Leadership in Norwegian hospitals: a qualitative study of clinical managers´ pathways, identities, and influence strategies

Abstract

Clinicians have a central role in the design, implementation, and improvement of care, and they exercise a key role in treatment decisions with implications for overall budgets. Increasing expectations to health care, increased costs and a growing number of older patients with complex diseases have raised public awareness towards effectiveness and quality of care. Several authors and commentators have pointed to the need to involve doctors in management in order to control resource use and costs. There has consequently been an increased interest in recruiting clinicians to management positions in health care.

The overall aim of this study is to uncover conditions for successful engagement of clinicians in management. The thesis consists of three articles that seek to explore clinicians´ journeys into management and their experiences of becoming a clinical manager (paper I); how their professional background influences their identity and transition into a manager role (paper II); and how their professional background influences the strategies that they use to exert influence in hospitals (paper III).

The thesis is based on observations and interviews with 30 clinicians in two different health trusts in Norway. While the main interest was on doctors, nurses were also included in the study to provide a contrasting lens for analyzing and interpreting the findings.

We found that the career paths of clinical managers were characterized by coincidences and peer pressure to take the position as manager, rather than deliberate choices (paper I). A common experience among participants was insufficient preparation for the required tasks for their new position. Clinicians told that they had to learn management “on the fly”, and experienced frustrations related to administrative work and challenges delegating work effectively. Doctors also experienced difficulties in reconciling the role as health professional with the role as manager (paper II). They maintained a professional identity and reported to find meaning and satisfaction from clinical work. The thesis also highlights some of the institutionalized rules and norms in hospitals, namely the perception that power relies on professional expertise and that clinical managers were more likely to draw on expert power than on formal position power (paper III). The managers´ professional background was both a resource and a constraint in this context; while nurses were mostly restrained from acting within an expert base, doctors believed that they had to draw on expert power to influence peers. Participants who were not able to influence higherlevel managers sought to find informal workarounds.

The thesis suggests that theories on role and identity increase the understanding of how clinicians experience and perform the manager role and that psychological needs for autonomy, competence and relatedness might be instrumental in effective identity building and role transition. Clinical managers who do not experience need satisfaction in their managerial role might become frustrated and instead seek satisfaction in the clinical and research aspects of their role. Decision makers and top managers should acknowledge the social structure that exists in hospitals and the limitations facing managers with different backgrounds, before implementing new management models and responsibilities. Clinicians entering management need training and preparation at an early stage, rather than having to learn important skills after becoming managers. Management programs should also acknowledge the sense of meaning and purpose imbedded in the professional role, and the sense of loss involved when clinicians enter into managerial positions.