Healthcare managers’ attempts at easing tensions and solving conflicts
Aiming to solve tensions through roles other than managers
The need for close collaboration between the administration and the line organisation, to avoid conflicts and tensions, was mentioned by the managers. However, a recurring means was to put the responsibility for this collaboration on other roles, rather than themselves as managers. The extract below illustrates a line of reasoning in which challenges in collaboration between the core operations and the administration are attributed to specific roles, particularly those associated with the expanding administrative sector
Third-line clinical manager: [High] quality of the administrative service … can only be achieved if there is close cooperation between ‘the administrators’ and us and as well as responsiveness to what we need.
Interviewer: What was/is your role [in facilitating this collaboration and managing the situation]? What could you do?
Third-line manager: There are organisational developers … they fulfil a strategic function, as well as relieving the burden and getting operations going in projects and so on. We don’t have a lot of them here, but we have a few … [and] it is important to create personal relationships with them.
In the same vein, physicians and nurses in the core operations described a reliance of organisational developers to solve organisational issues by their managers. One physician, who worked 20% with the development of care processes, describes how she is lonely in this role, and no one is there to help her navigate the organisational structures necessary to make change happen. She says that while her managers support her in one way, she cannot help with overarching organisational issues: From my clinical manager … I get the hours that I need, and that is no problem … but … it is not like that is someone I can work with concerning implementation …
What has happened, she describes, is the increase in administrative personnel, like ‘organisational developers’ who are to support organisational issues. However, those [i.e. the organisational developers] who are to help … who are employed to work with development issues, they have even weaker mandates than I … They [the organisation] have not solved this issue …
Another recurrent means to solve conflicts was to escalate conflicts to the top management. On occasions when the highest managers in the administration did not manage to solve issues with their ‘counterparts’ in the line organisation, they had to turn to members of top management, who governed both the administration and the line organisation. These were usually former clinicians, mainly physicians, and, although not seen as ‘real’ physicians, their professional status, together with their place in top management, usually made them able to solve conflicts at least in the short term and concerning specific issues.
Aiming to ease tensions through education
One conflicting issue that the managers needed to navigate was that of competence regarding the administration. There were notable differences between all types of managers in their opinions about who should work with ‘administrative’ issues in healthcare. Some managers in the line organisation alluded to the idea that people with medical education should be the ones working with ‘administration’, whereas others did not see it this way. One third-line manager in the line organisation said: “We would never accept that in any other area [in healthcare], why do we accept it when it comes to fire safety and those issues … that [for example] nurses work with these things … when they have no education for it?” (Third-line manager, physician). Other line managers had the direct opposite opinion: “The best to work in finance in healthcare are former nurses or physicians!”. Another manager, a physician by training and now responsible for several care organisations, said, concerning how she chooses who should be doing development work (as one example of an ‘administrative task’): – [the] organisational developers have been chosen wisely, they are incredibly talented clinicians! They have a passion for development! In this context, passion appears to be considered sufficient for engaging in development work, rather than formal education in the subject. Overall, while the clinical personnel are guided by formal rules regarding roles and responsibilities, the competencies required within the administration were not regulated, leading to tensions and conflicting views.
To solve the conflict and tensions currently present, one suggestion given was to educate both clinicians and ‘the administration’ about each other and each other’s roles: One healthcare director describes: We are trying to build on the classic health profession training with additional skills … and we need to do the same in the other direction. So, if an engineer or an economist or whatever comes in, to increase confidence, you need to build up skills for their sake, linked to why we work in healthcare? I think there is a key … .
The first-line managers interviewed explained that this is where the” real” work gets done. Summarising their perceptions, anything above the first line could be conceptualised as ‘the administration far away’. When/if moving from 1st line to 2nd line manager, physicians and nurses describe undergoing a “transition”. They start to see healthcare as a system and thereby appreciate the administrative staff more. This step was notably distinct, and the gap between the first- and second-line seemed large and as if between different worlds. Once having made this ‘transition’, these line organisation managers emphasised that the clinicians were the ones who needed to be educated, but that this was done less formally, here a top management administrative manager said: I need to teach the physicians about the system. Another one (top manager, former physician, line organisation) adds: I take on the role as teacher in how society functions when I meet junior doctors. This latter view seemed to be an ‘epiphany’ for those former clinicians who moved beyond first-line managers. First-line managers, on the other hand, were keener on educating ‘the administration’ about ‘the real world’.
Conflicting loyalties
Not being a manager for the administration poses problems for managers in the line organisation
Line organisation managers described challenges in integrating administrative staff into their operations, as they were not the staff’s formal manager. A second-line manager in the line organisation says: I cannot manage and distribute their [the administrative people’s] tasks, even though I would have wanted to be able to do that. A typical scenario found in the data was that a second-line manager was the head of a top-management team comprising unit heads of different units, for example, healthcare centres or wards. In this top-management team, there were representatives from the administration, for example, a development leader, an HR representative and a controller. However, these representatives were not managers with formal mandates; they delivered information that someone else has decided. The second-line manager was not their manager and was, at the same time, one level above them in the overall organisational hierarchy. One second-line manager explains: They are not my employees, but I need to make sure that they are treated fairly … . I need to step in and align the different perspectives.
Some managers spoke about loyalty, and how there was a sense of distrust between the line organisation and ‘the administration’. The issue of loyalty was described as an invisible ‘feeling that was always present’, affecting the managers. One second-line manager in the line-organisation discusses the issues of loyalties that she experienced was always there yet not spoken about: … there is this … subtle thing that you may not really talk about that is constantly present and influencing. Where does the loyalty lie? What can I talk about? Can trust these people [belonging to the administrative unit]. Can I exchange some strategic talk here now so that we can get a good budget for next year, or will that lead to you giving me a fine? This relates to the issue of who your colleagues are. Are you employed in the same organisation or in a different organisation? The manager continues:… they [the administrative people] were not my employees. Not being one’s employee also meant having different targets that sometimes were contradictory, and, in those cases, the one who sets the salary is who you are loyal to. The manager ends by saying: So, they were not as close to me … when you talk about that loyalty, it’s also about who sets my salary.
Taking ‘sides’: first-line managers for the core operations distinguish themselves from others
Some managers described how they actively took sides in the ‘conflict’ between the administration and the core operations, the conflict being defined as who should make decisions on clinical work and practice. By joining in the jargon of their employees, consciously deciding to wear scrubs and ‘be one in the gang’, first-line managers would mark that they were on ‘the right’ side. Some clinical managers used the conflict between clinicians and administrative units to create buy-in from their staff, joining the jargon. This was, for example, shown in the following quote by a first-line manager: There are times when I take-sides and join my staff, and I say thing like: ‘They have no idea over there at the headquarters … about us and our reality’. Sometimes, this was done not because the managers entirely believed it, but because it would strengthen their credibility amongst their personnel.
First-line managers’ stories revealed a deep personal investment in their staff, often describing themselves as taking on a near-parental role, for example, assisting employees with personal matters such as finding housing. They often described trying to patch a broken system, working long hours and remaining constantly available to step in when needed. At the same time, they expressed a sense of imbalance, feeling that their own managers and higher-level leaders did not offer them the same level of support. To signal investment and engagement, wearing scrubs was important for first-line managers. A first-line manager describes the reason for her to wear scrubs: It’s a signal that you’re ready, that you’re not sitting on a higher chair or anything like that, but you are ready to dig in. In working hard and being engaged with their staff on a personal matter, this was contrasted with the lack of commitment from second-line managers, who were seen as less engaged and not dressed to work at a hospital. From the data gathered for this study, they were also less engaged in operative issues, in the sense that they did not personally seem to invest in their staff in the same way; they did not wear scrubs and did not engage in the clinical work. The first-line managers’ stories were that they were doing much, whereas others were doing too little: There’s no one who works as hard as first-line managers and who cares as much about their patients. And then, of course, you want there to be the same level of commitment in healthcare administration, throughout all levels, and not this kind of laid-back attitude. (Third-line manager).
Who works for whom?
While administrative managers described not being taken seriously, clinical line managers expressed frustration over a perceived lack of support. They questioned why their organisations should have to adjust to administrative structures, especially given that they were the ones financing support functions. Line managers felt that the administration appeared more focused on improving its own processes rather than supporting clinical work. One line manager describes a particularly frustrating example: they have introduced “phone hours”. i.e., time-slots when we can reach them. When you have questions about for example our time management program. That is one of those incredibly strange moves in my eyes and all our eyes. We finance that activity with our revenues. They are a support function for us! Then we need to adjust to their phone hours instead of meeting patients.
Conflicting views on where power resides and who has it
Administration: supporting or steering?
A common responsibility for administrative staff was to implement various tools and measures. However, a recurring view among line organisation managers was that the administration lacked an understanding of the realities of clinical work, and that the solutions being implemented did not align with operational needs. Tensions often arose when the administration was tasked with introducing changes that did not fit the existing structure of healthcare delivery. While the core operations sought to maintain established practices, ‘the administration’ aimed to reform them. One example of this disconnect was the issue of digitalisation. According to administrative units, digitalisation was intended to support a more patient-centred approach and enable co-creation of services, allowing patients to choose how they access care. However, the core operations staff argued that the way digitalisation was implemented did not align with their organisational structure, and they were unwilling to adapt to these changes. For example, when discussing new digital solutions to get in contact with care premises, a common perception was this: It is one thing that a person who knows IT can manage these things … but when [generic name of old lady] aged 85 is to connect to a different system. It does not work … then our/the care perspective becomes to explain that this is not how we work … your [reffering to organisational developer] ideas will not work and will not be used (Second-line manager, line organisation).
This was related to issues of mandates. Administrative managers expressed frustration as they were tasked to implement digital solutions to ease patient participation, spent a considerable amount of time on developing tools and measures to enable this, only to discover that first-line managers could just decide not to implement these tools and measures. A manager for an administrative unit, tasked to coordinate the care processes for a particular disease, explains: [name of other organisation] has developed [name of digital solution], which is about how the patient’s path through the hospital should look like … then it has turned out that this is implemented differently. Some wards have implemented it, and some haven’t because they think that ‘no, but we shouldn’t have to do that’, right? We say: “It’s not a discussion, like, it should just be implemented!” But I have no mandate at all, really. … It is up to the managers of the clinics and wards, and they do not want to implement it.
Another manager at an administrative unit complains that the clinical first-line managers have not managed to inform their personnel about current troubles that the administration is now working on to fix: I have come to units where the doctors don’t even know that we have poor telephone access. ‘What do we have that?’ And of course, if you don’t know that it’s a problem, then why would they welcome us?
This echoes the feeling from the administrative manager who expressed: We could work as much as possible, and still everyone is disappointed because they think we’re supposed to be doing something else.
Notably, the line managers reflected upon the fact that they, in general, did not know much about the administrative side of healthcare. One third-line manager reflected: I did not even know there was a financial organisation before I got my first paycheck.
Power is always somewhere else
In relation to where power resides, healthcare was described as a system, driven by a kind of ‘force’ that no one had the ability (or power) to control, which made it hard to collaborate. Members high up in the hierarchy, including representatives of top management, labelled the healthcare organisation ‘the system’ and described it like this: ‘The system’ is not designed for us to be able to show understanding for each other. First-line managers generally expressed that they were controlled by ‘upper management’, or more vaguely ‘those up there’ and would typically not mention their own power and possibility to influence organisational matters, but rather how they were exhausted due to delivering everything that ‘those up there’ had told them to do. One first-line manager described this as ‘being stuck in a tumble dryer’ with all demands making everything spin. However, on the contrary, representatives of the highest management typically alluded to the fact that first-line managers and clinical personnel are those with power: Both the formal power lies in the line, as well as the informal power, that is, what can be decided regarding resources. Each doctor has an enormous amount of decision-making power regarding the type of treatment, which medications, which care times, and how resources should be utilised. It is delegated all the way out (Director).
In addition to alluding power to the front-line staff, the higher up you came in the organisation, the power was either attributed to the very ‘bottom’ or the politicians. The politicians were, on the one hand, blamed for bad decisions, but there was also frustration from some administrative units that they had been privileged by the politicians and that this was not understood by the line organisation. One manager for an administrative unit describes how members of the clinical line organisation question him and how his organisation can have so much money: [they say] you get so much money! [Then I say] OK, but if you have a problem with that, maybe you should go into politics and not go at us who work to implement the political decisions! He and others referred to that if core operations want to change how things are done, they need to vote for other politicians, but often the core operations would not know of the power that politicians have over healthcare organising. Here, in this case, tensions could be argued to arise because different parts of the system did not know how healthcare is governed. Thus, tensions are then a consequence of a lack of knowledge of how the formal power is organised, which leads back to the idea of how to manage and ease conflicts and tensions: through education.
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