Hybrid managers in an evolving healthcare: Does gender matter?

The development of hybrid professionalism and the missing role of gender

In most Western countries, hybrid professionalism has been seen as the solution to reconcile traditional professional values and practices with the pressures for the managerialization of healthcare services. ⁴ These pressures are not only grounded on the need to reduce healthcare spending. Rather, they are the response to broader stakeholder pressures and societal changes that have made healthcare services more interconnected, requiring new forms of inter-professional and inter-organizational integration. ¹⁰ Furthermore, professionals are required to openly report professional outcomes and be accountable to citizens rather than (only) to the profession, and must respond to increased users’ expectations in terms of quality, timeliness, and perceived user experience.

However, being in a hybrid position is not easy, and not all individuals are able or willing to bridge the gaps between the two worlds of the profession and management. Consequently, research, by and large focused on the medical profession, has shown that individual responses vary greatly. While some professionals effectively manage to hybridize, others can feel trapped into the new role or openly or subtly resist management. ⁵ The variability of individual responses has been explained ⁶ as the interplay between the managerial competencies of the professional, his motivation in the managerial role and the opportunity provided by the organizational context, in line with the ability-motivation-opportunity framework. ⁷

Of course, in many instances professionals succeeded in developing hybrid identities, ⁸ and this was associated with positive performances. ⁹ Furthermore, it has been argued that for professionals with managerial roles it is not enough to juxtapose professionalism and management, rather they are called to a situation where “organizing becomes a normal part of professional work instead of a hybrid, ‘uneasy’ combination of professional and managerial principles”.^1,10 This approach, defined as “organizing professionalism”, is characterized by an attention to cooperative behaviours between professionals that allow for process coordination, attention to stakeholders’ views, and the capacity to serve multiple values at the same time. ¹⁰ This evolution can be framed not as a decline of professionalism, but rather as a reshaping of professionalism, required to align to evolved patients’ and citizens’ requests and to respond to broader societal needs.

However, although the literature reported above has addressed the individual and contextual factors that influence the process and outcomes of hybridization, the role of gender has been neglected. Various studies showed how the feminization of professions impacts work preferences and work patterns, or critically underlined the risk of marginalization and exploitation of women, with a segmentation and stratification within the profession. ¹¹ However, evidence regarding female hybrids is limited to a handful of studies. On one side, Ireri and colleagues found that “female doctor managers reported themselves stronger in personal qualities, working with others, and managing services”. ^{12 p 23} On the other, it was shown that female senior physicians are less willing to strive for managerial positions ¹³ or not to apply for managerial roles because the perceived costs of leadership outweigh the benefits. ¹⁴ Bismark et al. ¹⁵ found that women are pressured by senior professionals to show typically masculine attitudes as the only credible form for leadership. We wish to develop this field of research by qualitative analysis allowing an in-depth understanding of the specificities of women hybrids in the medical profession.

Gender diversity in leadership roles

Existing research has identified the positive outcomes of diversity in healthcare organizations. Diversity can help organizations improve both patient care quality and financial results, ¹⁶ while diverse care teams are associated with better clinical outcomes. ¹⁷ Greater social outcomes, especially for women and children, were found when governmental organizations are led by women. ¹⁸ On the contrary, homogeneity determines rigidity, groupthink, and discrimination ¹⁹ which are particularly detrimental in organizations facing multiple and conflicting requests from stakeholders and operating in contexts that are in continuous evolution.

As far as women in decision-making positions are concerned, organizational research has shown that “female leaders bring a unique constellation of leadership-related traits, attributes, and behaviours to the workplace that may provide advantages to their organizations”. ^{2 p 1} A vast research has addressed the issue of female leadership and organizational performances, with varying results.^21–23 In particular, women leaders were rated as more effective in organizations with a largely female workforce, and in general in middle management positions. ²⁴ Multiple studies consistently found that female leaders tend to show transformational leadership approaches,^25,26 based on the capacity to “transform their followers by raising their awareness of the importance of organizational outcomes thereby activating their higher order needs and inducing them to transcend their own self-interest for the sake of the organization” ^{27 p 76} . And, while being aware that the effectiveness of leadership styles varies according to the specific organizational contexts, ²⁸ the effectiveness of these approaches has been confirmed in a plurality of fields including healthcare. ⁶

However, it is also well known that women encounter challenges at the personal level and at the level of the social context that may undermine their career chances. ²⁹ First, women show a higher disinclination to self-promote and a lower appreciation for competition. ³⁰ Also, they tend to undervalue themselves, rating their performances as significantly less effective than men. ²⁴ As far as work-life balance is concerned, women often experience lower self-esteem as well as lower job satisfaction when struggling to balance work and nonwork activities. ³¹ A vast literature has also found that women often encounter prejudices in the workplace that obstacle their role-taking. ³² In particular, it is important to consider what followers think regarding the traits that a leader should have in the workplace in order to be effective. According to the “think-manager-think-male” phenomenon, when thinking of managers, traditionally people “think male” ³³ as those competences considered typical of leaders, like competition, ambition, analysis, emotional stability, aggressiveness, are more frequently attributed to men. Indeed, research found that these personality traits are more common among males, ³⁴ however, as previously reported, the assumption that they are associated with better workplace results is not justified. Furthermore, women encounter work-life balance difficulties, limits in accessing networks of influence, lack of role models. ²⁹ Therefore, they more easily lose their career capital over the years, accumulating a cumulative disadvantage which reduces the chances of being appointed to managerial roles. ³⁵

Study context

We focus on medical managers in Italy in the field of neurology. In Italy doctors are required to take up middle management roles as head of directorate, head of specialty unit, or head of subspecialty unit. The involvement of doctors in management, especially at the specialty unit level, has always characterized the Italian NHS. ³⁶ Unit chiefs oversee responsibilities concerning the organization of work as well as human and physical resources. This comes together with the legal responsibility for monitoring, directly and indirectly, the clinical activities performed by the other doctors within the unit. After the managerialization reforms of the ‘90s they were provided with responsibilities for achieving targets and controlling costs, and were given a pivotal role in supporting the new focus on quality of care, continuity of care and integration. As far as managerial training is concerned, a management course of a minimum of 12-day is mandatory for unit chiefs upon appointment. Despite the fact that two thirds of new Italian medical graduates nowadays are women, and 44% of the medical population is female, just 18% of specialty unit chiefs are women. ³⁷ Neurology, with 15% of female unit managers (approximately 30 in 200), scores in the average of medical specialties and just below the overall average. ³⁷

Methods

In line with most of the literature on hybrid managers in healthcare [e.g.,^8,38], we adopted a qualitative approach in order to gain an in-depth understanding of the specificities of women hybrids. Data was collected through semi-structured interviews. We conducted 20 interviews (14 one-on-one and one group interview with six participants) with hybrids. Interviews took place between the end of 2020 and the beginning of 2021, were conducted online, with guarantees of anonymity, and lasted 40–70 min (the group interview lasted 150 min). 17 interviews took place with female neurologists who had participated in a large nation-wide workshop on neurology unit management held at the University employing the authors. Among participants, we selected the relatively few women holding managerial responsibilities and willing to participate. Interviewees’ average age was 57 years, 53% were tenured professors, 65% worked in Northern Italy, about one third were unit directors and the others were directors of subspecialty centers with organizational autonomy (e.g., multiple sclerosis or dementia centers) within the unit. Data collection was completed with one interview with the head of the Diversity and Inclusion committee of one of the main neurological hospitals in the country, as well with two interviews with male neurology units’ directors.

The interview protocol was prepared by the authors analysing existing literature^12–15 and was developed and fine-tuned after a discussion with the members of the Italian Neurological Society working group on Gender and Neurology, which we asked to act as advisory board for the research. The interviews were framed by various core question areas, including the reasons for moving into management; the specificity of female neurologists in professional practice, if any; the specificity of female neurologists in management roles, if any; the professional activities that are more attractive to women neurologists, if any; the career barriers and facilitators encountered as a woman, if any. Interviews were maintained as open as possible, and follow-up questions were included whenever necessary. To reduce the risk of collecting interviewees’ stereotyped speculations rather than actual experiences, we invited interviewees to provide concrete descriptions and narrative accounts. We were particularly careful in the group interview, in order to collect different viewpoints and avoiding giving the impression that a consensus had to be achieved. ³⁴ In order to reduce the risk of intrusion of unwanted researchers’ biases and assumptions, we favoured self-reflection and discussed within the research team on how to avoid influencing participants’ responses. ⁴⁰ Interviews were conducted by one or both authors and summarized with the aim to condense the most important findings emerging from the answers. ³⁹ We collected and analysed data until saturation, when little new information was provided to address our research question.

A first order analysis of data was developed by one of the authors through in vivo coding ⁴⁰ when relevant, to give voice to interviewees’ own words and to the concepts used to elaborate on personal experiences. For instance, we opted for codes like “need to prove one’s value”, “new priorities after children” or “specificities as weaknesses” as they helped to preserve participants’ meanings. We then went back and forth from data, emergent theory, and literature, looking for patterns and idiosyncrasies across respondents, in order to identify our emerging themes, ⁴¹ with an abductive analytical strategy based on promoting constant dialogue between theory and empirical findings. ⁴² While collapsing themes into broader and theoretical categories we saw that competence, motivational drivers, and the opportunity to perform as a manager were emerging as key specificities. Therefore, we opted to make use of the “ability-motivation-opportunity” (AMO) framework, ⁷ which underlines that behaviours are determined by the interplay between one’s capacity, willingness and the opportunity provided by the organizational context. As anticipated, this perspective, rooted in the human resource management tradition, has already been applied to make sense of hybrid professional trajectories. ⁶ For instance, first-order codes, such as “attention to relations” or “attention to care”, were aggregated in the second-order code “empathizing”, which refers to the aggregate category “specific abilities”. Similarly, first-order in vivo codes such as “need to prove one’s value” and “specificities as weaknesses”, were aggregated in the second-order code “facing prejudices” and associated with the category “specific (lack of) opportunities”. Findings and their interpretation were discussed and validated with the members of the Italian Neurological Society working group on Gender and Neurology, which increased our confidence in the trustworthiness of respondents’ statements and in avoiding possible researchers’ biases while performing data interpretation. Appendix 1 shows the data structure.

Specific abilities: Having a holistic approach, empathizing, and involving the team

“When the patient arrives, I ask myself: “where does he come from, who welcomes him at home, what will his future development be like?” My male colleague thinks about the stroke and how to treat it” #6

Sixteen out of twenty interviewees reported the presence of specific abilities of women hybrids. Firstly, interviews showed that women tend to show a greater attention to organizational elements within professional work, i.e., showing an overall understanding for patients, caring for familiar or social aspects that may have a relevant impact in the care process, or taking care of patients over time. On the contrary men tend to be more focused on dealing with individual cases and treatments. The potential risk associated with this competence, as stated by one interviewee, is that women spend too much time on relations, reducing the number of cases treated and therefore underperforming, vis a vis men, when quantity of cases treated is computed.

“When asked the value of azotaemia, women go to check before answering, men don’t […]. A woman experiences clinical practice with more emotional participation, which often generates motivation and attention to detail.” #15

In these quotes we see how women tend to exert their profession with a greater emphasis on relations, and this has a positive impact on the attention to details and therefore the quality of work. Also, they are less exposed to the risk of behaving with traditional paternalistic approach, and rather show a greater capacity to involve patients in the decision-making process on their care pathway. However, this specificity has also potential drawbacks, as this can drive to an excessive identification with patients ending up in burn out, as pointed out by one respondent.

“A woman has a broader, more available, more open, more empathetic vision. This means that the leadership of groups is not the same: the male tends to command, the female tends to share and create a team” #5

As stated by this interviewee, when asked to lead a team, women report being more empathic to co-workers, and create a more participatory work environment, that appear in line with the needs of contemporary professional work. Furthermore, women hybrids tend to be more sensitive to the personality of team members, as well as relational affinities within the group, while men are more focused on hard performance indicators.

Specific motivations: Being driven intrinsically and devoting to other priorities

“I have always tried to carry forward the group’s projects, not my own, as various male colleagues did instead. Of course, there are also women who answer to no one, but in my experience it is more a male prerogative to reach the goal anyway, even if it is necessary to pass over someone’s corpse.” #4

The majority of interviewees (twelve) stated that women hybrids have specific work motivations. Multiple respondents reported that, based on their experience, women hybrids tend to be more idealistic, and in taking up the managerial role they are more frequently motivated by the possibility to have a positive impact on the provision of healthcare services, or on the quality of work for the team. Also, they feel rewarded by professional achievements, such as a taking care of complex case treatment or being engaged in research. Accordingly, as shown in previous quotes, that they are less driven by the achievement of power and status and suffer less the risk of co-opting management to pursue self-interest, which, on the contrary, appears to be more frequent among men. Consequently, women tend to suffer more hypercompetitive work environments, and prefer to look for contexts or organizational roles which allow for better working relations. However, self-selection can occur, with women eventually giving up promising career pathways to avoid facing undesired conflicts or accepting compromises.

“It is difficult to see a retired woman professor returning here to work to the hospital, while it is frequent among male colleagues. I have never experienced this issue as a problem, it seems to me that we are simply different […]. Overall, we [women] invest less in the professional sphere, we are attentive to non-work priorities - those that sometimes make us leave the professional focus - while men identify more with work”. #11

The anecdotal evidence provided by these interviewees is that women with a family tend to experience a lower self-identification with the work than men. This is largely due the fact that they have competing priorities, in particular children, that redefine the hierarchy of motivational factors.

Specific (lack of) opportunities: Facing prejudices, compromising authenticity, and struggling for work-life balance

“I make participated decisions, I listen to everyone before deciding, but this is sometimes considered a form of weakness […] there is the difficulty of valuing more feminine characteristics, which are perceived as limits and not as strengths”. #9

A third element which clearly emerged during the interviews is related to the differences in the situational constraints which were experienced in taking up and in performing the hybrid role, underlined by fifteen interviewees. Women are subject to prejudices by executives, who fear that they lack sufficient strength to fight for the interests of the discipline and bear the weight of power. They perceive the expectation to explicitly demonstrate their value, in a way that is not required to male colleagues, and that their more participatory managerial approaches can be perceived as a signal of weakness. And these prejudices are not only found among male colleagues, rather they also come from female co-workers. The same often occurs with patients: when looking for the head doctor they imagine finding a man. One of the consequences reported by the interviewees is that women hybrids, especially in the past, tended to mimic managerial approaches typical of men in order to be legitimized and survive within organizations that implicitly select specific ways to be a hybrid manager, at the expense of others.

“Kindergartens, even if placed in the hospital, have a timetable… But a doctor is not a clerk [with a scheduled working time], if you are treating a sick person and he has a heart attack… you have to stay there. In professional work, not everything can be pre-arranged […] and if you are responsible for someone else, you are not available”. #7

Lastly, our data confirm that female professionals with family and children struggle for work-life balance. This has an impact in the career pathway towards managerial roles, as maternity leaves hamper professional development, with the risk that other colleagues can profit from this. Furthermore, family commitments reduce flexibility and shrink the time available for work or research activity, and make travelling abroad for congresses, as well as relocating to accept an interesting work opportunity, more difficult.

Future developments

“Today there is a greater homogenization in behaviours. We noticed with other colleagues that many of the young residents, male and female, tend to be very fast but a little superficial. Even women are more superficial, quicker and a little ruthless. They will make a career faster, and perhaps will be perfect emergency doctors, but will not be that good in treating chronic diseases”. #4

As far as the future of hybrid management is concerned, opinions are unclear. While the vast majority did not mention this element, four respondents envisioned a blurring of the female hybrid specificities among younger generations. They argue that some junior women doctors show attitudes that are more similar to male codes of behaviour, with less attention for details and personalized care. However, this is not without regret, as such features are deemed very important for providing an effective neurological care. Seemingly, they appear to reveal motivational drivers that do not differ from those of their male colleagues.