Clinicians into management: the experience in context

Involving clinicians in management: assessing views of doctors and nurses on hybrid professionalism in clinical directorates

BACKGROUND

Hybrid professionalism is one of the most effective ways to involve clinicians in management practices and responsibilities. With this study we investigated the perceptions of doctors and nurses on hybridization in clinical directorates (CDs) in hospitals.

METHODS

We investigated the attitudes of healthcare professionals (doctors and nurses) towards eight hospital CDs in the Local Health Authority (LHA) of Bologna (Emilia Romagna, Italy) 6 years after their implementation. We used a validated questionnaire by Braithwaite and Westbrook (2004). Drawing on Palmer et al. (2007), we added a section about the characteristics of department heads. In all, 123 healthcare professionals in managerial roles completed and returned the questionnaire. The return rate was 47.4% for doctors and 31.6% for nurses.

RESULTS

Doctors reported an increase in clinical governance, interdisciplinarity collaboration, and standardization of clinical work. Hybridization of practices was noted to have taken place. While doctors did not see these changes as a threat to professional values, they felt that hospital managers had taken greater control. There was a large overlap of attitudes between doctors and nurses: inter-professional integration in CDs fostered alignment of values and aims. The polarity index was higher for responses from the doctors than from the nurses.

CONCLUSION

The study findings have implications for policy makers and managers: mission and strategic mandate of CDs; governance of CDs, leadership issues; opportunities for engaging healthcare professionals; changes in managerial involvement during the COVID-19 pandemic. We also discuss the limitations of the present study and future areas for research into hybrid structures.

Managing Doctors and Saving a Hospital: Irony, Rhetoric and Actor Networks

This article examines the changing configuration of professional-management relations within the English health service, focusing on hospital doctors and managers. It draws on a case study of a hospital apparently under threat of closure during a period when management is pursuing a policy of attempting to rationalize medical work, for example, by expanding day surgery. At the same time, the strategies of medical staff for the defence of their professional interests are also explored. The usefulness of rhetoric, irony and actor-network theory for the analysis of the threatened hospital closure and the implications for professional-managerial relations is explored within the broader context of `governmentality' (Foucault).

Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal

BACKGROUND

The need of improving the governance of healthcare services has brought health professionals into management positions. However, both the processes and outcomes of this policy change highlight differences among the European countries. This article provides in-depth evidence that neither quantitative data nor cross-country comparisons have been able to provide regarding the influence of hybrids in the functioning of hospital organizations and impact on clinicians' autonomy and exposure to hybridization.

METHODS

The study was designed to witness the process of institutional change from the inside and while that process was underway. It reports a case study carried out in a public hospital in Portugal when the establishment of a clinical directorate was being negotiated. Data collection comprises semi-structured interviews with general managers and surgeons complemented with observations.

RESULTS

The clinical directorate under study illustrates a divisionalized professional bureaucracy model that combines features of professional bureaucracies and divisionalized forms. The hybrid manager is key to understand the extent to which practising clinicians are more accountable and to whom given that managerial tools of control have not been strengthened, and trust-based relations allow them to keep professional autonomy untouched. In sum, clinicians are allowed to profit from their activity and to perform autonomously from the hospital's board of directors. The advantageous conditions enjoyed by the clinical directorate intensify internal re-stratification in medicine, thus suggesting forms of divisionalized medical professionalism grounded in organizational dynamics.

CONCLUSION

It is discussed the extent to which policy change to the governance of health organizations regarding the relationship between medicine and management is subject to specific constraints at the workplace level, thus conditioning the expected outcomes of policy setting. The study also highlights the role of hybrid managers in determining the extent to which practising professionals are more accountable to managerial criteria. The overall conclusion is that although medical and managerial values link to each other, clinicians reconfigure managerial criteria according to specific interests. Ultimately, medical autonomy and authority may be reinforced in organizational settings subject to NPM-driven reforms.

Social identity and self-enactment strategies: adapting to change in professional-manager relationships in the NHS

Significant variation has been identified concerning the impact of management agendas on health professionals in the National Health Service. While attempts to explain these responses among health professions have identified a range of factors to account for such differences, existing research is still unable to explain the sources of variation that can occur within professional groups. Current approaches to studying professional-management relations either attempt to explain variation between organizational contexts and subgroups at a collective level of analysis or they struggle because of the absence of a theoretical framework capable of integrating social, psychological and contextual elements that can explain the sources and purposes of differentiated individual and group behaviours. In the present study, we argue that if we are to go beyond the mere mapping of broad outcomes, we need to develop an understanding of how the effects of imposed managerial agendas on health professional groups come to evolve and take shape. In particular, this requires us to identify a social psychological process framework that can help explain how initiatives aimed at managerializing roles and responsibilities affect the professional employees' understandings of group membership and their relations with hospital management. By using interview data from a group of 18 hospital doctors and through a comparative grounded analysis we show how a social identity perspective may provide a suitable framework to develop verifiable explanations of this process and its implications for nurse managers.

Giving Voice to Health Professionals' Attitudes About Their Clinical Service Structures in Theoretical Context

Within the context of structural theories this paper examines what health professionals say about their clinical service structures. We firstly trace various conceptual perspectives on clinical service structures, discussing multiple theoretical axes. These theories question whether clinical service structures represent either superficial or more profound changes in hospitals. We secondly explore which view is supported though a content analysis of the free text responses of 111 health professionals (44 doctors, 45 nurses and 22 allied health practitioners) about their clinical service structures in a questionnaire survey in two large hospitals that had implemented clinical service structures three years previously. Commentaries unfavourable toward clinical service structures were made by 47.7% of staff, favourable by 24.3%, mixed (both favourable and unfavourable) by 17.1% and non-evaluative statements were made by 10.8%. The most frequent criticisms were inefficient organisation of change (27%), poor management (24.3%), lack of cooperation between staff (15.9%) and failure to empower health practitioners (13.5%). All professions made more negative than positive evaluations of their clinical service structures but the ratio was highest for doctors and lowest for allied health. Ranking of nurses' and allied health staffs' specific evaluations were similar but both differed significantly from doctors'. Unfavourable or negative comments predominated, and change appears more superficial and less profound than advocates of structural contributions hope. Four types of belief systems about clinical service structures are apparent. Some study participants are disposed toward the status quo; others toward restructuring; yet others are team oriented; and a final group is tribally oriented. The implication of this paper for managers is that more work is needed if clinical service structures are to realise the promise of more multi-disciplinarity and less fragmentation across professional groups. For scholars, the implication is that marrying different theoretical frames with empirical data can serve to produce fresh perspectives and perhaps new insights.

Converging patterns in hospital organization: beyond the professional bureaucracy

This study builds a framework to investigate the current trends emerging in hospital organizational design and its main consequences on human resources management. The analysis derives from an extensive literature review, which shows over the last 30 years a significant lack of works on organization design for hospitals, and from a number of experiences in hospital settings, which provide useful insights on changes taking place in hospitals. We intend to contribute to the filling of the gap in literature created by the lack of interest scholars have shown on hospital organization. The framework we discuss depicts the major converging trends of reorganization that can be observed in hospital contexts of industrialized countries. What we found is that large multi-specialty hospitals--by large we mean hospitals over about 300 beds--located in different countries, though starting from different internal and external organizational and environmental features are mostly converging towards a common design scheme. We labelled that scheme the care-focused hospital and we analysed in-depth its features in the attempt to facilitate cross-national comparison, otherwise difficult due to the fact that organizational concepts are value loaded and tend to be culture-bound. Challenges and managerial implications of this more and more widely diffused organizational paradigm are debated in the last part of the study.

A tale of two hospitals11We draw on the title from Charles Dickens. He opened his famous novel A tale of two cities (London: Signet, 1859/1997) with the lines “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness”.: assessing cultural landscapes and compositions

Clinical directorate service structures (CDs) have been widely implemented in acute settings in the belief that they will enhance efficiency and patient care by bringing teams together and involving clinicians in management. We argue that the achievement of such goals depends not only on changing its formalized structural arrangements but also the culture of the organisation concerned. We conducted comparative observational studies and questionnaire surveys of two large Australian teaching hospitals similar in size, role and CD structure. Martin's conceptualization of culture in terms of integration, differentiation and fragmentation was applied in the analysis of the data. The ethnographic work revealed that compared to Metropolitan Hospital, Royal Hospital was better supported and more favourably viewed by its staff across six categories identified in both settings: leadership, structure, communication, change, finance and human resource management. Royal staff were more optimistic about their organisation's ability to meet future challenges. The surveys revealed that both staff groups preferred CD to traditional structures and shared some favourable and critical views of them. However Royal staff were significantly more positive, reporting many more benefits from CDs e.g. improved working relations, greater accountability and efficiency, better cost management, more devolvement of management to clinicians and a hospital more strategically placed and patient focused. Metropolitan staff were more likely to claim that CDs failed to solve problems and created a range of others including disunity and poor working relationships. There was greater consensus of views among Royal staff and more fragmentation at Metropolitan where both intensely held and uncertain attitudes were more common. The outcomes of implementing CDs in these two similar organisations differed considerably indicating the need to address cultural issues when introducing structural change. Martin's framework provides a useful antidote to researchers' tendency to focus at only one level of culture.

Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates

OBJECTIVES

To examine assumptions made by proponents and critics of clinical directorate (CD) structures in hospitals. Proponents argue that CDs are supported by the health professionals who constitute them and confer organisational and clinical benefits compared with traditional structural configurations. Critics deny these benefits and suggest CDs can compromise clinicians by incorporating them into management, to their cost. We investigated the attitudes of health professionals working in CDs to gather and consider evidence for these claims.

METHODS

A questionnaire survey of 227 health professionals (78 doctors, 89 nurses and 60 allied health) in two large hospitals in Australia that had implemented CDs three years previously.

RESULTS

Respondents were more negative than positive about CDs. Significant attitudinal differences were found between professions. Doctors were the most negative and held their attitudes with the greatest certainty and intensity. Allied health staff were the most positive but their attitudes tended to lack strength or certainty. Nurses' attitudes were polarised and intense but more positive than were doctors'. Increased organisational politics was cited by 58% of respondents as CDs' most frequent effect, followed by improved accountability (48%) and dumping hard decisions on staff (39%). Only 26% thought patient care had improved.

CONCLUSIONS

Clinical directorates were designed to promote team approaches and to improve patient care delivery, but the results call for a rethink of what can be expected from structural reforms in organisations.

Power versus participation in health service teams: a delicate balance

The purpose of this paper is to critically review the effectiveness of a participative management approach within health service teams. It questions the reality of staff empowerment as an essential product of this approach, and examines the influence of power issues on the degree of empowerment that the organization may allow. The benefits and challenges of staff participation are highlighted, with reference to the manager's role in the participation process. The article concludes by advocating the positive use of power in order to maintain the integrity and effectiveness of a participative management approach.

Marketing healthcare: lessons for smaller hospitals

Recently, I have noted ubiquitous trends that lead me to conclude that we are on the brink of a fundamental change in the structure of healthcare delivery. Hospitals are changing. The hospital, that enduring and pervasive organization, which for decades has delivered the vast majority of acute care services is being re-conceptualized. Administrators and executives in today's hospitals are beginning to recognize the disaffection of constituents and the necessity to change from placing their own agenda or that of their profession over the needs of the customer. A lesson that is increasingly being heeded, particularly by the leading hospitals, is that a belief in one's own importance or a feeling of invulnerability represents an anachronistic stance. No hospital today can afford to retain a view that it is more important than the patients it serves, or that it is invulnerable. The external pressures are already clear--the actors, factors and forces in the external environment are forcing hospitals to re-evaluate efficiency, effectiveness and delivery arrangements. The rise to prominence of the outcomes movement is part of this trend. The present study was an attempt to assess the practices and trends in the modern smaller hospitals as a part of their strategy to match the competitive pressures.

Health-care professionals and management development

Discusses the impact of a self-governing hospital trust's accredited management development programme designed for health-care professionals responsible for managing natural clinical groups. The programme was a dual qualification: a level 5 national vocational qualification in management, and a diploma in management. Identifies key issues resulting from this type of programme. Discusses participants' evaluation of the two different formats for management development. Highlights the reservations of health-care professionals in respect of competence-based management development, particularly regarding assessment of their work performance. Recognizes that when a group of senior health-care professionals are involved in a long-term in-house management development programme, they may be perceived as a threat by senior management. Concludes that health-care professionals will only engage proactively with management development activities which they perceive to have value for them.

Defining the role of the consultant psychiatrist in a public mental health service

OBJECTIVE

The aim of this paper is to clarify elements of the role of a psychiatrist working in the public sector.

METHOD

The relevant literature was examined to help clarify some of the reasons psychiatrists have been leaving the public sector and to help define the key roles of a psychiatrist working in the public sector.

RESULTS

Two principal roles for the consultant psychiatrist in the public sector are identified: the psychiatrist as a clinician and the psychiatrist as a manager. The management role is contrasted with the role as an administrator and important differences between these roles are identified. The management role includes planning, advocacy and managing human resources. The importance of professional development in the career path for the newly qualified psychiatrist is discussed.

CONCLUSIONS

The role of the psychiatrist in public sector psychiatry is a challenging and exciting one. Psychiatrists will start to return to the public sector when they recognise this new role for the consultant psychiatrist. This will be to the advantage of public sector psychiatry in general and to the job satisfaction of psychiatrists. The key features of the clinical role are the demonstration of sophisticated clinical skills, providing clinical leadership via supervision, being accountable for patient care and providing consultant opinion on complex clinical problems.

[The "Heart Area" of Juan Canalejo Hospital Complex. A new approach to clinical management]

The present work describes the process by which the pilot project of clinical management of the Hospital Complex Juan Canalejo, designated as "Heart Area", was implemented. In the first section, the needs and reasons that led to the undertaking of this project are explained. The project's objectives and operative strategies are listed. In the Material and Methods section, three basic aspects of the "Heart Area" are described: selection criteria of the "Area", its structure and function, and its foundation and development. In the Results section, we compare the activity undertaken in the "Area" to the situation present prior to its implementation, in relation to quality and costs. Finally, in the Conclusions, we comment on the important implications that our project can have within the Hospital Complex Juan Canalejo as well as in the health care field in general.

Strategic marketing and clinical management in health care: a possible way forward

This article examines and comments on the role of clinical directors in the NHS (UK), with specific reference to the relevance of a strategic marketing emphasis. It utilises qualitative methodologies to collect data from stakeholders--in particular, clinical directors and other managers--from two NHS trust hospitals. It examines the extent to which a marketing approach is applicable to clinical managers working in these two hospitals. It utilises a conceptual framework devised by Kottler and Andreason, to highlight whether a marketing approach is, in fact, utilised by these managers. It suggests that a strategic marketing approach (based upon relationships), remains relevant to clinical management, notwithstanding recent changes in government policy.

Being a clinical director: first among equals or just a go-between?

This article explores doctors' experience of the role of clinical director in a large National Health Service (NHS) teaching Trust. The advent of doctors in management, as a relatively new phenomenon in the NHS, is reviewed to provide a contextual setting for the case study. The empirical findings are presented as a 'clinical diamond' which emerged as a form that captured the multifaceted nature of the role. The research demonstrates that, for a doctor, being a clinical director potentially threatens the professional identity, collegiality and autonomy of both the individual and the professional group the directorate represents. Moreover, stress that emanates from the structural tension inherent in the role is displaced into personal and professional stress. Clinical directors embody the tensions and conflicts of different managerial and professional cultures, whilst attempting to reconcile the demands of purchasers with the views of disparate and difficult professional colleagues. The argument concludes that there is an urgent need to recognize the demands being placed upon doctors who take on this role, and identifies the benefits and challenges that the role creates in leading health care. The final section identifies the issues that need to be considered to sustain this role in future and the recognition that it has substantially increased the power base of the medical profession, but often at a high price for the individuals involved.

Analysing changes in the nature of health service management in England

Health service management maintains a balance between collective values concerned with service provision and individual values concerned with health practice. It is also balanced between the application of co-ordinative and directive approaches to management. Over the last quarter century economic and ideological factors have caused health service management to experience more directive. Today, the role of health service management becoming more directive. Today, the role of health service management appears further threatened by staffing cuts and changes in traditional patterns of organising work. This, while it may lead to bifurcation between specialist and general management roles, is unlikely to restore the dominance of practitioner values or notably soften the form of management.

The physician executive: role in the adaptation of American medicine

In the arena of managed care and large delivery systems, professional associations find it increasingly difficult to influence the environments in which their members practice. Physician executives appear likely to play key roles in the response of medicine to change. This article discusses how an analysis of the work of physicians involved in management fails to yield a clear analytic distinction between physicians engaged in management and the behavior of others who have managerial responsibility.

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.

Transforming the National Health Service. The challenge for career management

Claims that, for the 1990s, images of careers are multidimensional and individualistic. Notes that employees are encouraged to take responsibility for their own self-development, incorporate horizontal as well as vertical moves and forge careers based on "employability", i.e. learning, networking and reputation. Bases its arguments on the findings of a study into senior executives in the NHS, and explores the consequences of organizational restructuring for the careers of clinical, general and functional managers. Suggests that organizational and professional barriers exist to undermine the notion of the multidimensional career. Argues that prescriptive approaches to career self-development need to take account of organizational context and that, to meet the challenges of careers in the 1990s, both the organization and the individual need to become more willing to take risks.

Myth-management in the NHS

Reviews the role of clinical directors from outside the usual managerial framework to challenge the managerial myth applied to professionals who take on these roles. Defines management, managing, managerialism and leadership and develops an empirical framework to compare the roles of doctors and managers. Uses the framework to identify the cognitive map that clinical directors use and how they perceive their role. An emergent model illustrates how clinical directors combine a new cognitive map with their existing professional behaviours to undertake their role. Clinical directors both perceived and described their role in terms of leadership rather than management reinforcing the inappropriateness of using managerial frameworks. Instead clinical directors should be developed and evaluated as professional leaders. This raises wider questions of whether management and the language of management are either useful or appropriate for professionals in the NHS or whether their value is really a myth.

Junior doctors and management: myth and reality

Uses an empirical investigation based on a survey of junior doctors in five NHS trust hospitals, to examine their attitudes towards both the general principle of clinical involvement in hospital management and the particular prospect of exercising such a role themselves. Finds that junior doctors, with few exceptions and irrespective of grade, were very positive towards clinical management roles in NHS trusts and were almost universally keen to assume management responsibilities when they were more senior. At the same time, finds junior doctors to have little concept of the doctor manager role or the recognized and demanded specific preparation for assuming management responsibilities.