Ulla Isosaari Power in Health Care Organizations: Contemplations from the First-line Management Perspective

1. Ulla IsosaariPower in Health Care Organizations: Contemplations from the First-line Management Perspective

2. Background • Aim of the study • To examine public health care organisations’ power structures through unit level management • Questions • What does power mean in health care? • What power type do health care organizations represent and what factors are connected to it?

3. First-line Management in Health Care • Employees who have one hierarchical level under them • Member of two subsystems • the managerial structure • the unit supervised • In health care • Physicians (doctors as first-line managers) • Nurses (charge nurse, ward manager, first-line/unit nurse manager etc.)

4. Power • The intended sphere of influence • Includes force, manipulation, persuasion and authority • Always relative and seeks balance • Can be examined in three dimensions • Structural • Individual • Interpersonal

5. Sources of power (Morgan 1990: 159) • Decision-making power • Formal authority • Control of decision processes • Discretion • Use of organizational structure, rules and regulations • Structural factors that define the stage of action • Control of resources • Control of shared resources • Ability to cope with uncertainty • Control of technology

6. Control of knowledge and networks • Control of knowledge and information • Control of boundaries • Interpersonal alliances, networks and control of ‘informal organization’ • Control of counter organizations • Symbolism and the management of meaning • Gender and the management of gender relations

7. Power Configurations (Mintzberg 1983) • Instrument • Closed system • Autocracy • Missionary • Meritocracy • Political arena

8. Power configurations and sources of power Instrument Closed system

9. Power configurations and sources of power Meritocracy Political arena

10. Empirical study • A survey of 10 Finnish hospital districts both in specialized and primary care • Respondents : • all first-line managers (physicians and nurses) • a sample of staff members from internal disease, surgical and psychiatric units, as well as outpatient and primary care units • number of respondents: 1197 • response percentage: 38 • The data was analysed statistically • building sum variables • correlation analysis • Kruskall-Wallis test • table elaboration

11. Results • Decision making power • In the unit, at a higher level or outside the organization? • In the unit concerning operation management and human resource management • At higher level or outside the organization concerning resources • Who makes the crucial decisions for the unit? • Nurse manager has a strong role concerning operation management and human resource management • Factors influencing the development of power • Position and competence

12. The respondents who think decisions are made inside the unit

13. Discretion • First-line managers reported more discretion than their subordinates assessed they had • Nurse managers used more discretion than physician managers • Much discretion was connected to task description in written form

14. First-line mangers’ views about discretion

15. Control of resources • At average level • Very little competition • Very little political games or bargaining

16. Control of knowledge and networks • Networking is a strong source of power according to • Subordinates • Primary care • Main responsibility for communication • Nurse manager • Physician managers’ role more notable • First-line managers: Specialized care, surgical units, male and physicians • Staff: Specialized care, psychiatry, male and physicians

17. Conclusions • Staff: Features of meritocracy and political arena • First-line managers have lots of space and many possibilities to influence • First-line managers: Instrument • Position bounded by rules and regulations • Reaching goals set outside • Specialized care: Instrument and meritocracy • Primary care: Closed system and political arena

18. Conclusions • Surgical units: Closed system, meritocracy and politicalarena • Physicians:Closed system and meritocracy • Implications: • Are first-line managers’ recruiting, qualification requirements and training in balance with real conditions in the units? • Traces of effects of municipal restructuring process in primary care