Clinical management as boundary management. A comparative analysis of Canadian and UK health-care institutions

Beyond hybrid professionals: evidence from the hospital sector

Background

The involvement of doctors in managerial roles seems to be the solution to reducing the friction between traditional professionalism and modern organizational paradigms. However, these “hybrid” professionals responded in different ways to these conflicting demands, and we need to better understand the contextual factors that explain such variation.

Methods

The paper studies hybrid professionals in a hospital characterized by numerous organizational changes. The site is located in Italy, a country in which healthcare organizations have been exposed to managerial reforms for years but where the degree to which professionals embraced management varies. A longitudinal case study was performed that involved gathering data through multiple sources of evidence to understand the complex organizational dynamics that take place in the hospital.

Results

The analysis shows that the taking up of hybrid managerial roles is enabled by a number of interrelated features of the social/organizational context. Professionals willing to become hybrids were favored by the support provided by the organization. While for those doctors initially more reluctant towards medical management, distinctive contextual factors, in particular, the presence of space for interaction with colleagues within the professional domains but beyond disciplinary boundaries, was of key importance. This second group also proved capable of interiorizing organizational values and practices in a reconfigured way.

Conclusions

In order to understand hybridization, it is necessary to look beyond hybrids at the context surrounding them. This study provides evidence for scholars and practitioners willing to understand how medical management is evolving and how this transition can be supported, and it contributes to the literature on hybrid managers by showing how contexts facilitating social interactions enable professionals’ hybridization.

Trial registration

The article does not report the results of a health care intervention on human participants, and material used in the research did not need ethical approval according to Italian law.

Making doctors manage… but how? Recent developments in the Italian NHS

Background

Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate.

Methods

This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant “lab” to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management.

Results

We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector.

Conclusions

This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are “forced” or willing to take formal management roles.

Organisational professional conflict and hybrid clinician managers: the effects of dual roles in Australian health care organizations

PURPOSE

This article aims to examine tensions between hybrid clinician managers' professional values and health care organisations' management objectives.

DESIGN/METHODOLOGY/APPROACH

Data are from interviews conducted with, and observation of, 14 managerial participants in a Cancer Therapy Unit set in a large teaching hospital in New South Wales, Australia, who participated in a Clinical Leadership Development Program.

FINDINGS

The data indicate that there are tensions experienced by members of the health care organisation when a hybrid clinician manager appears to abandon the managerial role for the clinical role. The data also indicate that when a hybrid clinician manager takes on a managerial role other members of the health care organisation are required concomitantly to increase their clinical roles.

RESEARCH LIMITATIONS/IMPLICATIONS

Although the research was represented by a small sample and was limited to one department of a health care organisation, it is possible that other members of health care organisations experience similar situations when they work with hybrid clinician managers. Other research supports the findings. Also, this paper reports on data that emerged from a research project that was evaluating a Clinical Leadership Development Program. The research was not specifically focused on organisational professional conflict in health care organisations.

PRACTICAL IMPLICATIONS

This paper shows that the role of the hybrid clinician manager may not bring with it the organisational effectiveness that the role was perceived to have. Hybrid clinician managers abandoning their managerial role for their clinical role may mean that some managerial work is not done. Increasing the workload of other clinical members of the health care organisation may not be optimal for the health care organisation.

ORIGINALITY/VALUE

Organisational professional conflict, as a result of hybridity and divergent managerial and clinical objectives, can cause conflict which affects other organisational members and this conflict may have implications for the efficiency of the health care organisation. The extension or duality of organisational professional conflict that causes interpersonal or group conflict in other members of the organisation, to the authors' knowledge, has not yet been researched.

Analysing structural and cultural change in acute settings using a Giddens-Weick paradigmatic approach

An examination of the salient literature on hospital clinical directorates (CDs) is presented. A critique of the largely managerialist, instrumental, hortatory and normative extant literature about CDs is offered. In analysing the literature this way the earlier promotional and critical literature is eschewed in favour of an evaluative approach. CDs are then reconceptualised by locating them within two overarching accounts of social structure--formalised, prescribed frameworks, and enacted, patterned interactions--following the kinds of distinctions made by Giddens, Weick, social action and institutional theorists. Social structure as it relates to culture is also considered, following Martin. Such an approach facilitates an understanding of the general weaknesses of health service perspectives and methods of analysis, and exposes the strengths of Giddens-Weick type paradigms.