Background
There has been an increased emphasis on engaging clinicians into management [
1]. While the focus on efficiency, effectiveness and quality of care has played a role in public discourse, others point to the engagement of clinicians being critical to successful healthcare reforms [
2]. There have also been attempts to co-opt clinicians into management roles in response to the shortcomings of New Public Management and professional resistance towards top-down initiatives and directives [
3‐
5]. Researchers have argued that policy makers fail to understand professional social structures that could threaten the effectiveness of policy drives and management reforms designed to engage clinicians in management [
6,
7]. Resistance to change and conflicts in health care organizations may be rooted in power struggles and the organizational structure. There has been little research on the ways in which managers with a clinical background exercise influence. Understanding more about the factors that determine their influence strategies may be important for training and support.
In Norway, a new law required unitary management at all levels in hospitals from 2001 [
8]. Previously, hospitals had been run by doctors and nurses in two parallel hierarchies. Unitary and “profession neutral” management was enforced to strengthen accountability and professionalize management. Managers became responsible for all employees in a department, and a manager with a nursing background would be managing the doctors in a department and vice versa. The model departs from governance models commonly used in other countries, where the main responsibility for running clinical departments usually lies with a doctor, either alone or together with a general manager and a nurse [
9]. The Norwegian case represents a unique opportunity to study the variations in influence strategies used by managers with a clinical background.
Aim of the study
We did a study to explore influence strategies used by doctors and nurses who are managers in hospitals with a model of unitary and profession neutral management at all levels.
Theoretical perspectives
Hybrid management
The terms “hybrid leadership” and “hybrid management” have been used to describe managers who combine a professional background with managerial skills and responsibilities [
5,
10]. Within healthcare, the term “hybrid” reflects an underlying assumption that medicine and management represent two different logics, and that a hybrid manager is able to embody, translate and mediate between the logics of management and medicine [
5,
11‐
14]. The term is used to refer to doctors [
10], but has also been used to describe nurses and other professionals [
15,
16]. Savage and Scott [
17] have defined hybrid management as “a new type of management in which non-medical health care professionals engage in aspects of general (or ‘generic’) management, combining this with their clinical management responsibilities”. While there are national differences in how clinicians have reacted to top-down initiatives, new hybrid roles have appeared in several countries, including Denmark, Finland, England and Australia [
4,
14,
18].
In this study, we focus on clinicians in formal management positions who may or may not retain a role in clinical work. These managers could also be described as “hybrids”, as they combine a professional background with a formal position in management.
Influence and power
Power may be defined as “the ability to affect others’ beliefs, attitudes, and courses of action” [
19]. Hospitals are sites for continuous exercise of influence and power, including competition over resources, jurisdiction, tasks and mindsets [
20‐
22]. The language of “battles” and “fights” has been especially apparent in the sociological literature, such as in the work of Abbott [
20] on the system of professions and Freidson's [
23] work on professionalism and professionals’ claims of expertise. The literature on hybridity reflects these struggles, and Waring and Currie [
24] have shown how managerial expertise can be detached from managers and drawn into professional practice, enabling professionals to extend their influence over management and avoid unwanted interference in their work.
Mintzberg [
25] has described hospitals as “professional bureaucracies” in which power resides in expertise through knowledge and skills. These organizations are characterized by an inverted power structure, where front-line staff usually has more influence over daily decision making than those in formal positions of authority. Managers need to acknowledge this culture when negotiating with staff [
26]. Braithwaite and colleagues [
27] assert that their jobs “are more about negotiation and persuasion than command and control”. French and Raven have published a typology of various power bases [
28]: legitimate (having a formal position or title), reward (ability to compensate another for compliance), expert (superior skills, experience and knowledge), referent (perceived attractiveness) and coercive (ability to punish others for non-compliance). Informational power (potential to utilize information) was later added as a sixth power base [
29]. Building on French and Raven’s [
28] framework, Northouse [
19] distinguishes between position power, the power an individual derives from a position or status that embodies notions of legitimate, reward and coercive power, and personal power that embodies the notions of referent and expert power [
19]. We hypothesized that a hybrid managers’ professional background could have an impact on what power bases they had access to.
Role as resource
Roles are often defined as the behavioral expectations associated with and emerging from positions in a social structure [
30]. Usually, structures will be a constraining feature of social roles, while interactionist perspectives highlight independence and agency in role-playing [
31]. The theory of role as resource is an example of an agent-centered perspective. Baker and Faulkner [
32] found that filmmakers used different roles, such as producer and screenwriter, strategically to gain legitimacy, underscoring that roles can be used as platforms for exercising power and influence. Callero [
33] followed up on this idea, arguing that roles, being cultural constructs, could both facilitate and constrain. Roles enable access to cultural, material and social resources, and an individual in a given role can exploit these to pursue personal or group interests. Firstly, a minimum level of cultural endorsement or acceptance needs to exist for a role to be used as a resource. Stronger acceptance of the role increases its accessibility as a resource. Secondly, Callero [
33] makes an analytical distinction between cultural endorsement and cultural evaluation. Although a role might be recognized and perceived as legitimate, it can simultaneously be evaluated in a negative light. Thirdly, roles with high prestige become more effective tools for gaining power. Callero argues that these types of roles tend to require long-term education (specifically mentioning doctors as an example), be severely limited in number, or require a highly valued commitment to the role.
Hybrid managers combine a professional background with a formal position or status as manager [
1], and they often move in and out of roles [
34]. The focal point of interest in our study is the manager’s role as doctor or nurse. Doctors generally hold a high social and cultural position within society [
35]. Compared to nurses, doctors have higher income, longer education and more professional autonomy. Both professions have high degree of cultural endorsement, but evaluation and prestige is usually lower for nurses, a pattern seen in society in general, as well as in hospitals [
36]. We believe that the differences in status may have an impact on how they use their professional role as a resource. We anticipated that there may be differences in their access to power, and, consequently, what strategies they use to exert influence. Viitanen and Konu [
37] studied the leadership roles that were used by middle managers in Finnish health organizations, and nurses more often took on a mentor and facilitator role compared to doctors, who were more task-oriented. Furthermore, hybrid managers are located in-between a managerial and clinical mindset. While the former emphasizes a hierarchical approach towards power and influence, the latter emphasizes decentralized decision making [
38]. We therefore expected that managers’ influence strategies vary according to whether they seek to exert influence upwards (towards a managerial mindset) or downwards in the hierarchy (towards a clinical mindset).
Results
Managers with a nursing background argued that medical doctors could more easily gain support for their views. Nurses reported deliberately not disclosing their professional background, and could use a doctor as their agent to achieve a strategic advantage. Doctors believed that they had to use their power as experts to influence peers. Doctors attempted to be medical role models, while nurses spoke of being a role model in more general terms. Managers who were not able to influence the system directly found informal workarounds. We did not identify horizontal strategies in the observations and accounts given by the managers in our study.
We have organized the results in two sections: the strategies that managers used to influence upwards in the management hierarchy (towards their supervisor and top management), and the strategies they used to influence downwards in the organization (towards section managers and the professional staff). Table
2 summarizes the variety of strategies used by the managers in our study, and how they relate to different bases of power. We describe these in detail below.
Table 2
Examples of the variation in influence strategies used by managers in our study, and how they relate to different bases of power [
28]
Upwards in the hierarchy
| |
Advance professional considerations/concerns | Expert |
Use a doctor as one’s agent to increase argumentative strength | Expert |
Use different titles strategically | Expert |
“Whine”/argue that “everybody else gets more resources” | Informational |
Avoid shouting “wolf” too often | Informational |
Sabotage | Coercive |
Downwards in the hierarchy
| |
- Be a professional role model (e.g. performing surgery) | Expert |
- Challenge arguments (e.g. “I have done this procedure before”) | Expert |
- Be a general role model (e.g. arriving early to work) | Referent |
- Be a facilitator (e.g. doing the “crappy” work) | Referent |
- Rephrase and redefine language | Informational |
Influencing upwards
Participants told that they attempted to emphasize their employees’ competence when arguing upwards in the organization. They believed that they had to present professional arguments in order to be heard, but also expressed distrust towards the higher level managers, feeling ignored or being misunderstood. A department manager with a medical background told how he had rearranged his working day to make a point:
The management thinks that [our department] hospitalizes too many patients, based on some numbers from a few years ago. We hospitalize more patients than another hospital in our health trust. The other hospital sends them to another hospital and never sees them. It’s a very complicated and expensive patient group, the other hospital doesn’t have that at all, while it’s a large part of our activities. […] And those numbers don’t take into account the travel distance. Some patients travel three hours to get here. Elderly, complicated illnesses. Are we going to send them home again with a taxi? That’s expensive.
[They said] “we have to do something about it”. And then I said: “Ok, everything will go through me. No one can hospitalize a patient to this department without going through me”. I did this for several weeks. It didn’t really influence the number of admissions.
Interviewer: Did you communicate this to the top management?
Yes, but it isn’t so easy to, you know, what we are talking about now are excuses. The figures [emphasized by the participant] are there. They deal with the figures. And then we have to show that we are doing something about it. And what we do is that I deal with these admissions myself.
The participant spoke of this as a form of “sabotage”, as a way of making his concerns visible and being heard upwards, even though it prevented him from performing his other managerial tasks: “It has influenced my work day to the point where it has become almost impossible”. It was important for participants that their superiors understood their work and the challenges they had to manage. The manager took on these tasks because he experienced that the management was only interested in figures, without asking what was behind them. This was a frequent concern, and utterances such as “the management level above doesn’t know our day-to-day reality” were frequent. In cases where department managers experienced that they were not able to persuade higher level managers through professional or logical arguments, they found ways of sabotaging or circumventing the system, as illustrated above. There were also other examples of workarounds and sabotage. A department manager spoke of circumventing the system by calling IT-support directly on their mobile phone. This was faster and more efficient than going through the formal system for contacting technical support:
We have people we can use when we understand how to circumvent the system. We have their private mobile phone numbers and can call them unofficially and say “you have to help me”. “Well, I’m not allowed, but I’ll come”. We make it work that way. But it’s absolutely unofficial and illegal. Because it’s not supposed to be like that. And they get reprimanded if they help us, unless it’s through the service phone or the helpdesk phone.
During one of the observations, a department manager with a medical background suggested to one of his section managers that they could buy modern, experimental equipment, and when other necessary equipment would be broken, the health trust would have to replace that equipment. This would be a way of ensuring additional medical equipment, without having to use the existing money on upgrading old equipment.
Budgets were described as something one had to “fight” for. A manager with a nursing background told that she had managed to “whine” herself into acquiring a new member of staff, by saying “why should the other [departments] have more staff than us, when we have just as much to do”. Another participant spoke of the importance of not complaining or shouting “wolf” too often, in order to be taken seriously by one’s supervisor.
Nurses in section management positions spoke of benefits of having department managers with a medical background, because their department would stand stronger in negotiations for budgets and resource allocations:
…and then you can say that in some battles it would be an advantage or disadvantage if my supervisor was a nurse or doctor, you know, will the nurse be as strong in all situations and discussions as if the person had been a doctor instead. Because the doctors have strong credibility in the system.
Some managers with a nursing background used their medical advisors strategically to carry their own agendas across. An example is provided below:
And it happens sometimes, when I’m arguing for certain issues, when I’m going into discussions with groups of doctors […] I may consciously use the senior consultant to strategically front my views. There are some that think, or at least I think that a part of the system regards your arguments as weak when you don’t have that medical background, unfortunately. So I sometimes push the head senior consultant [doctor] strategically in front of me to win through (department manager with a nursing background).
A section manager with a nursing background told that she had sometimes used her job title strategically. Following changes in organizational titles, her title had changed from “department nurse” to “section manager”. Although she still used her old title, because she liked the connection to her profession, she made sure to change from the less powerful “department nurse” title to the more ambiguous “section manager” to gain leverage in strategic situations:
What I have sometimes used it for, the section manager title, is related to authority, it gives a little more authority to say that you are a section manager, I’ve experienced. For example, if we have to contact the chief district doctor. I’ve noticed that another title can be useful in those circumstances. Then you get more impact. I’m also a deputy for the department manager, so I’ve used that as well. I’ve had a sign where it said “deputy for the department manager”.
Influencing downwards
A recurrent theme in the accounts given by the doctors, was the importance of being perceived as a competent clinician in order to be taken seriously by the medical staff. A surgeon described it with the following example:
If a non-doctor attempts to take medical decisions it usually goes wrong. Not because the decisions are bad, but because they don’t get support from below… and that’s why it has been important for me to demonstrate that, yes, I am doctor, yes, I understand what we do and yes, I can contribute. And that’s why I also made a point of going in and doing a complicated procedure, because nobody else were able to do it, because the guy who was supposed to do it was ill, and a patient coming from a city [1,600 kilometers away in distance] would have to be sent home. And then I did it, even if it messed up my day. Because it gives, you know, afterwards people talk about it and say “yeah, at least he is able to contribute and work”, and that gives respect among surgeons.
Another influence strategy mentioned by participants with a medical background was to become good at a particular niche in their professional field. This served as a form of compensation for clinicians who had to cut back on the time spent in the clinic, because of increasing management responsibilities. “One strategy is to become very good at one specific thing, for example pacemakers. The doctors will say: ‘well, he can’t really do that much surgery, but he is really good with pacemakers’” (a department manager working within a surgical department).
Nurses were more concerned with profession neutral ways of appearing as role models. In the example below, a department manager with a nursing background told of the importance of arriving on time for meetings:
The attitude one radiates, it influences, like expectations, you know. For example, when we meet in the morning at eight for joint meetings and when someone holds a lecture like today, then I think it’s rude to arrive five or seven minutes late. It interrupts and it’s impolite towards the person who has spent hours to prepare the presentation. It’s obvious that if I come dragging myself in five six seven minutes late every day or every other day, it will give signals. That these things are ok to do.
Although nurses told that they were proud of their nursing background, they appeared to downplay their professional background, emphasizing instead their role as facilitators or someone who took care of the “crappy things” for the doctors. One of the department managers with a nursing background told that she was challenged by doctors on how they would be able to do clinical research in the department:
When I began as a manager and was a nurse, then you hear that thing about “how are we going to do research in our department?” I say that I will facilitate so that you can conduct research. I will take all those crappy things outside, the practical things, you won’t have to sit and talk with all these people about whether you need to fill out this or that form. […] They won’t need to have to do all that. I think that’s really important for the doctors, that they feel that someone can take all of those things and that they can do their own things. Facilitating, enabling them to do it.
Participants also spoke of the importance of having worked among front-line staff. A participant with a medical background commented:
It’s worth its weight in gold that I have worked on the floor, then I know as a manager how things work, and what’s realistic and can say “it’s not like you say”. How can you prioritize between all the demands from the different section managers, if you don’t know what goes on in the department and how useful the different devices are?
Observations of participants in meetings and in discussions with staff provided examples of how their professional knowledge and experience became relevant when confronted by staff. In one situation, a department manager with a nursing background “won” a dispute with a section manager (also with a nursing background), because the former had previous experience with a specific intervention that they were discussing. The section manager tried to argue against the current organizing of syringes in relation to the intervention, to which the department manager disagreed. The department manager effectively ended the dispute by stating: “I have done those interventions myself”. While nurses generally appeared to downplay their professional background in negotiations with medical staff, this example illustrates that they could still use their nursing background strategically to “win” arguments against other nurses.
Participants did not only rely exclusively on their professional skills and experience in negotiations with staff. Observations of the participants also showed that both doctors and nurses engaged in rephrasing. A department manager was observed in a meeting with his section managers. He explained that the hospital would only get one new anesthetic machine, but the section managers replied: “We need more”. The department manager attempted to calm the situation by saying: “If we are going to have a ‘who has it the worst’, then [another hospital in the health trust] has it the worst”. “We need more” was in this way redefined to “others have it worse”.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors were involved in the design of the project. IS carried out the observations and interviews. JCF and LEK provided assistance with coding and analyzing data from the interviews. The drafts of this article were revised critically by all authors. All authors have approved the final version of the manuscript.