Ulla Isosaari

Power in Health Care Organizations:

Contemplations from the First-line

Management Perspective

26.6.2008 2

Background

Aim of the studyTo examine public health care organisations’ power structures through unit level management

QuestionsWhat does power mean in health care?What power type do health care organizations represent and what factors are connected to it?

26.6.2008 3

First-line Management in Health Care

Employees who have one hierarchical level under them

Member of two subsystemsthe managerial structurethe unit supervised

In health carePhysicians (doctors as first-line managers)Nurses (charge nurse, ward manager, first-line/unit nurse manager etc.)

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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

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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

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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

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Power Configurations (Mintzberg 1983)

Instrument

Closed system

Autocracy

Missionary

Meritocracy

Political arena

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Power configurations and sources of power

Decision-making

Discretion Control of resources

Control of knowledge

and networks

Centralized

Controlled

from

outside

Bureaucratic

Little

Standardized

goals

Strong

situations

Seeking

own interests

Little

Inside

organization

Strictly

defined

Clear targets

Routine

operations

Strong

situations

Rewards

bound to

success

Own

interests are

central

Control of

formal and

informal

organization

Inst

rum

en

t C

lose

d

syst

em

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Power configurations and sources of power

Decision-making

Discretion Control of resources

Control of knowledge

and networks

Experts make

decisions

Managers

arbitrate

Much in

expert tasks

Weak

situations

Political

bargaining

Competition

for resources

Outside

organization

(labour unions,

government)

All play along

Multiple goals

or none

Political

decisions

instead of

expert

decisions

Extreme

expert

discretion

Weak

situations

Competition

Greed

Manipulation

Meri

tocra

cy

Poli

tical

are

na

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Empirical studyA 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

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Results

Decision making powerIn 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

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The respondents who think decisions are made inside the unit

0

10

20

30

40

50

60

70

80

90

100

Wor

king

shifts

Dist

ribut

ionof

wor

k

Small

purc

hase

New

work

ingm

etho

ds

Staf

f'spa

rticip

ation

in tra

ining

Vaca

tions

Leav

e of

abse

nce

Hirin

gsu

bstitu

tes

Settin

gta

rget

s

Dete

rmina

tion

of s

alary

Subs

tant

ialpu

rcha

se

Parti

cipat

ionin

proje

cts

inside

the

orga

nizat

ionPa

rticip

ation

in pr

oject

sou

tside

the

orga

nizat

ion

Operation management Human resource management Management of resources

%

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DiscretionFirst-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

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First-line mangers’ views about discretion

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,024

or

unde

r

25-3

4

35-4

4

45-5

455

or

mor

e5

orun

der

6-10

11-2

0

21-3

0ov

er 30 5 or

unde

r

6-10

11-2

0

21-3

0ov

er 3025

or

unde

r

26-5

0

51-7

5 76

or

mor

e

Age (y) Working time in health care(y)

Working time in leadingposition (y)

Proportion ofmanagerial duties at

w ork (%)

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Control of resources

At average level

Very little competition

Very little political games or bargaining

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Control of knowledge and networksNetworking is a strong source of power according toSubordinatesPrimary care

Main responsibility for communication Nurse managerPhysician managers’ role more notable

First-line managers: Specialized care, surgical units, male and physicians

Staff: Specialized care, psychiatry, male and physicians

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Staff: Features of meritocracy and political arenaFirst-line managers have lots of space and many possibilities to influence

First-line managers: InstrumentPosition bounded by rules and regulationsReaching goals set outside

Specialized care: Instrument and meritocracy

Primary care: Closed system and political arena

Conclusions

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Conclusions

Surgical units: Closed system, meritocracy and political arena

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