Abstract
This article, situated within the strategy-as-practice field, explores how healthcare middle managers interpret, contextualize, and adapt sociotechnical systems to achieve strategic objectives. It begins by recognizing how formulation, implementation, and monitoring/evaluation are not separate steps in policy and strategy; rather they are entangled and working in concert to deliver outcomes that meet an intent based on principles and planning assumptions. Next it provides insights into the coevolution of middle manager practices and the sociotechnical systems that guide alignment and misalignment. It then concludes with four recommendations to improve middle manager practices in policy and strategy implementation.
Introduction
In healthcare organizations, policies and strategies function as organizational artefacts intended to guide collective action towards preferred outcomes and goals. While rich in meaning, they often take the form of broadly applicable summary statements that operate as boundary objects to align and coordinate organizational efforts, even in the absence of shared interpretations or complete agreement. 1 These artefacts, sometimes supported by detailed directives, are intentionally designed to allow interpretive flexibility and local adaptation. For example, healthcare access policies in urban settings may differ substantially from those in rural contexts.
Middle managers are central to aligned and coordinated practices in operational service delivery and serve as an engine of implementation for strategic and policy goals. 2 Alignment depends heavily on their interpretations, which are inherently subjective and often only partially informed. These interpretations, shaped by unit- or program-level operating contexts, unfold within complex healthcare environments involving patients, clinicians, support staff, and administrators whose actions are not always fully aligned. Although middle managers are not solely responsible for implementation outcomes, examining their practices helps explain why policies and strategies do not always guide collective action as intended. 3
This article argues that middle manager implementation practices are shaped by the interaction between strategic intent, sociotechnical systems, and evolving routines and that misalignment among these elements produces systematic divergence in practice. Understanding this interaction is therefore central to improving policy and strategy implementation in healthcare organizations.
Organizational Systems and Actions
Structures, procedures, rules, and processes are examples of sociotechnical systems, organizational constructs designed to both enable and constrain practices in ways that align effort and guide interpretation. 4 Collectively, these elements contribute to the ostensive routines that signal “how we do things around here.” However, such constructs cannot fully address the complexity and diversity of the settings in which they are expected to operate. Intangible influences such as senior leader behaviours and preferences, resource availability, local adaptation, and organizational culture shape day-to-day actions. In practice, these constructs are continually interpreted, contextualized, recontextualized, and adapted. 5 Rather than functioning as stable transmission mechanisms for strategic intent, they mediate how intent is understood and enacted. Alignment therefore depends not only on formal system design but also on how middle managers engage with and modify these systems.
Middle Manager Engagement With Sociotechnical Systems
The Strategy-as-Practice (SaP) field has flourished since the mid-1990s, mirroring a broader social science shift towards practice-based studies. While early work focused on centralizing the practitioner, the field has expanded substantially. 6 Since 2021, scholarship has moved into new frontiers, notably exploring the intersection of socio-materiality and routine dynamics. 7
Healthcare represents a particularly relevant context for such inquiry. The sector requires strategic flexibility, as demonstrated during the COVID-19 pandemic, yet comparatively little is known about how healthcare middle managers enact policy and strategy in practice. Despite the growth of SaP research, this remains an underexplored area.
This concept paper arises from consideration of the tensions between middle managers’ day-to-day operational imperatives and the implementation of strategic or policy change. It develops a deliberate synthesis of perspectives from SaP, sociotechnical systems, and routine dynamics to explore common patterns observed in healthcare management to address the question: “How can understanding middle manager engagement with systems improve policy and strategy implementation?” By locating strategic management in situated practice, the analysis foregrounds middle managers as central actors in alignment processes. 4
Certain elements of this study may be more relevant to some roles than others. Recognizing middle managers differ in experience, role, and context, this study focuses on shared theoretical mechanisms through which implementation is enacted. In doing so, it builds on observations by Seidl et al that SaP research can benefit from examining how strategic tensions become visible in operative routines and how these dynamics can be incorporated into broader theorization of strategy enactment. 7
Structure of the Article
The first section outlines the purposes and stages of policy and strategy, with particular attention to environmental scanning and objective development. The second section examines the entangled relationship between middle manager practices, sociotechnical systems, and organizational routines in healthcare organizations. The article concludes with four general but actionable recommendations designed to support middle managers in strengthening policy and strategy implementation across diverse organizational contexts.
Policy and Strategy
A policy is a principle or course of action that guides organizational effort, commonly described as progressing through agenda setting, formulation, implementation, and evaluation. 8 Similarly, strategy articulates shared goals that align work across organizational levels and connect senior leadership, middle management, and operational teams. Policy establishes guiding principles and boundaries, while strategy translates these principles into coordinated objectives and actions. The three classic stages of strategy are formulation, implementation, and monitoring. 9 Although policy and strategy are often considered as cyclical processes, in practice their stages are non-linear, entangled, and concurrent.
Policy and strategy are developed in consideration of external and internal contexts with a need to continually revisit and update them based on changes in the operating environment and outcomes from monitoring and evaluation.3,10 Development approaches frequently treat problems as complex, multi-factorial, and contextually situated.8,9 This involves conducting an environmental scan to aid in sense-making and gain understanding about the operating environment. 11 They are also dependent on an understanding of which internal capabilities can be used or must be developed; however, key organizational knowledge held by middle managers may be understated or overlooked. Strategy development as a communicative process 10 can tend towards statements of goals and objectives that are relatively easy to memorize or repeat.
Strategic goals and policy objectives are grounded in planning assumptions derived from organizational intent and guiding principles. Intent expresses organizational purpose and overarching priorities, while principles define standards for decision-making and action. Together, they provide a normative framework within which implementation occurs.
Despite the need for continual iteration, middle managers may interpret policies and strategies as stable “north stars” or authoritative “playbooks.” This perception is often reinforced by hierarchical structures and organizational cultures that privilege consistency and compliance. Such conditions can limit managers’ willingness or perceived authority to question underlying assumptions or adapt strategic direction. The resulting tension between contextual flexibility and perceived durability shapes how middle managers approach implementation.
The successful implementation of policy and strategy depends on four interrelated dimensions of alignment. First, alignment requires congruence between formal principles and organizational culture; divergence generates interpretive dissonance. Second, clarity of strategic intent enables managers to recognize the value of aligned action. Third, managerial self-efficacy influences the capacity to enact prescribed practices, with perceived constraints contributing to partial or symbolic compliance. Finally, alignment depends on the compatibility of existing organizational systems with new policy and strategic objectives. When intent conflicts with established norms or structures, interpretive divergence is likely.
These alignment conditions create both constraints and opportunities for practice. Divergence allows scope for experimentation, tailoring, and situated adaptation,4,12 but it also introduces variability in how policy and strategy are enacted. Middle manager practices therefore remain closely entangled with sociotechnical systems (e.g., structures, rules, processes, and procedures) designed to promote alignment between organizational priorities and everyday work. It is within this entanglement that strategic intent is ultimately translated into operational routines.
Sociotechnical Systems
Social subsystems and technical subsystems comprise an organization’s sociotechnical systems. 13 As middle managers attempt to implement strategies sociotechnical systems both enable and constrain practices. Many systems operate invisibly or are overlooked by practitioners, embedded in everyday routines and taken for granted as being aligned with organizational intent.
Social subsystems include organizational structure, professional roles, cultural norms, and patterns of interaction.13,14 Hierarchical and lateral relationships inform middle manager perspectives of cultural norms and expectations for behaviours through boundary negotiation. Communication expectations and team dynamics tend to operate through informal and evolving patterns, which influence information sharing even though they may not be defined by formal structures.
Technical subsystems include such elements as tools and equipment, software systems, procedures and workflows, and the physical layout of workspaces.13,14 Technical subsystems are generally designed to solve a practical problem or address a practical outcome. 13 For example, workforce management systems for scheduling clinical staff envision use cases that result in employee availability for work, but may overlook complementary skills in employees cross-trained in clinical sub-specialties. Similarly, hospital physical layout is often organized in ways that promotes efficiency, for example, the emergency department, medical imaging, and the ambulance bays are commonly adjacent spaces.
Even with thoughtful design, actual technical subsystem use commonly differs from how they were designed. 13 One example of this is over census beds in hallways in hospitals which cause congestion and workarounds. Workarounds and adaptations exploit a natural plasticity in the use of subsystems. Middle managers routinely adapt, circumvent, or supplement formal systems to sustain service delivery, and these adaptations become embedded in organizational routines.
Through these processes, sociotechnical systems mediate how strategic intent is interpreted and enacted. Alignment depends not only on system design, but also on how social and technical elements interact with managerial judgment and situated action. Where systems reinforce strategic priorities, they stabilize aligned practice; where they conflict with local realities, they contribute to divergence and improvisation. In this way, sociotechnical systems function as frames for both coordination and ongoing negotiation between intent, context, and routine performance.
Routines
In practice theory, routines provide a shorthand for how things are done, recognizable patterns that are repeated in the practices of various actors 15 such as middle managers. An ostensive routine describes the principle, 7 or ideal case for how the routine is intended to be enacted 7 and can be forward looking, whereas a performative routine is the way a routine has been enacted in practice7,16 and can only be described retrospectively. Recent findings in the field of routine dynamics describe how each enactment of a routine is situationally novel and how actors’ practices will be affected by every enactment and routines will change.5,7,16,17 Routines are not static, but repetitive patterns of interdependent actions create semi-permanence, the status quo, until the patterns are changed in response to situational variation and agency. 17 Routine dynamics encourages exploration of the routines themselves offering opportunities to advance SaP theory.
Practices and routines are entangled with the sociotechnical systems within which they are enacted, and these interrelationships have substantial implications for understanding middle manager practices in policy and strategy implementation. Routine enactment thus becomes the primary mechanism through which alignment is reproduced or disrupted.
Implications for Middle Manager Practices
This section presents four interrelated recommendations for appraisal, critical reflection, and learning that respond directly to the central challenge identified in this article: the persistent misalignment between strategic intent, sociotechnical systems, and enacted routines. They build on Jarzabkowski’s practice-based accounts of strategizing, how practices both shape and are shaped by environmental factors, 12 juxtaposed with Dionysiou et al.’s description of situational novelty in routine dynamics, how routines are adapted each instance of their performance. 17 Because middle managers translate policy and strategy through situated practice, alignment cannot be assumed or imposed through formal structures alone. Instead, it must be continually produced through reflective engagement with intent, principles, systems, and routines. The recommendations that follow focus on strengthening middle managers’ capacity to diagnose, interpret, and recalibrate their practices in complex and evolving organizational contexts.
More Than the Parts
The first recommendation encourages middle managers to appraise their understanding of strategy and policy as an integrated bundle of related actions rather than as discrete or sequential stages of formulation, implementation, and monitoring. Since these stages are entangled in practice, separating them encourages fragmented interpretation and increases the risk of misalignment.
This appraisal involves applying critical thinking and problem-based analysis techniques to query: (1) How will this be implemented within existing sociotechnical systems? (2) How will outcomes be assessed through available routines and performance mechanisms? and (3) How should the approach be adapted if contextual conditions change? Addressing all three questions clarifies intent, exposes embedded assumptions, and aligns implementation practices with evaluative expectations.
Treating policy and strategy as static artefacts or viewing their stages as independent processes fractures interpretive work. Such compartmentalization invites divergence between intended and enacted practices by limiting managers’ capacity to anticipate how systems and routines will shape implementation.
How Did We Get Here?
The second recommendation emphasizes the importance of middle managers understanding “how did we get here?” as a foundation for aligned practice. Since policies and strategies embed historical assumptions and institutional priorities, effective implementation depends on managers’ capacity to reconstruct and interpret them.
This process involves clarifying the intent and principles that underpin the policy or strategy and identifying areas of congruence and tension between espoused values and organizational norms. Mapping these elements in a matrix can reveal potential sources of interpretive dissonance. It also involves listing the objectives and identifying the planning assumptions that informed the selection of objectives, with particular attention to contextual, resource, and capability-related factors. Where available, these assumptions may be traced to original planning documents.
The application of competencies such as systems thinking, data-informed reflection, and evaluative reasoning enables managers to test whether foundational assumptions remain valid under changing conditions. During implementation, systematic comparison of observed outcomes with initial assumptions supports ongoing recalibration of practices and strengthens alignment between intent, systems, and routines.
What’s Helping and What’s Not?
Sociotechnical systems powerfully shape middle manager practice, yet their influence often remains implicit and unexamined within day-to-day routines. The third recommendation is for middle managers to deliberately surface, analyze, and evaluate systems to learn what enables and what constrains aligned implementation.
This requires explicit reflection on how formal procedures, digital tools, reporting structures, workflows, and physical environments mediate interpretation and action. By applying competencies such as reflective analysis, systems thinking, and process mapping, managers can identify structural sources of friction, duplication, or distortion.
An initial practical assessment tool may take the form of a three-column list with the headings: Name (of the sociotechnical system), Fit (to purpose), and How Used? (used as-is, adapted, avoided, or circumvented). Systematically documenting these interactions can bring overlooked mediating mechanisms into focus. This analysis supports informed decisions regarding local adaptation, escalation to system owners, or engagement with governance structures to address persistent misalignment.
Different This Time
Since every enactment of a routine is situationally novel, the final recommendation is for middle managers to engage in structured reflection on their performances for routines as a mechanism for sustaining alignment over time. Routines are simultaneously sources of stability and vehicles for change; without deliberate examination, adaptive practices may gradually diverge from strategic intent.
Managers are encouraged to reflect on each enactment using three guiding questions: “What did I plan to do (ostensive routine)?”, “What did I actually do (performative routine)?”, and “What contextual or systemic factors shaped this difference?” A fourth reflective question “What adjustments are within my scope or require escalation?” may further support practical action.
By systematically examining variation between intended and enacted routines, middle managers can identify patterns of drift, structural barriers, and opportunities for redesign. This process enables movement beyond awareness of misalignment towards targeted interventions, such as modifying workflow steps, clarifying role expectations, removing procedural bottlenecks, or initiating system-level review.
Collectively, these four recommendations position middle managers as active stewards of alignment rather than passive recipients of policy and strategy. By integrating reflection on intent, assumptions, systems, and routines, managers can more effectively navigate institutional complexity and mitigate the structural sources of divergence that undermine implementation. In doing so, they contribute not only to local performance improvement but also to the continuous refinement of organizational governance and capability.
Conclusion
This article has highlighted the pivotal role of middle managers in shaping implementation within complex healthcare systems, where strategic intent must be translated through sociotechnical systems and evolving routines. By integrating perspectives from strategy-as-practice, sociotechnical systems, and routine dynamics with the operational realities of healthcare organizations, the analysis emphasizes that middle managers mediate between high-level objectives and frontline activity. Hierarchical structures, cultural norms, and technical subsystems shape the conditions under which this translation occurs, influencing how intent is interpreted and enacted in practice.
From a practice perspective, the manuscript encourages middle managers to engage more deeply with organizational principles and intent, the “why,” rather than focusing exclusively on prescribed procedures, the “how.” The use of structured reflection and guided questioning enables managers to identify sources of misalignment and adapt their practices or advocate for system change in response to changing conditions.
From a scholarly standpoint, this study contributes to the strategy-as-practice literature by foregrounding sociotechnical systems as a central dimension of institutional complexity in healthcare management. Drawing on routine dynamics, it illustrates how social subsystems, technical design, and patterned action interact to shape the possibilities for effective strategy enactment. The integration of conceptual synthesis with practical guidance strengthens the manuscript’s relevance to ongoing debates concerning routine dynamics, managerial agency, and strategy implementation.
Future research may further examine how operative routines are instantiated as middle managers negotiate competing expectations, exercise influence within multilevel governance structures, and respond to technological and organizational change. Greater attention to healthcare strategy and policy documents as boundary objects, to processes of managerial interpretation, and to the relationship between discretion and professional autonomy may yield additional insight into the conditions that enable or constrain implementation.
Overall, this study demonstrates that alignment between strategic intent, organizational systems, and managerial practice is continuously (re)produced through situated action. A clearer understanding of middle managers’ interpretive and adaptive practices contributes to more sustained organizational performance and more effective policy and strategy implementation in complex healthcare environments.
Footnotes
AI Disclosure
ChatGPT was used to change the format of the reference list from MLA to AMA 11 format. All other uses were assistive, limited to word choice suggestions and suggestions for text revision.
Acknowledgements
The author gratefully acknowledges financial support from the MITACS Accelerate program as a part of their doctoral studies that contributed to the research, authorship, and/or publication of this article.
Ethical Approval
Institutional review board approval was not required.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author has received funding through the MITACS Accelerate program (IT35034). This program operates as an internship for the researcher. The research is supported by 1335327 B.C. Ltd. which is a private company. The researcher is a minority shareholder in this company.
Declaration of Conflicting Interests
The author declared the funding related potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This potential conflict of interest has been disclosed to all interest holders.