Developing leadership awareness
Many participants recounted personal characteristics that they believed had predisposed them towards entering management. A female surgeon suggested that she had inherited a natural authority from her father:
“[My father] has always been a leader. And his father was a foreman […] I believe that personalities are inherited”.
When reflecting on their careers, participants described that they had always been taking responsibility, such as taking on commissions from a young age and becoming elective representatives. They speculated that this might have prompted them to seek or accept managerial proposals, although they had not initially envisioned any career plans involving management. Other explanations were centered around being outspoken or informal leaders. This is reflected in a statement from a male surgeon, who stated:
“I have become a manager because I cannot shut up”. Some participants, mostly notably at the department level, described themselves as energetic and inclined towards seeking new challenges. One doctor cited boredom in his job as a clinician, as his work had become characterized by routine after years of experience in clinical practice:
”It becomes unsatisfying, that is a reason that I am sitting here now. […] I could perform it so well and felt so confident […] then the work day also becomes sad, kind of boring”.
He described how he had become easily bored in other situations too:
“I attempted several years ago to teach at the medical school [..] And I remember the first group of students, they were very interesting students. I used evening after evening to make nice [lecture] slides… The next group, it was ok […] and the third time I had had it up to my throat. I couldn´t be bothered to say the same things for the third time… and that probably characterizes me somewhat. I… need to have changes”.
Some participants recounted that they had a need for controlling their surroundings, while others admitted that they liked the feeling of power and being able to influence decisions. A male nurse said that he had wanted to influence decisions, but that he was not able to do this as a nurse. He said that this had sparked a desire to become a manager instead:
“I have enjoyed working in teams, but never [when] someone else has decided many things for me… and that corresponds very badly with the nursing profession […] And the need I had, contrasted with always being overridden by a professional group [doctors] with knowledge, power and authority, that suits me badly”.
Taking on the manager role
With the exception of some clinicians who actively sought the position because they wanted to seek a new and interesting challenge, or promote professional interests, many of the initial entries into management were characterized by informal ways of recruitment, often by persuasion from the current manager. Participants stated that they had not had ambitions of becoming a manager initially, but that their superior, who was either retiring from work or stepping down, persuaded them to take their place. This was a consistent account given by the participants when describing their first, and sometimes consecutive manager roles. Participants expressed a feeling of pressure following these encouragements, which drove them to apply for the position. They recounted that they knew they would effectively become the new manager, as there were rarely other applicants for the position. Some participants had to take some time to think over the offer before accepting it, because it came suddenly and unexpectedly. One nurse was unsure whether to take on the job as a department manager, because she had no experience or preparation for the role. For her, the confidence in the skills of the staff was a contributing factor for finally accepting the management proposal:
“The reason why I dared was that there were so many competent people in that department, so I thought it could not possibly be hard to be the leader of the flock here, because there is so much competence”.
A doctor who also had to take some time to think through the offer, finally accepted the proposal because of a matter of principle, as he did not want the job out of personal interest or motivation:
“But I have the view that I think it is important that also doctors are managers. Not that all managers should be doctors, but that at least some managers are doctors. […] And then I was going around thinking that if I mean that, then perhaps I have to take the consequence of that view, and then at least be a manager for a while”.
Some participants experienced a pressure to accept the management proposal due to choices they had made in the past. A nurse had taken a course in management and team building at a business school, in order to increase her managerial competence after being asked to take over as a manager assistant at her section. Shortly after, she received a phone call from her supervisor who strongly urged her to take a section management position that had opened up. Although she wanted to take some time off after finishing the course, she was eventually persuaded to take the position:
Interviewer: “What were you thinking when you received the phone call?”
Participant: “I thought that I really didn´t want to […] but I have to admit that my current boss has quite strong persuasiveness and challenged me strongly about the fact that I had gone to the business school. [My boss] said `you
do
[emphasized by the participant] mean something by that?´”
Another nurse who worked as a manager assistant was formally and automatically appointed as the section manager, after the previous manager had stepped down. Some of the participants with a medical background mentioned that the motivation to protect their own profession from external influence had pressured or driven them into taking a management position:
“Advancing the professional field was the reason for why I applied. One could say that it was kind of a negative motivation, that I saw that it wasn´t so many others that were appropriate or… more suitable to do it, myself I am perhaps more of a professional man and engaged with the profession and research, so that I believed I could contribute to preserve and develop the profession in the hospital”.
A surgeon used the words “painted myself into a corner”, when describing an attempt to prevent someone else from being chosen for a vacant management position:
“The person they were about to hire was someone I could not live with as a boss, and the others in the department could not live with as a boss either […] so I went into dialogue with the management and painted myself in a corner, where finally the only solution was that I applied for the position as department manager, something I really hadn´t planned”.
Only one participant was actively recruited to her current position as part of a formalized system, in which nurses took turns holding a section management position for a year.
The experience of entering management
Participants experienced that they had been “thrown into” the management position, and that they were unprepared for several aspects of their new position. The most significant challenges were related to the workload and understanding the language and procedures associated with budgets and HSE (health, safety and environment). Some experienced the job as lonely and wished for a mentor or colleagues with whom they could share experiences. They had a sense of being left to themselves, having to
”reinvent the gunpowder” or learn management
“on the fly”. One department manager with a medical background told that he longed for a book with “the right answers”, which he could go to when dealing with medical issues:
“We don´t have, where is the book, you know. And I can go to my book if I receive a professional question, so that I can find out what is recommended and the reference list for those recommendations and so forth. And if I bother, I can even go in and read it myself, and see if I agree, you know? And that reference list does not exist here”.
A consequence of the unpreparedness was that participants saw their days being filled with increasing workloads. Participants told that they did not have time to perform their managerial tasks in a satisfactory way, and many had a long list of unread emails. One manager had a list of several hundred unread emails. A nurse said that the unattended workload had become so large after she returned from a vacation that she “contemplated a new vacation in order to escape the workload”. A doctor who was appointed as acting manager when the previous manager went into a year-long management course, had difficulties completing tasks in time, because he continuously had to learn new terminology associated with each new task. The number of new tasks increased faster than he was able to finish the old ones. The lack of local support personnel, such as IT support and financial controllers, was also mentioned in the interviews, and several participants wished for an assistant that could relieve them of administrative work. One of the managers had to assemble new office furniture by herself. Some participants told that the lack of organizational support prevented them for practicing newly learned skills that they had acquired from external management programs; they were to busy with administrative tasks. One participant said that he experienced increased interest in management after having participated in a national top management program. The interest waned quickly after returning to work, because administrative work had piled up in the meantime. Some of the managers at the larger departments had a formal assistant, and while one of the managers described this person as ”indispensable”, because the assistant categorized her emails in a prioritized order, another said that his assistant had made the job “ more livable”.
Participants mentioned that their motivation for taking the manager role was not related to financial incentives, but doctors told that they now worked more than they had done as full-time clinicians, for less money. A recurrent theme was that the payment inherent in the manager role did not compensate for the ensuing overwork. Doctors had reduced the amount of time they spent on patients, but they usually retained some degree of clinical work.
Another theme that emerged in the interviews was the challenges related to task delegation. Some participants were unsure of what tasks they could or should delegate. A clinician who had been three months in a new department manager position felt that this affected his job satisfaction negatively:
“I think that this is
too
[emphasized by the participant] much, too much that I haven´t managed to delegate yet, because everything is new and unknown and there are too many barriers for this to be a gratifying job now. Unfortunately, I don’t really enjoy being in this role”.
Others wanted to maintain an overview of every aspect of the organization, including personally overseeing as many emails and assignments as possible. One manager had taken on so many tasks that she was unsure if she wanted to continue in management:
“Because I do feel somehow that I have become stuck, that there are many assignments, and I think many things are exciting, maybe saying yes to too many things, assignments have become pretty extensive […] it has become pretty all-encompassing”.
A third group felt guilty for burdening their assistants or managers below in the hierarchy, because they were already overwhelmed with work. One participant felt that other managers were delegating too much:
“And then we have manager assistants that can take something of course, but, it´s about how much you want to delegate to them. And some people… I feel that some people are maybe delegating too much to them”.
While the stories above were characteristic of participants who were new in the role, participants with more experience were under the impression that a good manager was someone who delegated work tasks, rather than attempting to do everything themselves. However, participants also emphasized that, unlike in private companies, they were not allowed to hire their own support personnel.
Finally, some of the nurses who had become department managers experienced resistance from medical staff. Encouragement and support from colleagues was recounted as important in the process of overcoming this resistance and learning to take unpopular decisions, as illustrated below:
“So in the beginning when I first took over as department manager, I felt that everybody at times were against me, I won´t forget that once […] everyone was angry, and then one of the doctors I know came in [to my office]… and then I cried. And then she says: `now they are tough on you´. `Yes´, I said, `now they are so tough on me that I don´t know if I can bear to be in this situation any longer´. And then she said: `remember that you were not chosen in this position so that you would be liked, you are here to do a job, and that´s why you are here´. And that´s true, it´s okay to think about that now and then”.
Observations validated the accounts that participants gave about their experiences of the manager role. Observations confirmed that clinicians struggled with terminology related to finance and health, safety and environment. There were also examples of participants receiving urgent emails and work tasks during the day which meant that other planned tasks needed to be postponed, simultaneously increasing their total workload. In one specific case, a department manager struggled to delegate work tasks to his section managers during a management meeting, because of reluctance on the latters´ part to take on the task. In the end, the issue was left unresolved, because no one volunteered or accepted to do the task. Accounts that participants gave in interviews were also repeated in discussions with other healthcare workers and colleagues, indicating consistency in attitudes.