Examining hybrid nurse managers as a case of identity transition in healthcare: developing a balanced research agenda

Abstract

This research note synthesizes sociology of work and organization studies literatures, to outline a research agenda examining the identity transition of nurses. Academic studies suggest that nurses face a greater challenge to enact, and are more likely to be marginalized within, hybrid manager roles. Further research is encouraged that has a comparative professional dimension, focused upon social position and power and which takes account of the gendered nature of policy reform and professions.

Keywords

doctors hybrid managers identity new public management nurses

Introduction

Globally, healthcare organizations have been exposed to public policy reforms, moving them towards more ‘managerialist’ structures (O’Reilly and Reed, 2011). In countries susceptible to Anglo-Saxon influence, these policy reforms are aggregated under the rubric of ‘new public management’ (NPM) (Hood, 1991). NPM reforms broadly encompass the need to cut costs and improve quality through managerial, rather than professional, power. However, despite frequent attempts at organizational change, professionals resist NPM reforms (Ahmad and Broussine, 2003). Such professional resistance to policy reform and enduring commitment to professional identities and cultures has led to an increased focus by policy makers on the role of hybrid managers, who combine managerial and professional responsibilities. In healthcare contexts, upon which this research note focuses, hybrid managers are pivotal to policy-driven aspirations for change, based upon their ability to view organizational issues through ‘two-way windows’ (Llewellyn, 2001), reducing resistance to, and encouraging uptake of, managerial reforms by professional groups (Kirkpatrick et al., 2009). By moving between managerial leadership and professional leadership (Marnoch et al., 2000), hybrid managers theoretically encourage the ‘colonization’ of managerial priorities in professional practice, standards and discourse (Ackroyd et al., 2007; Bejerot and Hasselbladh, 2011), redressing professional resistance to organizational reform (O’Reilly and Reed, 2011).

Policy makers assume hybrid managers are homogeneous, affecting professionalism and public organizations uniformly, and neglect to consider the nuances of the way different hybrid managers enact their role (Burgess and Currie, 2013). The influence of hybrid managers on managerial processes is also assumed by policy makers to be uniformly positive. However, nurses and doctors, who together represent the bulk of the hybrid manager cadre in healthcare (Walshe and Smith, 2011), are likely to respond differently to the demands of their managerial role, due to their professionally bound socialization and relative position in the professional hierarchy (Blomgren, 2003; Bolton, 2005; Goodrick and Reay, 2010; Nugus et al., 2010). Further, some hybrid managers may be willing, and others reluctant, to enact their role (Doolin, 2002; Hallier and Forbes, 2004; Kitchener, 2000). Some professionals embrace managerial, ‘entrepreneurial’ (Llewellyn, 2001), or ‘calculative’ financial and accounting discourses (Kurunmaki, 2004) using them to shape their hybrid managerial identities and roles (Doolin, 2002). Others resist managerialism or ‘play’ with hybrid managerial identities (Iedema et al., 2004), or ‘balance’ and ‘blend’ managerialism and professionalism (Montgomery, 1990). In essence, evident in the studies cited above, academic commentary increasingly highlights that moving from a purely professional role towards a hybrid managerial role in a healthcare setting is a matter of identity transition. This provides a springboard for the research note.

The extant literature relating to hybrid managers in healthcare tends to be concerned with one professional occupation, commonly nurses (Bolton, 2005; Cooke, 2006) or doctors (Bolton et al., 2011; Ham and Dickson, 2008; Ham et al., 2011; Kirkpatrick et al., 2009). As such, existing literature does not take advantage of the opportunity for comparative study of professional occupations, which may engender more robust analysis. Secondly, extant literature has orientated relatively narrowly in disciplinary terms. On the one hand, sociology of work (SoW) focuses more upon the resistance of hybrid managers towards their new roles and emphasizes structural constraints upon enactment of such roles (Bolton, 2005; Bolton et al., 2011; Cooke, 2006). Meanwhile, notable exceptions aside (cf. Thomas and Davies, 2005), organizational studies (OS) focuses upon doctors, ignoring the voice of lower status professional groups and issues of power and uncritically seeks to offer organizational prescriptions to support an enhanced strategic role of hybrid managers (Thomas and Linstead, 2002). Given the different tendencies of SoW and OS literatures, their synthesis is likely to engender a less monolithic view of hybrid managers, from which can be derived a research agenda that accounts for variety in role enactment.

In summary, this research note addresses the need for more robust and critical analysis of the enactment of hybrid manager roles, given their policy importance. In setting out a research agenda, our intention is not merely to encourage studies to generate prescriptions for the organizational support of hybrid managers, nor to highlight how hybrid managers can resist co-option into managerialist roles. Instead, the research note derives a balanced research agenda, which recognizes the significant role that hybrid managers can play in developing and delivering high quality public services. At the same time, we do not wish to reduce analysis of the role of hybrid managers to one that aligns with contemporary healthcare policy, which is overly managerialist. In particular, given the greater challenge that nurses face in transitioning into hybrid manager roles, set out in the next section of our research note, we are keen to derive a comparative analysis that encourages more study of nurses, who constitute the largest segment of hybrid manager ranks in healthcare (Walshe and Smith, 2011).

The remainder of our research note proceeds as follows. First, we detail the hybrid middle manager as our unit of analysis in the context of NPM. Second, we review literature within SoW about identity transition. Third, we review literature about identity transition within OS. Following this, we bring together the literatures to further explore the identity transitions of nurses moving into hybrid manager roles. Finally, in our concluding section of the research note, we synthesize SoW and OS literatures to set out a future research agenda to guide other scholars studying hybrid nurse managers and their medical counterparts.

NPM reform and hybrid managers

To understand why hybrid managers may be unwilling, as well as unable, to enact a strategic role, it is necessary to highlight the genealogy of policy reforms, with specific reference to healthcare organizations. Up to the 1980s, healthcare organizations can be seen as a Weberian bureaucracy, with a standard administrative hierarchy from national government, through regional or more local government, to operating units. The stance of management was neutral, with a well defined administrative cadre, which ‘valued probity, stability and due process’ (Ferlie et al., 2013: 6) and was often characterized as a ‘diplomat’ role (Giaimo, 2002). This was manifested in ‘professional bureaucracy’ arrangements (Mintzberg, 1979), where doctors and nurses were ‘first among equals’ in taking on managerial roles. Commonly, regarded as the ‘senior’ professional by their peers, they would manage colleagues, as a representative that buffered them from external intrusion from the administrative cadre.

In contrast, under the NPM doctrine, such arrangements were challenged as ineffective and inefficient and markets, general management and performance measurement introduced within policy reforms (Ferlie et al., 2013). Under NPM, doctors and nurses in hybrid managerial roles were now expected to proactively manage their colleagues towards organizational aims (Ferlie et al., 2013; Thomas and Linstead, 2002). As such, NPM can be viewed fundamentally as encouraging identity transition (Du Gay, 1996; Thomas and Linstead, 2002). Rather than controlling professionals through managers, the policy intent was to convert professionals into managers, reconstituting doctors’ and nurses’ subjectivities through their co-option into such roles, enabling professional governance from a distance (Martin and Learmonth, 2012). However, the general management cadre has not gained power from professionals, as those moving into hybrid roles have drawn upon professional and caring values to drive managerial actions, enhancing their control and influence over key budgetary decisions. Despite this, it is clear that some hybrid managers lack credibility with their professional peers (Ferlie et al., 2013).

In considering the effects of NPM, the case of nurses and doctors moving into hybrid manager roles provides an interesting comparison. Commonly, doctors perform clinical duties as a ‘day job’, accommodating managerial duties within this. They are elite actors within healthcare settings and so might be assumed ‘natural’ managers by themselves and others (Ham and Dickson, 2008). Nurses, meanwhile, enjoy less power and status and have been described as subordinate to doctors. Despite relinquishing some or all clinical duties when taking up a hybrid manager role, nurses are commonly assumed by themselves and others to be unsuitable for management, specifically where influence is expected to extend beyond their own ranks (Apesoa-Varano, 2007; Nugus et al., 2010).

To emphasize, hybrid managers’ experiences of identity transition towards a strategic role are likely to be varied, specifically across the ranks of nurses and doctors. Identity transition represents a focal point for the analysis of policy effect upon willingness, as well as ability, of nurses and doctors to enact a hybrid management role. This is a research issue into which SoW provides considerable insight, particularly when considering how identity provides the basis for resistance to the enactment of a more strategic hybrid managerial role demanded by policymakers (Baldry and Barnes, 2012; Bolton, 2005; Collins et al., 2009; Cooke, 2006; Pritchard and Symon, 2011; Thursfield, 2012). The analysis is extended in this direction below.

Identity transition: sociology of work

SoW literature has focused on the relationships between work and identity (Bain, 2005; Doherty, 2009; Lee and Lin, 2011) and professional identity (Baldry and Barnes, 2012; Bolton, 2005; Collins et al., 2009; Cooke, 2006; Pritchard and Symon, 2011; Thursfield, 2012). However it takes a largely micro-level perspective, with little consideration of antecedents to identity transition.

Bolton (2005) empirically examines hybrid nurse managers, conceptualizing the development of hybrid roles as normative control by senior management over professionals. She illustrates how some aspects of the hybrid managerial role, such as an entrepreneurial orientation, are rejected, even as role holders accommodate other aspects. She concludes: ‘It is a little more surprising, perhaps, to note that 48 per cent of nurses who are now senior managers express discomfort with managerial values […] they feel the role of the nurse and manager are in conflict’ (Bolton, 2005: 17). Bolton’s quote suggests variation in enactment of hybrid middle manager roles, which is a consequence of identity transition. Bolton’s study is insightful, nevertheless her analysis of identity transition focuses upon micro-level emotional work to mediate transition and less so on antecedents to the enactment of hybrid middle manager roles. Further, the tone regarding the response of nurses transitioning into hybrid managerial roles is one of resistance. Yet, there remain significant numbers of nurses in hybrid middle manager roles (Walshe and Smith, 2011). Whether reluctant managers or not, nurse hybrids are important actors in service improvement as well as operational management and some are likely to embrace their managerial role in line with organizational, as well as professional, interest (Croft et al., 2014; McGivern et al., 2015).

Meanwhile, Cooke (2006) characterizes the development of hybrid nurse managers as work intensification and also emphasizes resistance. He argues that the development of hybrid nurse managers increases managerial control over mainstream nursing to engender distrust and cynicism about so-called ‘seagull’ managers, ‘seagull’ on the basis they rarely visit wards or provide support for those delivering frontline care. Cooke argues such managerial control fosters a culture of blaming frontline staff for failings, with hybrid managers exhibiting defensive responses themselves to any blame. While Cooke considers how the competing discourses of NPM create tensions for hybrid manager roles, there is little attempt to explain why these tensions are faced most acutely among nurses. Conclusions drawn from existing work into other professions, such as the financial sector (Collins et al., 2009), trade unions (Thursfield, 2012) or call centres (Pritchard and Symon, 2011) suggest that nursing is an area which struggles more than most when attempting to take on hybrid roles.

Meanwhile, drawing upon sociology of professions literature (Abbott, 1988; Freidson, 1994), Kirkpatrick and colleagues examine the transition of doctors into hybrid manager roles (Kirkpatrick et al., 2009, 2011). Taking a comparative approach internationally (rather than professionally) between doctors in Denmark and England, Kirkpatrick et al. (2009, 2011) consider the interplay between management and doctors from the perspective of the division of labour among professions. They conclude that doctors continue to exert substantial dominance, even within the managerialized healthcare context. Other articles also take an international perspective in considering the influence of doctors and their willingness to take on managerial roles, showing less conformity to managerial priorities and more co-option of such priorities (Degeling et al., 2006). Again, this confirms variation across healthcare professions in enactment of hybrid manager roles, with power and social position a significant contingent influence. The next section of the research note highlights how OS literature, focused upon doctors, can prove helpful in comparative analysis of the experiences of nurses moving into hybrid manager roles.

Identity transition: organization studies

OS literature identifies medical hybrid managers as an elite group within global healthcare systems (Doolin, 2002; Iedema et al., 2004; Llewellyn, 2001; Montgomery, 1990). Doctors in these roles hold influence over their peers and other managers, as they combine their professional identity, values and ethics with the achievement of management initiatives (Ferlie et al., 2013). By combining their strong professional identity with a managerial role, doctors retain credibility among their professional group, while also enjoying influence in the management of the organization (Kitchener, 2000; Nugus et al., 2010). The ability of doctors to overcome potential conflicts in their hybrid role comes from their pre-existing social influence within the organizational structure and the relative compatibility of their role with managerial demands.

Pratt et al. (2006) suggest that, despite a continuing commitment to their professional ideology, doctors will adapt their identity to make it fit with the demands of their new role. In doing so, they may protect or ‘buffer’ their professional interests (Fitzgerald and Ferlie, 2000). While a limited number of doctors, from particular medical specialities, may enact hybrid manager roles in a more strategic fashion in line with organizational interest (Currie et al., forthcoming), overwhelmingly, doctors tend to co-opt, rather than be disciplined by, managerial systems, to bolster professionalism, as found with patient safety systems (Waring and Currie, 2009) and medical appraisal (McGivern and Ferlie, 2007). They may represent their peers, while simultaneously enhancing their position as a managerial ‘elite’ compared to their peers (Battilana, 2011). Such a response may not be available to other professionals with lower inter-professional status, such as nurses. Thus, some comparison across professions is necessary, as they are differentially arranged regarding their social position from which status and power derive (Battilana, 2011) and this impacts their agency in identity transition towards hybrid managerial roles. This point is considered further in the next section of the research note.

Nurses in hybrid management roles: medical dominance and gender

Comparisons with the nursing profession offer an interesting contrast to doctors, with respect to the former’s enactment of hybrid manager roles and the relationship with their social position. As a starting point, implicit within our analysis thus far has been the suggestion that professional hierarchy and socialization are important antecedents to identity transition towards hybrid manager roles. The research note extends this notion further.

First, regarding professional hierarchy, the continued dominance of medicine has perpetuated a system in which nurses are seen as ‘followers’ rather than ‘leaders’, encouraged to maintain stereotypical ideals of obedient, silent, altruistic and passive caring (Goodrick and Reay, 2010). As such, a commitment to an over-idealized professional image, which encourages subordinate identities and may conflict with NPM objectives, creates particular conflict for nurses transitioning into hybrid manager roles (Bolton, 2005).

Second, it would be remiss of this research note not to take account of the gendered nature of the nursing profession, which underpins their comparative experiences of exerting influence in hybrid manager roles. NPM policy has been described as ‘gendered’, which generates particular challenges for those within more ‘feminine’ occupations moving into hybrid managerial roles (Thomas and Davies, 2002). Managerial behaviours are seen as masculine, directive and authoritative (Keller, 1999), while nursing is seen as ‘women’s work’, reflected in media images and social expectations of nurses (Davies, 2003). It is not merely the high proportion of women to men within nursing that causes problems for those taking on hybrid roles, but the continuing adherence to a professional identity stereotype, encouraging a protective stance from nurses towards feminized ideals and behaviours. The commitment to a feminized professional identity continues to shape identity for nurses. Despite increasing technical skills, academic education and management roles required by modern nurses (Apesoa-Varano, 2007; Ashforth and Kreiner, 1999), commitment to feminized identity further compromises the willingness, as well as ability, of nurses to take on hybrid manager roles.

Notwithstanding the above, modern nurses are increasingly required to take on ‘hybrid’ manager roles. They are expected to be representative of their professional group by maintaining clinical presence, such as in the case of ‘Modern Matrons’ (Read et al., 2004) or ‘Ward Managers’ (Bolton, 2005), while positioning themselves within the managerial hierarchy of the organization. The identity conflict faced by hybrid nurse managers was highlighted by Blomgren (2003), who concluded that nurses struggled to protect the integrity of caring work in an NPM environment. While the potential for conflict was noted in the article, Blomgren argued that nurses in Sweden had successfully adopted NPM reforms to become ‘administrative leaders’. In this respect, the nurses underwent a period of identity transition to align their professional identity with the demands of their managerially led role. However, hybrid nurse managers did not appear to be constructing a new elite professional cadre, as in the case of doctors (Doolin, 2002), but rather distanced themselves from other nurse hybrids. It seems NPM managerial structure can benefit nurses as administrative leaders, but remains problematic for those in clinical roles. While senior nurses with no clinical contact do not encounter large amounts of identity conflict, those remaining in hybrid roles (attempting to align competing identity demands) may continue to experience problems (Croft et al., 2015).

Conclusion

This research note sets out insights gained by combining SoW and OS literatures. On the one hand, the research note extends SoW literature that studies hybrid managers (Bolton, 2001, 2005; Bolton et al., 2011; Cooke, 2006; Kirkpatrick et al., 2009, 2011) and responds to Strangleman’s call for SoW to engage with disciplines such as OS, to avoid marginalization within the epistemic community of sociology (Strangleman, 2005). On the other hand, the research note recognizes that travel of ideas from OS to SoW is not a ‘one way street’. Many of the ideas that OS scholars ‘peddle’ have their roots in sociological analysis, such as sociology of professions literature (Abbott, 1988; Freidson, 1994). Drawing upon sociology of professions literature is particularly relevant for OS scholars studying hybrid managers, rendered different from their more generalist counterparts in that they are orientated as much, if not more, towards their professional peers, rather than towards senior managers. Aligning with SoW allows OS scholars to avoid marginalization within their own epistemic domain, which has shown increasingly positivist and less critical tendencies (Grey, 2010). So, it seems that a beneficial research agenda for both SoW and OS scholars may be derived from our analysis.

Following synthesis of SoW and OS literatures, the research note calls for a critique of hybrid managers, one which considers challenges they face in taking on these roles due to identity transition, with a particular focus on their professional status. This research note argues that academic study needs to take a micro-level viewpoint to examine the enactment of hybrid manager roles in practice across professions. At the same time, research needs to consider more fully the social structures that frame this enactment. In line with SoW concern about those actors potentially marginalized in policy reforms, we suggest that research continue its focus upon those from nursing that move into hybrid manager roles, but draw more upon OS literature about identity transition and its antecedents. In terms of balance, the research agenda should privilege neither resistance nor enactment of strategic agency. We set out the following research agenda.

First, comparative analysis across doctors and nurses transitioning into hybrid manager roles highlights that we cannot derive a monolithic account of their experiences and likely influence upon policy-driven strategic change. Returning to the earlier quote from Bolton’s (2005) work, her surprise that hybrid nurse managers reported a sense of conflict between their managerial and professional identities is perhaps not so surprising when existing OS literature is considered. Taking account of competing tensions between professional and managerial organization that nurses in hybrid managerial roles face, it is clear they struggle more than doctors in mediating identity transition. Subsequently, while Bolton (2005) suggests that her work, focused upon nurses, can be transferred to hybrid medical managers, the research note questions this, due to the distinct differences in the way these professionals experience identity transition within the same organizational context. Consequently, academic research needs to pay more attention to comparative differences between hybrid managers with different professional backgrounds and move away from a preoccupation with uni-professional studies, so that analysis is rendered more robust and takes account of contingencies.

Second, linked to the above, comparative analysis across doctors and nurses, the former having a relatively higher status than the latter, renders visible the particular challenge faced by less elite professionals in taking up hybrid manager roles, where professional interdependencies are framed by power differentials. When progressing micro-level research, academic researchers need to take more account of this institutional-level challenge for less elite professionals, such as nurses, enacting a hybrid manager role; and fully consider interdependencies with more powerful professionals.

Third, the issue of gender is raised as significant, both the gendered nature of policy reform and the gendered nature of some professions. The feminized nature of nursing interacts with the masculinized nature of NPM policy reform to exacerbate the challenge faced by nurses transitioning towards hybrid manager roles. Both OS and SoW scholars might attend more to such interactions and their effects upon professionals’ identity transition towards hybrid manager roles. When the gender issue is considered alongside professional hierarchy, the importance of social position and associated power is highlighted as an important dimension of identity transition for hybrid managers and those scholars focusing upon identity should attend more to such effects.

Finally, while we encourage research to focus upon nurses moving into hybrid manager roles, we suggest that some doctors, like their nursing colleagues, may also struggle to exert influence in their hybrid manager roles (Currie et al., forthcoming). Further research might consider the influence of the social position and power of doctors, based on intra-professional differences, when they transition towards hybrid manager roles.

Footnotes

Funding

This article presents independent research funded by the National Institute for Health Research (NIHR)–NIHR HS&DR 09/1002/05. The research contribution of the lead author (Currie) was in part funded through NIHR CLAHRC WM. The views expressed are those of the authors and not necessarily those of the NHS, NIHR, or the Department of Health.

Graeme Currie is a Professor of Public Management at Warwick Business School. His main areas of academic expertise in public management relate to leadership and governance, knowledge mobilization, translation of innovation, reengineering systems and professional roles. His research is largely funded by the National Institute of Health Research in the UK. He has published articles in the Academy of Management Journal, Leadership Quarterly, Journal of Management Studies, Organization Studies and Human Relations. Prior to becoming an academic, Graeme worked in organization development for the NHS and a car manufacturer.

Charlotte Croft is a post-doctoral Research Fellow at Warwick Business School. Her research focuses on issues of organizational behaviour, leadership and identity in professionalized organizations. Before moving into research, Charlotte worked as an intensive care nurse.

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