that enable remote self-reporting, real-time feedback to clinicians, and clinician-patient telecommunication [ 12 ]. Further research is needed on how best to support clinician engagement with ePROMs, including training on how to use results in partnership with patients to assist shared decision-making and self-management [ 41 ].

A worrying finding from the current study was that some or all aspects of pain care were perceived to fall between the scopes of practice for oncology clinicians from each discipline. Clinical practice guidelines emphasize the need for pain care to be inter-disciplinary in recognition of the need for comprehensive assessment, non-pharmacological as well as pharmacological management, and patient education and support for self-management [ 42 ]. While the patient self-management resource included in the intervention was perceived to support communication between clinicians and patients, its potential for assisting coordination of care between disciplines was limited where roles and responsibilities were not previously established. Our findings and other research suggest that future initiatives may benefit from ‘process mapping’ with clinicians to identify where clinical workflow and roles might be reconfigured to incorporate the various aspects of pain care in the most efficient ways that do not substantially add to workload [ 41 ].

Patient education has been proven to improve pain outcomes by clinical trials [ 43 , 44 ], and we have argued previously that supporting pain self-management should be core business for all clinicians working in cancer care [ 45 ]. The ‘coaching’ approach needed to empower patients to recognize themselves as ‘experts’ on their pain and equal partners with clinicians in its management is iterative rather than a single event, and is ideally built on established and ongoing therapeutic relationships of trust with a particular team member. However, findings from patient education research more generally suggest that patient education and behaviour change is also optimally supported when key messages are reinforced by differing disciplinary perspectives [ 46 ]. Results from the current study suggest that these principles of pain care need more formal recognition within the scope of practice of oncology clinicians to ensure they are afforded sufficient time alongside anti-cancer treatment and related supportive care. Findings also indicate that clinicians may require training in the person-centred, partnership-oriented aspects of pain care beyond the educational approach used in the Stop Cancer PAIN Trial and other research [ 47 ]. Such training should be repeated regularly to ensure it reaches the majority of personnel at cancer centres, allowing for turnover.

Limitations

The current study had several limitations. Transferability even within Australia is limited by a focus on metropolitan services in only three out of eight jurisdictions. Data relied on clinician perspectives, and the response rate was less than one quarter of personnel at each centre, with the disciplines and specialties of participants being unrepresentative of centre workforces. Over-sampling of medical compared to nursing personnel likely reflects the fact that all clinical champions were medical consultants, while the predominance of palliative care physicians among medical participants presumably arises from the central focus this specialty has on pain care. Notably, our sample included no perspectives from allied health disciplines, despite the important roles these can play in non-pharmacological pain management. Confirmability was threatened by the potential for cognitive bias among researchers towards a favourable view of the intervention given their long-standing investment as members of the project team. We attempted to offset this by explicitly inviting criticism of the intervention from participants, and having the initial analysis conducted by researchers with no prior involvement in the project. A final limitation concerns reliance on the COM-B Model for analysis rather than an alternative framework or more inductive approach. While the COM-B has been widely used to explore barriers and facilitators across a wide range of healthcare interventions, we applied the model in a somewhat novel way to systems and processes as well as individuals’ behaviour after finding that participants perceived their agency to be majorly constrained by these. An implementation framework such as the integrated-Promoting Action on Research Implementation in Health Service (i-PARIHS) framework (iPARIHS) [ 48 ] or Consolidated Framework for Implementation Research (CFIR) [ 49 ] would have conceived of factors and their relationships in alternative ways that might have proven equally informative [ 50 ].

This qualitative sub-study elucidated important factors influencing the success of guideline implementation strategies at six cancer centres in the Stop Cancer PAIN Trial. Findings underscore the value that a qualitative approach offers for understanding the role of context when evaluating complex interventions [ 51 ]. Ultimately, the Stop Cancer PAIN Trial may have been overly ambitious in the scale of its intervention, especially given limited resources available at each centre. Further research is needed to understand how multi-component guideline implementation strategies can be optimally introduced within the context of local roles, systems and processes.

Availability of data and materials

The qualitative interview datasets generated and analysed during the current study are not publicly available due to the conditions of ethical approval which acknowledge the risk of participant re-identification.

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Acknowledgements

The authors would like to dedicate this article to the memory of Sally Fielding, who worked as a valued member of the project team throughout the Stop Cancer PAIN Trial. We would also like to acknowledge the contributions of project manager A/Prof Annmarie Hosie, data manager Dr Seong Cheah, and research assistant Layla Edwards.

This research was supported by a grant from the National Breast Cancer Foundation.

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TL, JP, MA, PMD, TS, DCC, FB, LL, NM and ML contributed to the concept and design of this research. TL, LR, MR, MG and ML contributed to the acquisition, analysis or interpretation of the data. TL and ML contributed to drafting of the manuscript. All authors contributed to revisions of the manuscript and approved the final version.

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Luckett, T., Phillips, J., Agar, M. et al. Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial. BMC Health Serv Res 24 , 969 (2024). https://doi.org/10.1186/s12913-024-11243-1

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DOI : https://doi.org/10.1186/s12913-024-11243-1

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