SDO Protocol – project ref: 08/1808/241
Version: version 1
Date: 23 February 2009
Roles and behaviours of middle and junior
managers: managing new organizational forms of
health care
Chief investigator: Dr Paula Hyde
Sponsor: University of Manchester
Funder: SDO Programme
NIHR Portfolio number: n/a
ISRCTN registration (if applicable): n/a
The Service Delivery and Organisation programme is managed by NETSCC, SDO as part of the NIHR Evaluation, Trials and Studies Coordinating Centre
at the University of Southampton.
Alpha House, University of Southampton Science Park
Southampton SO16 7NS
tel: +44(0)23 8059 5586
fax: +44(0)23 8059 5639
email: sdo@southampton.ac.uk
www.sdo.nihr.ac.uk
Roles and behaviours of middle and junior managers: managing new organisational forms of
health care
1. Aims/Objectives
This study aims to:
1. Examine the realities of managerial life for middle and junior managers in healthcare
organizations
2. Understand and compare the various roles and behaviours of middle and junior
managers in respect of competing organizational forms of governance
3. Explore the interactions between middle/junior managers and frontline staff and their
effects on service delivery
4. Build knowledge relevant to the practice of managers in healthcare organisations as
they affect organisational performance
2. Background
Context and issues
The delivery of healthcare relies fundamentally on the capacity and capabilities of the
healthcare workforce, and therefore upon the ability of healthcare organizations to manage
and engage their workforces effectively (Meier and O’Toole 2002). In concert, there is
increasing recognition of the impact of management and leadership behaviours on
organizational performance (Pfeffer 2005). In the UK in recent years, this centrality of human
resource management to health services and healthcare delivery to patients has been
recognised by a range of stakeholders, including government, policy makers, managers,
professional organizations and clinical professionals. This has been brought into sharp focus
in current healthcare reforms aimed at modernising the NHS, dealing with longstanding
constraints on access, and promoting innovative and creative models of service provision
(Davies 2003, DH 2003, 2002a,b, 2000, 1999). The success or failure of these workforce
reforms and restructuring of services depends, in part, on improving managerial
competencies at all levels, and notably for our study in middle and junior ranks. It is, therefore,
critical that a detailed and realistic understanding of the actual roles and behaviours of middle
and junior managers be gained if stakeholders are to evaluate effectively the status of
contemporary reform and performance measures.
To expand, the work of middle managerial reaches of the organization has been described as;
administrative involving the collection and distribution of information, technical - relating to
original trade or profession and conferring authority and ability to detect operational problems,
and managerial - persuading others into a particular opinion or course of action (Torrington
and Weightman 1987). Attempting to explain the complex reality of this basic structural model
is an extensive literature on managerial work that draws on a variety of theoretical traditions.
This literature sees contributions ranging, for example, from functionalist and technical studies
of managerial time usage (Tengblad 2006, Mintzberg 1973), through labour process studies
of managerial skills and roles (McCann, Morris and Hassard 2008, Teulings 1986) to
poststructural analyses of managers’ narrative, storytelling, or ‘identity work’ (Sims 2003,
Thomas and Linstead 2002). Our research proposal will contribute to this literature by
developing a grounded and interpretive analysis of how managers in the middle reaches of
organizations are both bosses and employees; leaders and followers. This dichotomy has
caused considerable conceptual confusion in the literature and our study will attempt to
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provide greater clarity with regard to the theoretical underpinnings of this aspect of
management work. It will do so by considering in detail the theoretical implications of the
subjective meaning of work for NHS managerial staff. This concern is especially pressing at
middle and junior management levels in public sector healthcare, a setting in which
managerial roles and behaviours are changing rapidly (Morris and Farrell 2007).
Indeed, the NHS has undergone significant reorganization and restructuring in recent years
(McKee, Ferlie and Hyde 2008). This restructuring has incorporated three main models of
system design: 1. Hierarchical emphasising top down performance management to ensure
delivery of key targets; 2. Network - emphasising collaboration, managed networks, care
pathways and partnership; and 3. Quasi-market models - emphasising increasing the diversity
of providers (see Ferlie and McGivern 2003). These distinctions are important because they
imply different core logics for guiding managerial roles and behaviours. This sees
relationships between managers co-ordinated in different ways: In hierarchical mode,
command and control within vertical line management systems represents the means of
decision making; in network mode, consensus formation and joint action as a result of
communication and bargaining between autonomous parties forms the means of decision
making; and in quasi-market mode - (e.g. as in the US, and increasingly in the UK) pricing
acts as the signal and incentive to decision making (Thompson et al 1991, Ferlie and
McGivern 2003). Yet little is known
about how managers navigate these competing logics. Interrogation of the roles and
behaviours of middle and junior managers in healthcare organizations will serve to illuminate
the everyday realities of these various approaches and their effects on wider organizational
performance and service delivery.
Organisational restructuring and the new managerial role
Although it is tacitly assumed in much managerial discourse that the absolute number of
managerial staff in large organizations has declined in recent years – i.e. as organizations
globally are seen to downsize and streamline their operations – even this is far from clear
(see Littler and Innes 2004). The overall number of managers may actually have grown as
managerial responsibilities are delegated, staff attain managerial titles (sometimes
pejoratively referred to as ‘title creep’: see Hassard, McCann and Morris 2009) and HRM
responsibilities are devolved (Hyde 2009, McConville 2006). For example, the number of NHS
managers and senior managers increased by an average of 2,152 per year between 1995
and 2005, rising to 39,391 in 2005 ( The Information Centre 2006). As a result managers
comprised an estimated 2.9% of the 1.3 million people employed in the NHS in England by
2005.
As noted, organizational restructuring has been widespread in many OECD countries in
recent decades, which has led generally to flatter, less hierarchical organizational structures
and been accompanied by decentralisation and outsourcing of activities with consequent
downsizing and delayering (McCann, Hassard and Morris 2004). This restructuring has
engendered profound implications for employees, not least for middle managers who
historically operated in internal labour markets with relative job security and clear promotion
ladders (Morris and Farrell 2007). Recent international research, including both public and
private sector organizations, has suggested that new organizational forms have had
significant impact on the working lives of middle managers whose roles have undergone
substantial change (Ezzamel, Morris and Smith 2004). In short, middle managers were found
to be working longer hours at a more intensified pace (Hassard, McCann and Morris 2009).
Many managers were fearful of losing their jobs amid the decline of traditional career
structures. Some researchers have even demonstrated how such restructuring has brought
about not only ‘challenges’ to, but also ‘crises’ in, middle managers’ personal identities (Webb
2004, Hassard, McCann and Morris 2009).
This loss of identity is not solely of academic importance. Damage to employees sense of self
- especially in highly-demanding organizations in which they may have made many personal
sacrifices and donated huge amounts of effort and commitment over the years - can lead to
collapse of morale, withdrawal of effort, and in the worst cases, anxiety and depression
(Starkey and McKinlay 1994). In turn, further deleterious effects can emerge when these
conditions are widespread - bullying and intimidation, for example, occur more readily in
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‘distressed’ organizations (Rayner, Hoel and Cooper 2003). We can note for our study how
the incessant demand for higher-order managerial skills on the part of middle ranking staff
has been linked to ‘role dissonance’ in the context of the traditional ‘go-between’ function of
such staff (McConville 2006) to the extent that middle management has even been described
as a place ‘no-one wants to be’ (Dopson, Risk and Stewart 1992).
If organizational reform is to be carried out effectively, senior leaders need to be able to map
and interpret the human terrain of the organization, for all kinds of organizations are
vulnerable to these problems. Maguire and Phillips (2008), for example, identified serious
difficulties associated with a loss of institutional trust among managerial employees after
restructuring at Citibank, one of the world’s largest financial institutions. Cascio (2002a, 2002b)
similarly, in studies of a range of major private and public-sector firms, many of them highprofile corporations with international reputations for excellence in human resource
management and strategy, has documented how organizational restructuring can often cause
more problems than it solves. In what has become a well known work within the literature,
Cascio (2002a) documents how organizational change can frequently be difficult and fraught
with dangers. He argues that close regard to the personal effects of change are needed, and
that these should go beyond interviews to include genuine observation and participation in
order to understand the cultures and identities of managerial workers - cultures and identities
which can be vulnerable in times of change.
On a more positive note, many of the studies cited above have also suggested that following
large-scale restructuring middle managers often described their new work tasks as more
interesting and engaging. The practice of downward devolution of authority from senior levels
within the organization amidst the general flattening of managerial hierarchies had given them
wider spans of control and broader responsibilities, which offered the possibility of increased
status for competent middle managers. However, such seemingly positive factors emerging
from the flattening of hierarchies could also, in practice, lead to managers’ roles in the middle
reaches of organizations becoming massively over-loaded, whilst at the same these same
managers becoming frustrated by the lack of available vertical promotion prospects in the
medium term. As such, the expected organizational gains as a result of such restructuring
were not always realised (Hassard, McCann and Morris 2009, Cascio 2002a, 2002b). Similar
outcomes have been found in healthcare organizations in western nations (Morris and Farrell
2007) and within the spirit of ‘new managerialism’ in public sector restructuring (McKee, Ferlie
and Hyde 2008, Kirkpatrick et al 2005, Thomas and Davies 2005, Beynon et al 2002, Carter
and Fairbrother 1995; Pollitt 1993).
It should also be noted within the context of our proposed research, that despite middle
managers frequently being portrayed in the writings of management ‘gurus’ as scapegoats for
corporate ills - being criticized, for example, as obstructive and afraid of change (see Handy
1995, Peters 1992, Kanter 1989) - managers in the middle reaches of organizations play
important roles in securing performance improvements and service delivery (Purcell and
Hutchinson 2007, Fitzgerald et al, 2006, Hyde and Davies 2004). Given their pivotal situation,
it is perhaps surprising, then, that the relationship between our managers in the middle
reaches of the organization and frontline staff remains a relatively underdeveloped area of
administrative research (Hyde and Thomas 2002).
3. Need
The NHS has undergone unprecedented changes in recent years following experimentation
with a variety of organizational forms, notably top down performance management,
governance, and quasi-market models (Ferlie and McGivern 2003). These reforms have
taken place against a backcloth of major changes to large organizations, public and private,
across OECD nations, with organizations typically attempting to restructure in the face of
major performance pressures. Restructuring has taken the form of headcount reduction,
flattening of hierarchies, upskilling, outsourcing of all but core competencies, and making
increased performance demands on staff. Such changes, both in the NHS and in other large
organizations, have been shown to have made significant impacts on middle and junior
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managers in terms of their careers, job tasks and responsibilities, quality of working life, and
effects on their non-working lives (Hassard, McCann and Morris 2009). In light of these and
associated organizational changes, our project is dedicated to producing a detailed
ethnographic account of the contemporary realities of working life for middle and junior
managers in U.K. healthcare organizations.
Despite the suggested importance of middle managers to wider organizational performance
(Purcell and Hutchison 2007), ethnographic studies of managers have tended to focus on
senior leaders and chief executives (Amado and Elsner 2007, Tengblad 2006, Mintzberg
1973, Stewart 1973). Few studies have sought to understand the lived experience of middle
and junior managers (for recent exceptions see Hassard, McCann and Morris 2009; McCann,
Morris and Hassard 2008) and still fewer have done so in the specific context of NHS (for
exceptions see Currie 2006; Currie and Procter 2005). Although attention has been paid to
relationships between managers and staff in mental health organizations (Hyde 2005; Hyde
and Davies 2004) and between HR and clinical managers (Hyde 2008, Fitzgerald et al 2006),
there remains little understanding of how interactions between managers and frontline staff, in
terms of their roles and behaviour, contribute to wider organizational performance and service
delivery. This has been identified as an important priority area for the NHS and is the focal
issue that our study will address.
To expand, a recent replication study of Minzberg’s (1973) landmark research investigation
suggested that managerial work is changing significantly. In this work, Tengblad (2006)
identified in contemporary organizations managerial trajectories in the direction of increased
contact with subordinates in groups, more information giving, and greater overall workload,
but with less preoccupation with administrative tasks. Studies that have included analysis of
middle and junior managers in the NHS have suggested similar changes to roles and
managerial responsibilities (Boaden et al 2008, Morris and Farrell 2007, Fitzgerald et al 2006)
plus experience of an increasing devolution of HRM responsibilities (McConville 2006). In
seeking to make sense of the research data, we can say that whereas, on the one hand,
research into managerial work points to negative factors relating to service effectiveness (with
for example managers struggling to balance their managerial and patient-directed activities:
see Boaden et al 2008), on the other, public sector managers are often found to welcome
some aspects of their expanded role (e.g. having greater autonomy with regard to
appointments and grading: see McConville 2006, Hyde et al 2005).
Overall, the roles and behaviour of middle and junior management in health organizations
appears to be becoming more complex, with the interactions between different levels of
management and across different functions of the organization increasingly difficult to
comprehend. Managers interpretation of, and reaction to, change measures are increasingly
hard to predict, and cannot simple be ‘read off’ a formal list of top management goals. In sum,
the reality of modern managerial work is complex and of a form that is not easily disclosed.
What transpires at middle and lower managerial ranks is frequently obscured from the view of
top management, deliberately or otherwise. Relationships between managers range from
direct confrontation about changing roles and responsibilities, through collusion in denying
any difficulties, to collaboration in the redistribution of responsibilities (Hyde 2009).
Given this scenario, therefore, the aims of the study are to:
1. Examine the realities of managerial life for middle and junior managers in healthcare
organizations.
2. Understand and compare the various roles and behaviours of middle and junior managers
in respect of competing organizational forms of governance.
3. Explore the interactions between middle/junior managers and frontline staff and their
effects on service delivery.
4. Add to knowledge relevant to the practice of managers in healthcare organizations as they
affect wider organizational performance.
Deriving from these aims, the main outcome of the study will be an inter-related series of
detailed ethnographic accounts of managerial roles and behaviours across a range of
healthcare organizations and under different forms of governance structure. In the wider
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management literature, such ethnographic accounts have frequently produced influential
materials for use in improving the performance of future managers (see below).
Benefits of research to NHS
In the context of organizational change within U.K. healthcare, the research offers the
prospect of making a significant contribution to analytic frameworks applied to the
understanding of managerial work. The project will provide clarity as to the actual lived effects
of organizational change in managerial work, and how these effects are interpreted by
managerial employees at middle and junior levels. This will impact primarily on three groups
involved in health service and related research fields - policy makers, practitioners and
academics. With dissemination via both practitioner and academic journals and conferences,
findings from the study will influence the conceptual understanding and practical actions of,
for example, leaders and managers, members of professional bodies, trades unionists, and
researchers.
4. Methods: a. Setting b. Design c. Data Collection d. Data Analysis
The research will adopt a comparative case study design to provide in-depth tracking and
understanding of both the lived experience of managers and relationships between middle
and junior managers and those around them. Four organizational settings will be investigated
- an ambulance trust, an acute hospital foundation trust, a mental health trust, and a primary
care trust. For each organization, case studies will see clusters of middle and junior managers
(c.4-6 managers per cluster) selected from various sub-units/departments to form the basis
for our comparative ethnographic case analysis. The comparative case-study approach has
proved to be a powerful methodology (Eisenhardt and Graebner 2007), particularly in the
study of healthcare organizations (Ferlie et al 2005) and ethnographic methods have been
used effectively to illuminate organizational dynamics between managers and staff (Hyde and
Thomas 2002) and between staff and patients (Hyde and Davies 2004, Hassard, McCann
and Morris 2009).
We will be conducting, therefore, in-depth, ethnographic research focusing explicitly upon the
lived experience of middle and junior managers in a number of departments, purposively
selected to include a range of: organizational forms (involving potential overlaps between
hierarchical, network and quasi-market), types of healthcare organization (acute hospital,
mental health, primary care, ambulance service) and work (for example, in-patient unit, GP
surgery, catering department). Within the case study selection process we will seek out
heterogeneous managerial work with the expectation of finding both commonalities and
contextual specificities associated with roles and behaviours of healthcare managers. It will
also allow the researchers to observe and interpret local and departmental subcultures and
identities.
Specifically the study will explore the following specific issues or ‘tracers’ (Addicott, McGivern
and Ferlie 2007:97) in order to gain insight into the nature of managerial work for middle and
junior managers:
1. What managers do (roles, behaviours, subcultures and identities)
2. Organizational forms (governance modes and the navigation of competing logics).
3. Organizational dynamics (relationships between senior managers, managers and frontline
staff as they affect wider organizational performance and service delivery)
Our case study methodology will incorporate a multiple methods approach to data gathering,
which will draw upon, primarily, observation of managers at work and in-depth interviewing.
Theses methods will be used to observe, identify and interpret the nature of both explicit and
tacit forms of managerial roles and behaviour (Tengblad 2006, Mintzberg 1973). In addition,
analysis of organizational documents will be used to provide information on the historical
evolution and context of forms of governance (see project schedule attached). We anticipate
assembling case studies across four organizations involving at least 48 middle and junior
managers. This research will include, ultimately, over 350 hours of fieldwork observations and
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interviews. Observations of managers at work will offer rich insights into how managers relate
to those around them and provide material for exploration concerning organizational
dynamics in later interviews (Hyde and Thomas 2003, Gabriel 1999). Observation notes and
tape-recorded interviews will be transcribed and emerging themes will be used to organize
resulting data. Themes will be developed to provide a basis for categorizing and analyzing
data. Initial identification of broad thematic areas will take place across the research team.
The philosophy of conducting ‘multiple paradigm’ research (Hassard 1991, Hassard and
Kelemen 2002, 2009) through ‘triangulating’ (Wolfram Cox and Hassard 2005) a number of
data sources will underpin the research, the object being to provide more rich, robust and
contextual case accounts than can be provided by what Martin (1991) termed the ‘monomethod monopolies’. The research process will see each member of the team involved in the
primary research. Named applicants will each take a leading role at one healthcare
organization and the research associate will undertake research across all sites.
Contribution to existing research
Through the aims, objectives and projected outcome, we anticipate that our research will:
1. Add to the evidence base relevant to the practice of managers of healthcare organizations
in order that managerial roles and behaviours may be better understood. (Managerial
ethnographies have often become central texts informing the training and development of
managers [see Amado and Elsner 2007, Watson 1994, Mintzberg 1973] and the research
proposed here will contribute similarly in this respect).
2. Design a programme of research and disseminate research results with the objective of
promoting the joint engagement of academic and health care management communities (In
developing research capacity our study will involve building on established links, and
developing new ones, between the University of Manchester and NHS organizations).
The aims, objectives and outcomes of our proposal thus address the second area of primary
research identified in Theme (iii) of the present SDO initiative, ‘The realities of managerial life’,
namely, work investigating ‘The work life, roles and behaviours of middle and junior managers
in healthcare organisations, and their place in and contribution to wider organisational
performance and service delivery.’ (p5)
5. Plan of Investigation
Line management is a key feature of large organizations; the term implies a chain of authority
from senior managers through to staff delivering services. Whilst senior managers are
normally those who define and formulate strategy, first-line (or junior) managers are those
who control the daily detail of working practices on the shopfloor. Middle managers are
traditionally a more difficult cadre to distinguish, as boundaries between levels of hierarchy
are less clear. This is further complicated in more organic or simultaneous structures where
demarcation is often ambiguous (McConville 2006). For the purposes of this study, however,
and in common with previous studies, middle managers are defined as ‘people identified as
such within the organisation, provided that they were part of a clear chain of management and
involved in the delivery of an end service, being responsible for at least two subordinate levels
within the hierarchy, and with at least one superior between them and the organisational
executive.’ (McConville 2006: 639). Our middle managers , then, traditionally maintain a
rather invidious position - playing a co-ordinating role but having procedurally-limited
autonomy (McConville 2006).
While the main contextual variable in this research is new organizational forms of governance,
the central focus is the impact of these new forms on middle and junior managers in the NHS.
As noted above, there is a surprising lack of empirical research on the changing roles of
middle and junior managers. In order to rectify this situation, we suggest initially two
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arguments at the core of the logic of our project: Firstly, that any analysis of managerial
impact must be rooted in organizational context with cognisance of the rationale for current
managerial roles; this can only be drawn out, we argue, via ethnographic case study
methodologies. And secondly, the need to differentiate the managerial labour market with an
acceptance that it is highly segmented; for we argue that the impact on middle managers as
opposed to senior managers may be as great as that between skilled and unskilled staff.
In terms of initial development, the project will begin with a stakeholder meeting bringing
together policy makers, professional bodies, and senior/middle/junior managers from a range
of health care organizations to initiate the study of roles and behaviours of middle and junior
managers in a relevant and meaningful way. The proposed study concerns the lived
experience of middle and junior managers - it involves a three year ethnographic study of
managers in healthcare organizations involving observation of managers at work, diary
methods of recording managerial work and interviews with middle and junior managers and
their colleagues. Through this innovative study, we seek to gain an ‘inside view’ of the
realities of working life for middle and junior managers in healthcare organizations. This view
will enable us to observe roles and behaviour of middle and junior-ranking managers in terms
of agentic forces that may be out-with the understanding of those at the top of the
organization, and which may or may not reflect the organization’s publicly-disclosed models of
management and service delivery.
6. Project Management
Our three-year project will be structured as follows:
Project initiation:
Seek ethical approval as soon as confirmation of funding is received. Appoint research
assistant. Identify first set of four case studies and begin access interviews. Host the first
stakeholder meeting.
Cases 1-3:
Begin cycle of ethnographic study activity in first organisation. Begin observation of ‘tracer’
issues. Develop and conduct semi-structured managerial interviews. Commence data
transcription and analysis. Identify themes across cases as they relate to tracer issues.
Discuss and produce first versions of case study work to date. The first annual report will be
sent to SDO.
Cases 4-6:
Continue cycle of ethnographic study activity in the second organisation (with additional
managers). Continue data transcription and analysis. Compare and develop themes across
cases, revise, and conduct next semi-structured managerial interviews. Produce account of
second set of three case studies.
Cases 7-9:
Continue cycle of ethnographic study in third organization. Compare themes across cases.
Conduct next set of semi-structured managerial interviews. Produce account of third set of
case studies and commence cross case analysis. The second annual report will be sent to
SDO.
Cases 10-12:
Finish cycle of ethnographic study in fourth organization with final three case studies.
Compare and finalise themes across cases. Conduct final interviews. Produce account of
fourth set of case studies and continue cross case analysis.
Validation and theory building:
Conduct final interviews and analyse data. Complete cross case analysis. Hold stakeholder
conference to validate and disseminate indicative findings. Revise findings and produce final
report. SDO and stakeholder briefings will take place.
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7. Service users/public involvement
The project does not involve service users as the study concerns NHS managerial staff.
However, the project includes realistic plans for involvement of stakeholders. To increase the
external visibility of the project, we seek to involve interested stakeholders in the course of the
empirical research. These would include managers in key national agencies (e.g. NHS
Confederation, Health Professional Managers Association, Department of Health HR capacity
unit, IHM, NIHR), senior managers, HR managers, and staff in case study organizations with
a role in developing middle and junior managers. We would hold a stakeholder conference in
both the first and the final months of the project - the first to involve stakeholders early in the
project in order to shape the research and to increase wider awareness of the study; and the
second to consider the penultimate version of the report and increase wider awareness of the
findings.
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This protocol refers to independent research commissioned by the National Institute for Health Research
(NIHR). Any views and opinions expressed therein are those of the authors and do not necessarily reflect those
of the NHS, the NIHR, the SDO programme or the Department of Health.
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