Challenges facing healthcare managers:
what past research reveals
Cranfield Healthcare Management Group
Research Briefing
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How do they manage?
a study of the realities of middle and front line management work in healthcare
Janice A. Osbourne: January 2011
What does the research tell us?
To develop a broad perspective on the challenges faced by middle and front line healthcare
managers, we examined research from the UK and other countries. We found that both
groups face numerous challenges in their roles (see table 1).
Previous research shows that front line managers face challenges around self identity,
particularly for those in ‘hybrid’ clinical-managerial roles, and around the negative perception
of management in general. They also have problems with human resources, lack of
organizational support, and with too many systems and processes that are inadequate,
outdated, complex, or simply inconsistent with their responsibilities. Other challenges
included lack of preparation for a managerial role, balancing priorities, work pressures, lack
of recognition, role conflict, and the absence of power, influence and authority.
Previous research also showed that middle managers faced challenges around self-identity,
negative perceptions of the management role and human resources issues. They also
experienced a lack of involvement in decision making and felt challenged by hierarchical
organizational structures which inhibited their authority over particular groups. Other
challenges included role ambiguity and conflict, work pressures, job insecurity, work
relationships, organizational communication, and conflicting government directives such as
having cleaner hospitals, but being under pressure to save money by hiring fewer cleaners.
Self identity
Self identity
Negative role perception
Negative role perception
Human resources
Human resources
Unpreparedness for role
Unpreparedness for role
Balancing work priorities
Work pressures
Organizational support
Systems and processes
Lack of recognition
Role conflict
Lack of influence and authority
Middle managers
Front line managers
Table 1: Challenges facing middle and front line managers
Balancing work priorities
Work pressures
Decision making
Organizational structure
Job insecurity
Work relationships
Communication
Government policy
Lack of influence and authority
This table shows that middle and frontline managers experience many challenges, some of
which are similar. Let’s examine four which are shared by both groups.
Managers struggle with self identity: Managers struggle to maintain their professional
identity, especially hybrids who see themselves primarily as clinicians. They often see their
clinical role sidelined by managerial responsibilities (Paliadelis, 2008). Dopson (1996)
argues that inherent tensions exists between the professional values of clinical and medical
staff, and managerial demands for efficiency, cost control, and resource reallocation.
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Negative perceptions of management: The negative perception of management in
healthcare presents several challenges to middle and front line managers, especially as this
stereotype is held both by the public and by colleagues (Preston and Loan-Clarke 2000).
Llewellyn (2001) argues that clinicians who take up management positions risk loss of respect
and clinical visibility; they have to work to dispel suspicions that choosing a managerial track
is not because they lack the ability to progress in their clinical careers. For hybrids,
management values are seen as conflicting with their professional and personal values. The
management role is also seen as one of increased pressure with no tangible rewards or
recognition for the additional responsibilities.
Human resources: Many hospitals have problems recruiting enough appropriately skilled
staff, and also retaining current high performing managers (Loo and Thorpe 2004; Savage and
Scott, 2004). The research suggests that managers sometimes feel that their role lacks
definition, compounded by the lack of definitive job descriptions.
Unpreparedness for role: Many front line managers are given management roles without
having had any prior management training.
What our research has found
The managers who have taken part in our study expressed numerous challenges related to the
work itself, the organization, the NHS generally, and relationships (table 2).
Table 2: Management challenges from interviews and focus groups
The Work
Organization
Role pressures
Lack of autonomy
Time
Lack of recognition
and rewards
Workload
Job insecurity
Worklife balance
Self identity
Lack of training
Organizational
culture
The NHS
Pressure to meet
targets
Financial pressures
Relationships
Inter-professional
working
Managing external
relationships (e.g.
with PCT)
Managing peers
Poor systems and
processes (HR, IT)
What does this tell us?
Many of the challenges facing managers stem from government policies which are at
times conflicting, unachievable, and create paperwork and problems instead of solving
problems. Until these policies change, managers will continue to face these challenges.
Managers may be feeling pressured due to lack of capability. The NHS has numerous
leadership and management competency frameworks, but perhaps those competencies are
not appropriate to the changing work environment of middle and front line managers?
This is an issue that our study hopes to explore in more depth.
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Organizations can be proactive in confronting local challenges by addressing issues
within their control. For example, recognizing and rewarding managers who perform
well, giving managers greater autonomy to innovate and implement change, providing
training and development opportunities, and addressing organization culture issues.
Individual managers can explore whether some of the challenges they face are of their
own making. Are they managing their time wisely? Can they improve their work life
balance? Do they allow personal feelings to interfere when managing colleagues? Are
good peer support mechanisms - formal and informal - in place?
If you have a view on any these issues, please let us know.
Sources
Dopson, S. (1996), ‘Doctors in management: a challenge to established debates’, in Hughes, M. and
Glover, I. (eds) Beyond Reason? The National Health Service and the Limits of Management,
Avebury, Aldershot, pp.173-87.
Paliadelis, P. (2008), ‘The working world of nursing unit managers: responsibility without power’,
Australian Health Review, vol.32, no.2, pp.256-64.
Preston, D. and Loan-Clarke, J. (2000), ‘The NHS manager: a view from the bridge’, Journal of
Management in Medicine, vol.14, no.2, pp.100-8.
Llewellyn, S. (2001), ‘”Two-way windows”: clinicians as medical managers’, Organization Studies,
vol.22, no.4, pp.593-623.
Loo, R. and Thorpe, K. (2004), ‘Making female first-line nurse managers more effective: a Delphi
study of occupational stress’, Women in Management Review, vol.19, no.1/2, pp.88-96.
Savage, J. and Scott, C. (2004), ‘The modern matron: A hybrid management role with implications for
continuous quality improvement’, Journal of Nursing Management, vol.12, pp.419-426.
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The research
This study is based on interviews and focus groups with middle and senior managers at six acute trusts and one
primary care trust. The next stages of the project include a management survey, debriefing groups, and case
studies exploring how changes are managed in the aftermath of serious incidents.
Participating trusts
Bedford Hospital NHS Trust
NHS Bedfordshire Primary Care Trust
Cambridge University Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust
Northampton General Hospital NHS Trust
North Bristol NHS Trust
Whipps Cross University Hospital NHS Trust
Project team
Prof David A. Buchanan (PI)
Dr Charles Wainwright
Prof David Denyer
Dr Clare Kelliher
Ms Cíara Moore
Dr Emma Parry
Dr Colin Pilbeam
Dr Janet Price
Prof Kim Turnbull James
Dr Catherine Bailey
Dr Janice Osbourne
Acknowledgements: The research on which this briefing is based was funded by the National Institute for Health
Research Service Delivery and Organisation programme, award number SDO/08/1808/238, ‘How do they
manage?: a study of the realities of middle and front line management work in healthcare’.
Disclaimer: This briefing is based on independent research commissioned by the National Institute for Health
Research. The views expressed are those of the author, and not necessarily those of the NHS, the National
Institute for Health Research or the Department of Health.
For further information about this project, contact Jayne Ashley, Project Administrator:
T:
E:
01234 751122
J.Ashley@Cranfield.ac.uk
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