Mobilising Identities: The Shape and Reality of Middle and Junior Managers' Working Lives

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 08/1808/239. The contractual start date was in June 2009. The final report began editorial review in January 2013 and was accepted for publication in August 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Copyright statement

© Queen’s Printer and Controller of HMSO 2014. This work was produced by Harvey et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Definitions

Research aims and objectives

As advised by Mintzberg24 more than 40 years ago now, we sought to locate managerial work in the context of organisational structures and processes. Through this we hoped to discover whether or not managers with clinical and non-clinical responsibilities and at middle and junior levels have different sources of identification, leading to different identities, which might shape their interpretations of their roles and the ways in which they carried them out.

The primary typology of managers was based on the two dimensions of management level (middle or junior managers) and clinical engagement (whether the manager is counted as clinical or non-clinical staff). This generated four primary groups: junior clinical (JC), junior non-clinical (JNC), middle clinical (MC) and middle non-clinical (MNC). We also employ a more fine-grained categorisation according of ‘work groups’ (which maps back onto the four ‘primary groups’) for some aspects of the analysis which follows.

In summary, the aims and objectives of the research were:

1. to chart the work of middle and junior health-care managers, including identity work, and to produce an ethnography of the lived experience of middle and junior management within the specific context of the NHS

2. to explore the identities of managers (goals, values, motivations, beliefs and interaction styles) and how these are constructed, and further, how the performance of managers’ roles is shaped by these identities

3. to capture how middle and junior health-care managers leverage their identities to create success, establish trust and broker alliances to exert influence in different and various spheres and to determine how they interpret and take forward their ‘project’ to achieve organisational, group and personal goals within the framework of the NHS

4. to determine the influence of managerial identities on organisational processes and outcomes.

Structure of the report

Chapter 2 provides an outline of the key bodies of research relevant to the research and outlines the analytical framework that guided the conduct of the study and data analysis. Chapter 3 details the research methodology and Chapter 4 provides an overview of the two research sites (two acute hospital trusts). Chapters 5–8 set out the research findings. Specifically, Chapter 5 explores the ‘facets of identity’ of the four main categories of manager. Chapter 6 analyses what managers do in their work, based on the more fine-grained work groups. In Chapter 7 we consider the managers’ self-reported accounts of how effective they are as managers and what facilitates and what inhibits their effectiveness. Finally, in Chapter 8 , we report on how managers seek to mobilise their identities to exert influence in the various and different spheres in which they operate. Chapter 9 summarises the main findings and outlines the recommendations for practice and for future research. Although of necessity the chapters build on and relate to each other, the report has been written in such a way that readers interested in particular findings can also read each chapter as a stand alone.

Identity

Identity is defined as ‘a self-referential description that provides contextually appropriate answers to the question “Who am I?”’ (p. 327). 26 Identity as a concept helps to ‘capture the essence of who people are’ and ‘to explain why people think about their environments the way they do and why people do what they do in these environments’ (p. 334). 26

Identification is ‘the process by which people come to define themselves, communicate that definition to others and use that definition to navigate their lives’ (p. 334). 26

An individual’s self-concept consists of (a) personal identity, or ‘a person’s unique sense of self’ (p. 260)36 and encompasses their idiosyncratic characteristics, such as bodily attributes, psychological traits and interests, and (b) social identity, or ‘a person’s sense of belonging to some human aggregate’ (from a small group to a nation) (p. 21). 37 The focus of our project is on social identities.

Research on identity is prominent in anthropology, organisation science, philosophy, psychology and sociology. Of these, the research in sociology and organisation science is most relevant to the project topic.

In sociology, research on identity consists of two distinct strands (1) a (sociological) social psychology strand, which focuses on individual agency, and (2) a collective identity strand, which focuses on group agency.

The social psychology strand focuses on the identities of individuals and encompasses two inter-related research traditions. The first (e.g. identity theory38) emphasises ‘internalized role-identity meanings’ and examines ‘how the social positions that people occupy become stable, internalized aspects of their self-concepts’. The second (e.g. social identity theory39) emphasises ‘culture and situational context’ and investigates how ‘cultural meanings associated with identities are imported by actors into local interactions and how situational environments shape the localized meanings of the situationally relevant identities’ (pp. 480–4). 40

The collective identity strand focuses on the identities of groups, or collective identities, and examines how collective identities are constructed and influence mobilising joint action. The collective identities examined in this strand are primarily associated with the ‘holy trinity’ of social categories: gender/sexuality, race/ethnicity and class (p. 1). 41 A notable example of research in this strand is the studies of social movements. 40,42

In organisation science, research on identity traces its roots to the works of Simon43 and March and Simon,44 but has gained strength from the late 1980s following the publications by Albert and Whetten45 and Ashforth and Mael. 37 Recently, research on identity has been deemed ‘one of the fastest growing, most fertile, and . . . most contested’ research areas in organisation science46 impacting nearly all research domains in the field. 26 Identity and identification are considered as ‘root constructs in organizational phenomena’ because ‘they speak to the very definition of an entity – an organization, a group, a person’ and because they ‘situate the organization, group, person’, which is essential for interaction between the entities (p. 13). 47,48

Research shows that identity and identification are essential for the well-being of both individuals and collectives (groups and organisations).

For individuals, the two basic motives for – and the outcomes of – social identification are (1) self-enhancement and (2) uncertainty reduction. Self-enhancement (or self-esteem) underpins the striving for positive intergroup distinctiveness: ‘a belief that “we” are better than “them”‘. Uncertainty reduction is associated with social categorisation: ‘People . . . like to know who they are and how to behave and who others are and how they might behave’ (p. 120). 48 An additional motive/outcome, specific to work context, is employee strengthening, or a process of increasing individual capacity to endure stress and take on new challenges. Employee strengthening is associated with a particular type of social identity, dubbed ‘positive identity’, variously interpreted as ‘infused with virtuous qualities’, entailing ‘subjective feelings of self-regard’, or keeping ‘the multiple facets of the identity . . . in a balanced . . . relationship’. Positive identity leads to employee strengthening, because it helps to build social resources, i.e. ‘the number, breadth, diversity, and quality of relationships employees have at work’ (pp. 268–73). 46

With regard to collective outcomes, research has mainly focused on organisational identification, showing that such identification job satisfaction, intrinsic motivation, task performance, employee turnover, co-operation, teamwork, information sharing, organisational citizenship, creative and helping behaviours, customer orientation, improved organisational control, and positive evaluation of the organisation (though this list may be misleading) (pp. 336–7). 26

Despite the wealth of research on identity, considerable gaps remain in our understanding of this phenomenon, especially with regard to work-related identities.

Thus, the research on work-related identities has focused largely on the identification with the organisation as a whole (‘organisational identity’), whereas other loci of identification, namely work groups, organisational units and occupations, have received little attention (p. 348). 26 In particular, research on occupational and professional identification has been ‘sporadic’, though more frequent recently33,49,50 and the topic of managerial identity has been particularly neglected (for notable exceptions). 50,51 Hence, researchers have primarily concentrated on how managers manage the identities of other groups (e.g. medical professionals; see Covaleski et al. 52) and of the organisation as a whole, but largely disregarded the identities of the managers themselves. Within the research on the identities of managers, the identity of junior and middle managers has received much less attention than the identity of senior management; and the identities of those working in public service contexts have received far less attention than those working in the private sector (p. 5). 53

Our project addresses these gaps, contributing both to better understanding of management in the NHS and to the broader research on identity.

We also note that research on mobilising identities has been mainly confined to identity mobilisation in the context of social movements, with particular reference to social category identities, such as gender, race and class. We were unable to find any research on identity mobilisation in the organisational context and with reference to occupational/professional work.

Professions

The changing role of the professional worker in the 21st century has been identified as of critical sociological importance. 54

Early accounts of professions were based primarily on studies of the liberal professions (especially medicine) and focused on their distinctiveness from other occupations, cataloguing their traits and documenting their (successful) quest for power and autonomy. 55–57 These accounts clearly differentiated between professionals and managers. 58 The latter were described as depending for their power on their position within, and knowledge, of a particular organisation, whereas that of the former stemmed from abstract knowledge and was independent from organisations.

More recently, however, the emphasis has shifted to reflect new realities as the privileged position of traditional professions has been threatened by globalisation, technological change, neo-liberal ideologies,59 the encroachment of managerialism60 and the spread of ‘new professions’ (such as ‘knowledge workers’). 61,62 The boundary between managers and professionals has also been blurred by the increasing professionalisation of management and the co-optation of professionals into managerial jobs. Yet, although some have argued that the rise of new forms of professionalism advances co-operation and reduces barriers between occupational groups, others have observed the persistence of the classic patterns of professionalism, based on status hierarchy and exclusion. 63

Particularly germane to this research is the literature on the relationships between managers and (other) professionals in health care. For expediency, in what follows we present a stylised composite picture of this literature.

Most has focused on clinicians – as managers and vis-à-vis managers. Clinical and managerial logic are usually portrayed as incompatible and hence conflicting. Yet, with the advent of New Public Management (NPM), clinicians have been drawn into management processes, both indirectly, by having to contend with the increasing organisational constraints (e.g. leaner budgets, closer control of performance), and directly, by assuming managerial roles64,65 and moving into ‘hybrid’ (clinical and managerial) organisational positions. 66 As Kirkpatrick et al. (p. 121)67 relate with reference to physicians, extending clinical leadership in the hospital sector has become an ‘international fashion’ though how it is enacted and the level of engagement varies considerably and depends very much on local conditions. Research frequently has found that clinicians are reluctant to engage in managerial work,68 but are also uncomfortable with the idea of non-medics taking decisions that affect patient care69 and may be motivated to enter management by the desire to influence the direction of change. 66 Nurses see management as a step up the nursing career ladder, whereas medics see it as a step away from what really matters. 70 Most clinicians, on entering management, strive to maintain their clinical responsibilities and are keen to disassociate themselves from the term ‘management’. 71 This has led some to conclude that the boundaries between medicine and management are no longer sustainable. 72 As Kuhlmann et al. relate, organisations, such as hospitals, are ‘“switchboards” of clinical practice, where “medicine meets management” and control is made and remade’ (p. 723). 72

In post, many clinical managers see themselves as performing a critical boundary role, translating between different groups,33 and nurses in particular come to espouse managerial definitions of professional work. 73 At the same time, many feel isolated from other clinicians (the feeling exacerbated by hostility from their former colleagues)66 and ‘caught in the middle’ between the expectations of subordinates (to represent clinical interests) and the demands of senior management (to run efficient and effective services). 74 Qualitative research by Spehar et al. 75 in Norway on nurses’ and physicians’ journeys into management found that most had not anticipated a career in management but were persuaded into it. Most were thrown into the position unprepared for the challenges, which they had to learn to deal with ‘on the fly’ (i.e. with insufficient training).

Getting into management does not necessarily mean subjugating a clinical agenda to a managerial one. Indeed, as a detailed analysis of one US manager reveals, it can mean finding oneself on the boundaries of several discourses, such as the profession-specific discourse of medicine; the resource-efficiency and systematisation discourse of management; and the ‘inter-personalising discourse devoted to hedging and mitigating contradictions’ (p. 15). 76 In the UK, clinical directors have been shown to subvert market discourse by making rhetorical appeals to ‘service quality’ and to ‘market demand’ in order to bargain for extra resources, defend the status quo,77 and to counter managerialism by asserting their capacity to be ‘close to the customer’ in a way that management cannot. 78

Nor do the differences between clinical and managerial logics necessarily lead to a conflict. As Reay and Hinings79 demonstrated, based on their research on health care in Canada, a rivalry between these logics may be managed by a collaboration that allows the collaborators to maintain their independence (e.g. differentiating medical decisions from managerial decisions, seeking informal input from medics as part of decision-making processes, and working together against the Government). Similarly, drawing on ethnographic case studies of Dutch health-care organisations, Stoopendaal80 suggests that rather than provoking conflict between different interest groups, the position of non-clinical managers as ‘outsiders’, can allow managers to serve as a tie connecting these groups.

Clinicians may also become ‘managerialised’ without entering the ranks of management. As Waring and Currie81 argue, medics may draw managerial expertise into their professional practice in order to stave off managerial encroachment by taking responsibility away from managers (‘co-optation’), adapting existing professional systems to better reflect the aspirations of policy (‘adaptation’) or circumventing management systems (‘circumvention’) by emphasising the superiority of their own systems.

Yet, however blurred, boundaries between clinicians and managers persist, even when clinicians become managers. Thus, Hoque et al. 82 showed a clear divide between consultant managers and non-consultant managers in how they perceived each other and their own roles: whereas non-clinical managers spoke of being an interface between management and medical staff, promoting a quality service, fulfilling the daily needs of clinicians and patients, and improving the environment in terms of training, recruitment and personnel; clinicians alternatively talked about having a blueprint for the NHS and delivering it. Consultant managers, who retained a ‘strong identification with their profession’ were also left feeling unduly constrained, whereas non-consultant managers saw themselves as agents of government and their role as delivering targets and centrally derived objectives.

Junior and middle managers

The literature on managers mirrors management hierarchy, with senior managers attracting the most attention and junior managers the least. Furthermore, whereas the research on middle managers generally and in the NHS in particular, has burgeoned in the past two decades, the research on junior managers peaked between the 1940s and 1970s, and then petered out recently, with a paucity of studies in the health-care context.

Analytical framework

We use the term ‘analytical framework’ to signal that we consider our work as exploratory rather than aimed at testing or refining particular theories.

This analytical framework consists of a set of ‘sensitising’ concepts108 and ideas that guided our empirical investigation.

Identity

In order to examine the process and outcomes of mobilising identities, we needed first to map the social identities of the junior and middle managers in the NHS and establish what was characteristic of their identities. Although we acknowledge that social category identities (such as gender) and non-work-related identities (e.g. parent) might be important, our project focused on occupational/professional identities.

To describe the managers’ identities we adapted the model of social identity proposed by Ashforth et al. (pp. 328–31). 26 Their original model portrays social identity as a continuum that encompasses (moving from the narrow to the broad formulation): (1) core of identity, including self-definition (‘I am “A”’), importance (‘I value “A”’), and affect (‘I feel about “A”’); (2) content of identity (i.e. values, goals and beliefs, stereotypic traits, knowledge, skills and abilities); and (3) behaviour of identity. Our adapted version of their model is presented in Figure 1 .

FIGURE 1.

A model of identity.

We refer to particular elements of an identity, such as self-definition, values and work, as the facets of identity.

An individual’s identities may:

• conflict – when there is ‘an inconsistency between the contents of two or more identities, such as a clash of values, goals, or norms’

• converge – so that different identities become aligned and reinforce each other, and/or

• combine – so that different identities are compartmentalised (pp. 354–9). 26

Social identities are ‘relational and comparative’ (p. 16)39 because individuals develop the self-definition and the evaluative component of identity by contrasting the group with which they identify with a salient other group.

An individual’s identity is further ‘verified or falsified by experiences provided by interactions with similar others’ and by the ways one is described by others (p. 208). 109

Identities evolve, fluctuate and change. Individuals learn identities through the processes of identity enactment and sense-making (reflecting on the reactions to the identity enactment). ‘Much if not all activity involves active identity work: people are continuously engaged in forming, repairing, maintaining, and strengthening or revising’ (p. 626). 110

Introduction

We ascertained that the best way to capture the lived experience of middle and junior, clinical and non-clinical, managers was to situate their work within its organisational context. This follows from our theoretical approach. Identities are recognised to be highly contextual. In other words, they are formed in interaction with others and can alter in their emphasis according to the interaction context in which the individual is engaged. 13 Thus workplace organisational contexts – which in the case of hospital trusts are likely to be wide in scope for some managers (see Chapter 6 , General parameters of managers’ work) – are important to capture empirically because they facilitate the formation and enactment of identities.

Two large hospital trusts in the same region with similar organisational structures (at the start of the fieldwork) were selected for study (see Chapter 4 ). To recap, we endeavoured to collect rich, ethnographic data to enable us to provide an account of the every-day work of these categories of manager, and to capture any associations between their sense of identity, how they mobilised their identities in the course of their work, and how this contributed or detracted from their self-reported effectiveness.

The main data collection method was one-to-one, in-depth, semistructured interviews, including a reflection on respondent-generated schematic work diaries. This was supplemented by shadowing of a number of respondents and the observation of meetings. The fieldwork took place consecutively in the two hospital trusts over approximately 24 months between 2010 and 2012. The research was approved by the Regional Research Ethics Committee in December 2009 (i.e. before the harmonised edition of the Governance Arrangements for Research Ethics Committees,113 which excludes research on NHS staff by virtue of their professional role from the National Research Ethics Committee, came into effect).

The two research sites

Case studies are an appropriate method to use when posing ‘how’ and ‘why’ questions, when the researcher has little control over events, and when the ‘focus is on a contemporary phenomenon in a real-life context’ (p. 2). 114 Case studies are generalisable to theoretical propositions, not to populations or universes. 114

The case study hospital trusts were both multisite organisations which had not yet achieved foundation trust status: we refer to them as Metropolitan Hospital Trust (Metropolitan; case study 1) and Cityscape Hospital Trust (Cityscape; case study 2). As discussed further in Chapter 4 , at the design, inception and negotiation of access for the study (via senior board-level individuals in each trust), the two trusts were virtually identical in size and structure. Our initial expectation was that using very similar organisations would enable us to identify whether or not the association between identity and work activity was common for managers in both trusts following Yin’s114 concept of multiple-case design using literal replication with embedded units of analysis [i.e. the four groups generated from the primary typology based on the two dimensions of management level (middle or junior managers) and clinical engagement (clinical or non-clinical staff)].

However, this was impeded by organisational restructuring at Cityscape following changes in key members of their executive team. Even though Metropolitan was not undergoing the same degree of organisational change, it was not static either. In fact, the dynamics that the two trusts faced such as multisite working, year-on-year efficiency savings and cost improvement programmes, and mergers of services are mirrored by trusts across the country.

Once the full phase of data analysis began (see Data analysis), it became apparent that the organisational factors affecting the work of the middle and junior managers were of a similar order across the two trusts. A further factor inhibiting comparison was the distribution of respondents (see Sampling method). For example, all scientist managers were located at Metropolitan and the majority of nurse middle managers at Cityscape.

We, therefore, did not seek to compare the two trusts but rather combined the two sets of data for analysis to generate cross-case theoretical generalisations, drawing out specific references to any organisational differences where they mattered for aspects of the managers’ work where appropriate.

Data collection

Data analysis

The project generated a large volume of qualitative data in the form of interviews and field notes. As is common in qualitative research, the analysis ran alongside data collection. Thus the work to generate an initial coding frame began while the fieldwork was taking place at Metropolitan, the first research site. This was fleshed out and finalised while it proceeded there and began at Cityscape. The process of developing a coding frame is itself part of the analytical process, providing the researcher with an initial template against which to assess the data still being collected.

Anonymity and confidentiality

We assured anonymity and confidentiality to our respondents. To preserve this, where respondents held quite distinctive roles, these have been made deliberately vague. Equally, where respondents talk about particular work areas or kinds of patient-related work these have been made as non-specific as possible to avoid identification. We have also avoided giving too much specific detail on the organisational structures of the two trusts in Chapter 4 . In Chapters 5 – 8 we use abbreviations (JC, MC, JNC and MNC) to describe manager level. The accompanying numbers are those allocated to the interviewee from 1 to 91. Where the number is preceded by P (e.g. P4) this indicates that this was a pilot interview.

The two hospital trusts

It should be noted that the research took place before the implementation of the Health and Social Care Act of 201217 which has established different commissioning arrangements to those described below and elsewhere in the report.

Both trusts are based in medium-sized cities in England and, at the time of the research, belonged to the same strategic health authority regions.

Metropolitan, which was formed in the late 2000s, comprises two hospital sites and liaised with two primary care trusts (PCTs) in its area. Formed in the early 2000s, Cityscape consists of three hospital sites and liaised with three PCTs.

Each trust employs over 10,000 staff and provides services for 2–3 million people in their city, surrounding areas, and nationally for specialist services. Metropolitan has approximately 1700 beds and Cityscape 1900 beds. Both trusts claim in their annual reports that they are among the largest teaching trusts in England and have among the country’s busiest emergency departments (each with over 160,000 accident and emergency patients treated annually). They also have high aspirations. Thus, at the time of the fieldwork Metropolitan was aiming to be the country’s best acute teaching hospital, whereas Cityscape wished to be the number one provider of emergency and specialist services in England.

When the research began (June 2009), based on the Healthcare Commission Annual Health Check for the 2008–9 financial year, both trusts were rated ‘good’ for use of resources (the effectiveness of resource utilisation). For quality of services (covering a range of areas such as patient safety, cleanliness and waiting times), Metropolitan was rated as ‘fair’ and Cityscape was rated as ‘good’.

At the start of the research period, both trusts were in the process of applying for foundation trust status and were seeking to achieve it by the end of our 3-year project, but neither did.

Both trusts were engaged in organisational change programmes (see Organisational change and management development initiatives within the trusts).

Organisational structures

At the time when research access to the trusts was initially negotiated, they had similar organisational structures.

Metropolitan consisted of several clinical and corporate directorates each led by a clinical director, a general manager and a clinical lead, and was supported by heads of service and matrons that led each of the 50 or more service areas within the directorates. Each corporate directorate was led by an executive and a deputy.

Cityscape comprised a series of clinical and corporate directorates. Each clinical directorate was headed by a clinical director and a general manager and each corporate directorate by an executive or associate director. However, in 2010 a new structure was introduced, and the trust was organised into clinical divisions, with each division containing a number of clinical business units (CBUs) containing a number of services (a structure adopted by several other hospital trusts in England in recent years).

Therefore, the overall structure of both trusts consists of two blocks: (1) corporate and (2) clinical.

Clinical block

The clinical blocks are also similar across the two trusts, but there is a difference in the degree of aggregation and number of levels, owing to the corporate restructuring in Cityscape.

Metropolitan is divided into several clinical directorates, each encompassing a range of specialist services (about 10 on average), with some services further subdivided into smaller service areas, units or departments.

Cityscape is divided into clinical divisions (a smaller number than the clinical directorates at Metropolitan), each comprised two to four CBUs, with each unit encompassing a range of specialist services.

Figure 2 depicts the levels of hierarchy in each trust.

FIGURE 2.

Clinical block: hierarchical structure. CBU, clinical business unit.

Thus, a Cityscape division is broader in scale and scope than a Metropolitan directorate, and a Cityscape clinical business unit (CBU) provides an intermediate hierarchical level, absent in Metropolitan.

Organisational change and management development initiatives within the trusts

In this section we describe the organisational change programmes and management development initiatives that were under way in the two trusts during the period of the research. This provides an important contextual background to the interview data reported in the subsequent chapters, as these changes and initiatives had impacted on the work of the managers in the study. A more detailed breakdown of different types of management training and education activity appears in Chapter 5 .

Summary

As can be seen from the description of the two case study sites in this chapter, they are similar in many ways. Arguably, Cityscape considered structural reforms to be more important than cultural/training activities in seeking to deal with financial pressures and enhance services. Metropolitan’s XYZ Change programme was intended to facilitate engagement from all staff in seeking to make financial savings and develop services. The description of these activities reported in this chapter has deliberately reflected a corporate perspective. The subsequent results chapters report the perceptions of the middle and junior managers with respect to these corporate activities.

Self-definition

The focus of our inquiry was on work-related identities and, in particular, on the professional identity of the respondents as managers.

Group affinity

In terms of group affinity, we distinguished three types of responses, depending on whether or not the respondent identified with:

1. particular individual(s), rather than any group

2. work team

3. peer group [‘colleagues the same level as me’ (JC 12)].

The data are presented in Table 4 (and Table 22 in Appendix 8 ).

Over a quarter of the respondents who discussed the issue (8 of 31) perceived affinity only with a particular individual or individuals. We suggest that the lack of identification with any group narrows the person’s support base and makes this base vulnerable to any changes. To illustrate, one respondent related that he had developed a strong relationship with a colleague, only to find himself isolated when the colleague moved to a new post (MC 47).

One-third of the respondents (10 of 31) identified with their work team and the remainder (13 of 31) with their peers. The affinity with work team provides more social resources than the affinity with an individual, but these resources are less rich and varied than those that a peer group can provide:

The management group within the Directorate [i.e. the peer group] . . . understand some of the trust issues, whereas . . . people in radiotherapy [i.e. the work team] haven’t come out of the silo of radiotherapy because that is what they do all day long. So if you go into a room of . . . managers external from radiotherapy, you start to . . . understand the trust’s financial position, the trust’s strategies . . . Whereas people here don’t want to know about the trust’s financial situation even if you tried to tell them.

MNC 26

Both the internal (within the trust) and the external peer groups were quoted as important:

When you get to a senior level . . . you have your peer support within the organisation, but it’s quite useful to have that peer networking support outside the organisation. So I have got colleagues in dermatology around the country that I class as . . . peer support, so we bounce ideas off each other, and if we’re having a difficult time we can share those experiences.

MC 8

There were some examples of formal arrangements for building peer support within the trusts [e.g. the trust-level ‘sisters’ timeout days’ at Metropolitan (JC 40)]. Yet, it appeared that across the trusts some previously established peer networks were withering away:

The problem is, nowadays in physiology we don’t have the same sort of regional associations that we used to, [when] I would call on my peer in [another hospital] . . . to get some ideas from her. . . . It is lack of time and co-ordinating that sort of meeting, and I think it is a great shame because . . . it served a purpose. Now we just cope within our own trust . . . Something big has been lost there.

MNC 22

Although it appeared as if clinical managers were more likely to identify with peer group and non-clinical with work team, no significant association between group affinity and four management categories (Fisher’s exact p = 0.623), management level (Fisher’s exact p = 0.458) or clinical engagement (Fisher’s exact p = 0.394) was found.

Values

In terms of values, we distinguished two types of responses:

1. those reflective of public service ethos, and

2. those indicative of performance ethos.

Public service ethos is a well-established construct that encompasses public service belief (i.e. motivation to work for the public services, e.g. ‘altruism, compassion’), practice (i.e. organisational values supporting this motivation, e.g. accountability, fairness) and public interest (i.e. acting ‘in the interests of the common good’) (p. 34). 128 In our study, public service ethos was manifested in the work motivation to ‘make a difference to the patient’:

My values are that the patient should always be at the centre of everything that we do . . . It’s not about me, or the team, it’s about the patient.

MC 76

Performance ethos is a novel concept, introduced (but not defined) by Casey and Allan. 129 We define it as the work motivation to ‘get things done’, as manifested in the following quote:

Motivation is leading things forward, getting things done, . . . finding the inefficient areas and actually making them efficient, finishing things off, . . . getting it ticked off and getting the business, whatever it is, done and up and running.

MNC 75

The data are presented in Table 5 (and in Table 23 in Appendix 8 ).

Two-thirds of respondents (31 of 47) subscribed to the public service ethos. No significant association was found between values and management category (Fisher’s exact p = 0.482), management level (Fisher’s exact p = 0.215) or clinical engagement (Fisher’s exact p = 0.111).

Self-selection mechanisms were certainly at play. Most of the managers with private sector experience noted that they had become disenchanted with the ethos of profit maximisation and were attracted to the NHS by the desire to do good:

I was fed up of working in the private sector and all that mattered was the bottom line . . . In the public sector for me it was more about . . . what can I do to make a difference to the patient.

MNC 87

Yet, the dividing line between the public service ethos and the performance ethos was not very sharp. Many pointed out that ‘making a difference to someone’s life’ should not be narrowly interpreted in terms of the direct contact with patients but involves a bigger picture:

Part of being a physician is about determining best patient care, practice, pathways, and those sorts of things, and . . . you cannot do that in a void, so it needs to be done with directing . . . so one has a management role in terms of the team.

MC 59

The results were in agreement with the prior research, which has indicated that the public sector managers are less motivated by economic incentives and have a stronger desire to serve the public interest than the private sector managers. 130

Stereotypical traits

The responses clearly pointed to the existence of a stereotype of a manager. The respondents associated ‘being a manager’ with:

(a) a certain level in organisational hierarchy:

I’m a therapy radiographer who is in a manager’s position. [ . . . ] I’m a radiographer, because the manager is hierarchy, whereas my job is I’m a radiographer although I’m not on a machine day to day.

JC 26

I suppose my idea of an NHS manager would be somebody like one of the directors.

MC 23

(b) line management:

I don’t really think of myself in that light [as a manager] because to me you manage if you manage people and I don’t manage people. [ . . . ] . . . I do project management, I do training, I do support, admin . . .

JNC 54

(c) a particular job title and remuneration level:

When you read my job description, it says manage this, manage that, manage the other . . . but the word ‘manager’ isn’t actually in the job title or in the pay packet.

JNC 38

(d) decision-making power:

Yes, I do see myself as a manager; I probably don’t see myself as a manager . . . in the same sense as other managers within the hospital, who . . . have quite a high profile . . . I don’t have the same profile . . . as . . . the general managers . . . I think if you spoke to any diagnostics manager they would probably feel the same. They’re not part of the bigger management scheme they sit on the periphery feeding in. Complying; meeting targets and so on, but not necessarily a voice within the trust.

MNC 22

Knowledge and skills

To assess the respondents’ knowledge and skills we examined their self-reported general education qualifications, management education, vocational qualifications and other training, tenure in the current job, and work experience outside the NHS.

Facets of identity: an interim summary

Table 11 brings together the findings on the associations between the facets of identity and management category, management level, and clinical engagement.

Connections across the facets of identity

We also examined potential associations between self-definition and other facets of identity: group affinity, values, and knowledge and skills.

We employed two types of grouping of self-definition:

1. the original grouping into three categories: (a) ‘I am a manager’, (b) ‘I am a manager, but. . .’, and (c) ‘I am not a manager’

2. an alternative grouping into two categories: (a) ‘definite’ managerial identity (‘I am a manager’) and (b) ‘reluctant’ managerial identity (all other responses).

Depending on whether or not the analysis with the original or the alternative grouping showed significant association, we reported the data using one or the other grouping. Where the analysis showed no significant association, we reported the data using the original grouping. To conserve space, the data tables are presented in Appendix 8 ( Tables 22 – 27 ), but the results of analyses are summarised in Table 12 .

The results showed:

• A significant and relatively strong association between group affinity and self-definition which ran contrary to our initial intuition that identification with the management profession would be linked to a stronger peer group affinity. In fact, those who defined themselves as a manager more often expressed affinity with individuals and work teams, than with a peer group.

• No significant association between values and self-definition, indicating that the public service ethos predominated and neither affected nor was affected by identification with managerial profession (or lack of thereof).

• No significant association between general education qualifications and self-definition, suggesting that the identification with the managerial profession was unrelated to general educational credentials.

• A significant and moderate association between management qualifications and training and self-definition, which suggests that higher education qualifications in management strengthen managerial identity, but other forms of management education and training do not.

• No significant relation between tenure in the current job and self-definition, suggesting that, contrary to our initial intuition, the practical experience of managing did not affect identification with management profession.

• A significant relation between work experience outside the NHS and self-definition which indicates that work experience outside the NHS strengthens the identification with management profession.

Summary

Our main findings are as follows.

The junior and middle managers were not a homogeneous group on most examined facets of identity. The cleavages ran between all four categories of managers (JC, JNC, MC and MNC), though the differences by clinical engagement were more common than those by management level.

The professional identity of the respondents as managers was not particularly strong: 43% of respondents did not define themselves as managers and another 21% defined themselves as managers with some reservations. The main dividing line was between non-clinical managers, who were more likely to define themselves as managers, and clinical managers, who tended to espouse their ‘primary’ clinical identity.

The respondents who had higher education qualifications in management were more likely to define themselves as managers, as were those who had previously worked outside the NHS.

Only 42% of respondents reported peer group affinity. Those who defined themselves as managers were more likely to identify with individual(s) or a work team than with a peer group. Hence, the collective identity of the respondents as managers was not particularly strong.

The main unifying facet of the respondents’ identities was values, as the majority espoused a public service ethos, and there were no significant difference in values between either junior and middle or clinical and non-clinical managers.

There were considerable differences within the sample on all assessed aspects of knowledge and skills.

The disparities between general education and management qualifications and training were broadly in line with the anticipated differences owing to job requirements (between junior and middle managers and clinical and non-clinical staff), but were more extensive than expected. Although general education qualifications and, even more so, management qualifications and training were instrumental in predicting the management category, management level and clinical engagement (thus giving more credence to the anticipated differences), there was no similar tendency in the opposite direction, as management category, management level and clinical engagement did not affect the prediction of either general education qualifications or management qualifications and training. Hence, the managerial hierarchy did not appear to be congruent with the hierarchy of educational credentials.

The tenures in the current post were on average rather short (< 5 years), and the differences between management categories, though small, were significant: JC managers were in post on average about 4.5 years, 2 years longer than JNC managers, and MC managers were in post for about 3.7 years, or over 1 year longer than MNC managers. Yet, the experience of a managerial job did not significantly influence the respondents’ identification with the management profession.

Work experience outside the NHS also considerably differed between the management categories and this difference ran along the clinical engagement dimension rather than the management level, as non-clinical managers were more likely to have worked outside the NHS.

Implications

Our findings indicate that the managerial identity of junior and middle NHS managers was not sufficiently strong, as many respondents were reluctant to define themselves as managers. As noted in Chapter 2 , social identity leads to uncertainty reduction. Regardless of whether or not the individual managers accept it, the managerial identity is foisted on them by their position, and hence they cannot fully disclaim it. Those who prefer to distance themselves from a managerial identity face a challenging task of constructing an alternative identity that has to be congruent with their position and be recognisable to, and validated by others. It may complicate their relationships, as other people would find it difficult to place them. As one respondent observed:

If I didn’t [think of myself as a manager] it would confuse the staff, because we’ve had a supervisor in the past who was very, very friendly with the staff and it had confusing and conflicting friendships and things.

JNC 101

Furthermore, a positive social identity helps to build social resources and increases the individual’s ability to endure stress and take on new challenges. In this light, our finding that a managerial identity was problematic for many respondents gives a cause for concern, because an insufficiently delineated or partially adopted identity may negatively affect both individual outcomes (e.g. self-esteem) and organisational outcomes.

In contrast to the previous accounts of ‘reluctant managers’, we found, however, that the respondents were not so much reluctant to manage as reluctant to associate themselves with the label ‘manager’.

The interview responses suggested to us two potential explanations of such reluctance. First, the reluctance to call oneself ‘manager’ may stem from the difficulties of defining what it means to be a manager. Considerable diversity of the pathways into management, of the prerequisites for occupying a managerial position (see Knowledge and skills), and of the authority, responsibilities and activities associated with management (as noted above and described in greater detail in the following Chapter 6 ) make ‘manager’ a very broad and diverse category. This diversity is further compounded by the dualism of many management positions, which combine clinical and managerial duties. The language markers also do not provide clear guidance, as the term ‘manager’ does not always appear in the job titles of managerial positions. As a result, defining oneself as a manager increases rather than decreases the ambiguity of self-definition.

Second, the reluctance to identify oneself as ‘manager’ may stem from the negative image of NHS managers, propagated by politicians and the media, which in turn influence the public opinion. Our findings echoed those of the earlier research, which had shown that the managers were aware of this negative image, held by ‘their staff the media, the public and even their immediate families’ (p. 110). 137,138 Although our research did not pertain to the analysis of the reasons why politicians and the media tend to vilify the NHS management, the extant literature suggests that such vilification is a long-standing phenomenon. Thus, Learmonth139 found that NHS managers were held in very low esteem by the ‘general population’ and were ‘overwhelmingly . . . gratuitously insulted’ by the press. More recently, a report by The King’s Fund Commission on leadership and management in the NHS (p. 1)12 noted that ‘in the public sector – and in the NHS in particular – whenever politicians talk about management it is almost invariably a pejorative term. It is often equated sneeringly with bureaucracy. Whole political careers have been built on attacking it’ and deriding managers as ‘men in grey suits’ and ‘pen pushers.’ The report also noted that the public appears to take ‘its cue from the political attacks on bureaucracy’; it quoted the results of a recent poll by Ipsos MORI showing that ‘85 per cent of the public supported proposals to reduce the number of managers in the NHS by one-third’ (p. 2). 12 One possible explanation for these tendencies, with regard to middle management in NHS, has been proffered by Hyde et al. 140 Hyde et al. 140 trace their roots to the more general stereotype of middle management, dominant in both academic and popular management literature, and quote Mills,141 Whyte,142 Handy,143 Peters144 and Kanter145 as the prominent examples of portraying a middle manager as ‘someone stuck in their role with limited hopes of progression, with few managerial skills and little managerial ability’, ‘a person who slavishly dotes on paperwork and petty rule enforcement’, ‘obstructive and afraid of change’ (p. 13). 140 They note that ‘on the whole, this view has gone largely unchallenged, with only a small number of commentators identifying positive features of middle managerial work’ (e.g. Hassard et al. 146 and Huy147).

Hyde et al. 140 further argue that, as a consequence of such stereotyping, middle managers have become ‘a mythical or fantasy group of others’, with whom barely anyone identifies (p. 14). 140 This mythical group, however, serves ‘a useful scapegoat function in that policy failures can be blamed on poor middle management’ (p. 18). 140

We concur with this interpretation. We believe that it is, indeed, expedient for politicians to shift the blame for the public sector problems from the policy-makers onto the policy ‘implementers’ (i.e. managers). It is certainly easier to attribute the problems to the shortcomings of a particular group of individuals and to devise solutions by targeting such groups rather than to examine the underlying systemic issues and develop more comprehensive remedies. It is particularly convenient that the scapegoat group already has a poor reputation, lacks voice/representation, and is a group with which barely anyone wants to identify (even if they formally belong to the group).

Putting these findings into our theoretical framework of identity, we observe incongruence between the respondents’ role identities and group identities. Role identity refers to the shared expectations regarding behaviour that are attached to a ‘position’ in a social network (p. 559). 38 Group identity refers to ‘that part of the individuals’ self-concept, which derives from their knowledge of their membership of a social group . . . together with the value and emotional significance of that membership’ (p. 255). 148 By and large, the respondents are more likely to identify with management as a role and are less likely to identify with managers as a group.

Social identity theory offers two basic motives of group identification: uncertainty reduction and self-enhancement. Uncertainty reduction is associated with social categorisation: ‘people strive to reduce uncertainty about their social world and their place in it – they like to know who they are and how to behave and who others are and how they might behave’ (p. 120). 149 Self-enhancement is associated with the positive intergroup distinctiveness [i.e. ‘a belief that ‘we’ are better than “them”’ (p. 120)149]. In our context, identification with ‘managers’ as a group does not appear to provide either uncertainty reduction or self-enhancement, thus undermining the motives for group identification.

Our findings that the respondents were more likely to report an affinity with individuals or their work group rather than with their peer group, and that those respondents who did identify themselves as managers were less likely to identify with their peer group than other respondents, further amplify this point. They suggest that the respondents were not only reluctant to identify with managers as an abstract category, but also did not strongly identify with other managers in their own organisation.

The consequences of low identification of the ‘de facto’ managers with managers as a social group and with managers as a peer group in their own organisation are far-reaching. Thus, the low identification creates a self-perpetuating cycle: as fewer individuals opt to identify with a group, the group distinctiveness and attractiveness decrease, weakening its pull on prospective members. A smaller and weaker group becomes yet more vulnerable to vilification and scapegoating. This in turn contributes to low morale and high turnover in the management ranks (p. 18). 140 Scapegoating also obscures the group’s vital role in and contribution to the organisation and misguides the problem identification and the search for solutions. It undermines the group’s status and reduces its power to influence other groups. The low identification also presents a barrier to peer support and knowledge transfer.

Potential practical solutions to the problem of low identification with other managers as a social and a peer group may entail:

1. promoting a better understanding of the role of managers, to which both research on management and management education should contribute ( Chapters 6–8 below offer our research input and Chapter 9 highlights the implications for management education)

2. promoting intra- and inter-organisational peer networks (Group affinity above highlights both the importance of peer networks and the apparent withering away of the previously established networks, as reported by our respondents)

3. promoting the status of management as an occupational group by its further professionalisation via (i) establishing an NHS-wide system of accreditation and qualification prerequisites for managers and (ii) creating a professional association of NHS managers (these suggestions are further developed in Chapter 9 , Management education and training)

4. promoting a better-informed and more positive image of NHS management in political circles and in the media (in this, a professional association of NHS managers may be particularly instrumental).

Finally, we suggest reinstating the term ‘manager’. The waves of change in both the private and public sectors, in the UK and internationally, have already seen the replacement of the term ‘administrator’ (still enduring, however, in degree title, i.e. ‘Master of Business Administration’) by the term ‘manager’ and, more recently, ‘leader’. The reasons for these changes have been amply documented elsewhere (e.g. Learmonth,150 Parker151 and O’Reilly and Reed152), and we will not rehearse them here. We would, however, argue that the frequent name changes contribute to the lack of distinctiveness and attractiveness of managers as a group, noted earlier. We would further caution, following Martin and Learmonth (p. 10–11)124 that, as leadership discourse becomes ubiquitous (and management goes out of use), leadership is likely to lose ‘the positive cultural valences currently ascribed’ to it, which hinge on a contrast between management and leadership. This may then prompt a search for a new ‘Holy Grail’, with detrimental consequences for the group image. We also note the dangers of leadership discourse per se. As suggested by Martin and Learmonth,124 leadership discourse is often used to ‘seduce’ and co-opt the dissent, align individual aims with the policy aims and mask the contradictions ‘between claimed decentralization and actual retention of power by the centre’. We add that the discourse of leadership focuses attention on an individual, rather than organisational context. The ‘individualisation’ of issues, or the interpretation of organisational problems as stemming from the qualities of an individual (e.g. personality traits, leadership style), diverts the attention from the examination of organisational-level causes, such as strategy, structure and culture, and places the responsibility with the individual rather than the system.

We therefore advocate a ‘return to management’ (i.e. the use of terms ‘manager’ and ‘management’) in order both to strengthen management and managers as a group and to focus the attention on the organisational roots of problems and the organisational solutions to those.

A typology of managers’ work groups

Our study used a primary typology based on two dimensions: (1) management level (junior or middle) and (2) clinical engagement (whether the manager is counted as clinical or non-clinical staff).

Our examination of the managers’ work, however, revealed a greater complexity of roles which led us to develop a more fine-grained typology, which disaggregated the clinical and non-clinical categories based on the nature of their work:

• Within clinical managers, taking into account the differences between clinical professionals, we distinguished between: (1) medical consultants, (2) nurses, (3) health-care science scientists, and (4) AHPs.

• Within non-clinical managers, taking into account the differences between clinical and corporate units, we distinguished between managers working in (a) clinical units and (b) corporate units.

Table 13 presents the typology with illustrative examples from the sample.

General parameters of managers’ work

‘General parameters’ here refer to the more quantifiable aspects of the content of work (what managers do) and the form of work (how they do it). A richer qualitative picture of the managers’ working lives is presented in Work profiles of managers’ work groups.

To assess the content of work, we considered the scale and the scope of their activities.

The scale of activities reflects:

1. the span of responsibility, defined as the size of organisational unit over which the manager has responsibility

2. whether or not the manager has staff or functional responsibility over the unit

3. the span of control, defined as the number of the manager’s direct reports

4. any cross-site work; and

5. any responsibilities outside the trust.

The scope of activities is characterised by relative weights of ‘the strictly managerial component’ of a manager’s job, which reflects the ‘responsibility for getting others to do things’, and the technical component, which reflects the manager’s specialist contribution to a work process through what they do themselves’ (p. 20). 153

To assess the form of work, we considered the length of their average work day and the proportion of work time devoted to scheduled meetings.

The scale of activities

The span of responsibility

The span of responsibility is, to a considerable extent, determined by the manager’s position within the organisational hierarchy and reflects the organisational structure.

As described in Chapter 4 , the two trusts had similar structures, although Cityscape had introduced an additional level of hierarchy by creating CBUs. Figure 3 presents the hierarchy of organisational units.

FIGURE 3.

Hierarchy of organisational units.

The span of responsibility of the respondents encompassed the entire range of organisational structural units: from team to trust ( Table 14 ).

TABLE 14 - The span of responsibility: organisational unit level

Category	Team	Unit, subunit, ward, clinic, laboratory	Specialty or service	Group of services or specialties	CBU	Division or directorate	Trust	Total
JC	10	10	1					21
2b Junior nurse managers	4	9						13
3b Junior scientist managers	2	1	1					4
4 AHP managers	4							4
JNC	3	3	3	4			2	15
5b Junior managers of clinical units	1	1	2	4				8
6b Junior managers of corporate units	2	2	1				2	7
MC		4	7	1	7	8		27
1 Consultant managers			2		1	3		6
2a Middle nurse managers			4	1	6	3		14
3a Middle scientist managers		4	1					5
5a Middle managers of clinical units						2		2
MNC		2	6	3	2	6	9	28
5a Middle managers of clinical units		2	6	3	2	6		19
6a Middle managers of corporate units							9	9
Total	9	19	17	8	9	14	1	91

Junior clinical mangers had the smallest span of responsibility. Thus, junior nurse managers were responsible for a ward (ward sister), a clinic (charge nurse) or a team within ward (deputy sister). Junior scientist managers had a wider range: from team to specialty/service. AHP managers were all team leaders or clinical specialist lead.

Junior non-clinical managers were more broadly spread, between team and group of services/specialties, with the two ‘outliers’ in the group of junior managers of corporate units (these were the managers within the R&D department who had trust-wide responsibility for narrow areas of activity, e.g. research governance).

Middle clinical managers mostly had a wide span of responsibility [almost one-third of them (8 of 27) were responsible for a clinical directorate/division], but there was some variation by work group. Consultant managers and middle nurse managers were responsible for wider entities (from specialty/service up to and including directorate/division) than middle scientist managers (units or subunits).

The span of responsibility of MNC managers covered nearly the whole range of organisational unit levels, but there was a significant split within the category by work group. Although middle managers of clinical units were responsible for anything between unit and division, all middle managers of corporate units had trust-wide responsibilities.

Two further considerations impacted the span of responsibility:

Temporal differences in the span of responsibility Some clinical managers regularly assumed an expanded span of responsibility when they were assigned (as many ward sisters were) a bed or a staff ‘bleep’.

Additional trust-wide roles Some managers had additional trust-wide roles, such as being a lead on a specific project.

Staff versus functional responsibilities

The assessment of the scale of activities also took into account whether the manager primarily had staff responsibility (i.e. was accountable for the entire staff, operations and performance of an organisational unit) or functional responsibility (i.e. was only responsible for a particular aspect of the unit’s operation).

• Primarily staff responsibility All JC managers, most JNC managers and some MC (namely, all consultant managers and middle scientist managers and some middle nurse managers) and MNC managers (namely, some middle managers of clinical units) had the full responsibility for their unit and its staff.

• Primarily functional responsibility The remainder of respondents had responsibility only for a specific functional area. In particular, all middle managers of corporate units had trust-wide responsibility for a specific function (e.g. corporate communications, contracts and commissioning, occupational health).

The contrast between staff and functional responsibilities is reflected in Table 15 , which presents the data on the total number of staff for whom the respondents reported responsibility.

TABLE 15 - The number of staff in manager’s responsibility

Category	Mean	Minimum	Maximum	Missing	Total count
JC	18	2	46	3	21
2b Junior nurse managers	24	2	46	2	13
3b Junior scientist managers	8	4	10	1	4
4 AHP	8	3	10	0	4
JNC	22	0	90	2	15
5b Junior managers of clinical units	21	0	55	1	8
6b Junior managers of corporate units	24	0	90	1	7
MC	314	0	2000	9	27
1 Consultant managers	855	130	2000	3	6
2a Middle nurse managers	201	0	800	3	14
3a Middle scientist managers	11	9	13	2	5
5a Middle managers of clinical units	3	3	3	1	2
MNC	139	2	2000	8	28
5a Middle managers of clinical units	207	3	2000	5	19
6a Middle managers of corporate units	12	2	34	2	9
Total	131	0	2000	22	91

The notable discrepancy between the number of staff in a manager’s responsibility (presented in Table 15 ) and the span of responsibility (see Table 14 ) is attributable to the fact that most clinical managers had staff responsibility for their unit and thus reported being responsible for the entire staff of their unit, whereas most non-clinical managers had functional responsibility and thus reported only the number of their direct reports.

Span of control

For junior managers the span of responsibility was normally equivalent to the span of control, whereas for middle managers the span of responsibility considerably exceeded their span of control, as they had few direct reports (who in turn supervise the rank-and-file employees or other managers).

The span of responsibility of middle managers (numbering in hundreds of members of staff) was on average much broader than the span of responsibility of junior managers (numbering in dozens), but their span of control (below 10) was much narrower than that of junior managers.

Cross-site work

Some managers were responsible for the units that operated on several sites ( Table 16 ).

TABLE 16 - Number of managers working across two or more sites

Category	Frequency	Percentage	Total
JC	2	10	21
2b Junior nurse managers	0	0	13
3b Junior scientist managers	0	0	4
4 AHP	2	50	4
JNC	7	47	15
5b Junior managers of clinical units	5	63	8
6b Junior managers of corporate units	2	29	7
MC	9	33	27
1 Consultant managers	1	17	6
2a Middle nurse managers	4	29	14
3a Middle scientist managers	2	40	5
5a Middle managers of clinical units	2	100	2
MNC	8	29	28
5a Middle managers of clinical units	6	32	19
6a Middle managers of corporate units	2	22	9
Total	26	29	91

Very few JC managers (only AHPs) worked across sites, which is understandable given that they had to directly supervise staff providing patient care. The proportion of MC and MNC managers working across sites was near the average for the sample overall. Interestingly, JNC managers were the ones most frequently stretched across the sites (nearly a half of the category reported working across sites), with almost two-thirds of junior managers of clinical units working across two or more sites.

Responsibilities outside the trust

Some managers had responsibilities that spanned outside their trust, as shown in Table 17 .

TABLE 17 - Responsibilities outside the trust

Category	Frequency	Percentage	Total
JC	3	14	21
2b Junior nurse managers	1	8	13
3b Junior scientist managers	2	50	4
4 AHP	0	0	4
JNC	7	47	15
5b Junior managers of clinical units	4	50	8
6b Junior managers of corporate units	3	43	7
MC	7	26	27
1 Consultant managers	1	17	6
2a Middle nurse managers	3	21	14
3a Middle scientist managers	3	60	5
5a Middle managers of clinical units	0	0	2
MNC	9	32	28
5a Middle managers of clinical units	6	32	19
6a Middle managers of corporate units	3	33	9
Total	26	29	91

The different responsibilities outside the trust between management categories and work groups were similar to those for cross-site work. Again, JC managers were the least frequently involved, whereas the JNC managers were those most frequently involved (especially junior managers of clinical units) and MC and MNC managers were around the sample average.

The most commonly cited responsibilities outside the trust were (with the number of respondents in brackets) working with an independent sector treatment centre (ISTC) (n = 7), dealing with external contractors (n = 4), providing services for public and private sector organisations (n = 4), managing commercial and non-commercial trials (n = 2), and commissioning with NHS and non-NHS organisations (n = 2).

Work profiles of managers’ work groups

Summary

Below we sum up the main findings on ‘what do managers do?’ (a schematic summary can be found in Appendix 10 ).

Junior clinical managers had a span of responsibility from team to specialty, with all AHP managers having the smallest span (team) within this category, junior nurse managers ranging between team and unit (ward), and junior scientist managers between team and specialty. Junior nurse managers had a heavy staff management load, whereas the other two groups had a medium load. Although none of the AHP managers and only one junior nurse manager (specialist nurse) had work that spanned outside the trust, half of junior scientist managers did. Junior scientist managers were also the only group that worked across sites. All work groups within this category had an approximately 50/50 split between management and clinical responsibilities, worked about 50 (or just under) hours a week, and spent only a small fraction (about one-tenth) of their time in meetings. They had little involvement in strategy; though junior nurse managers were notable for their local entrepreneurial initiatives.

Junior non-clinical managers had a span of responsibility from a team responsibility to trust-wide responsibility. Junior managers of clinical units worked primarily across a group of specialties or services, often across sites, and half had work spanning trust boundaries. Junior managers of corporate units, with a couple of exceptions, managed smaller entities (teams or units), though nearly half worked across sites, and one-third was engaged in work spanning trust boundaries. They had no clinical involvement, worked about 45 hours a week, and spent a quarter of their time in meetings. They had little, if any, involvement in strategy.

Middle clinical managers had a span of responsibility from specialty to directorate/division. Consultant managers and middle nurse managers managed larger entities, from specialty to directorate/division, with the number of staff ranging from about 150 to 2000, respectively, whereas middle scientist managers mostly managed units within specialties, with about a dozen staff. Staff management responsibilities of consultant managers and middle scientist managers were considered fairly light, responsibilities of middle nurse managers were considered medium. Consultant managers had the heaviest clinical load (clinical/managerial split of 50/50), middle scientist managers a medium load (20/80), and middle nurse managers the least heavy (10/90; with some internal variation: nurse consultants, 50/50; matrons, 0/100). Just about one-fifth of consultant managers and middle nurse managers were involved in work outside the trust, as were most of the middle scientists. Consultant managers worked the longest hours (65 hours a week on average), middle nurse managers less so (55 hours a week on average), and middle scientist managers less still (45 hours a week on average). All spent about one-third of their time in meetings. Consultant managers had significant input into the trust strategy, whereas the two other groups had a minor input (though nurse consultants and middle scientist managers had a considerable impact on strategy outside the trust, via their role in professional associations).

Within the category of MNC managers, middle managers of clinical units had general responsibility for managing wide entities (a group of services or a directorate/division). Their staff management load was heavy and half of them worked across sites. Their strategic role consisted of strategy translation and elaboration. In contrast, middle managers of corporate units worked on the trust level but had only functional responsibility for their specialist area and their staff management load was low; only a few were engaged in work across sites. They had a strong input into strategy development in their specific functional areas. In both groups, about one-third of managers had responsibilities that spanned the trust boundaries, the managers worked on average about 50 hours a week and spent one-third of their time in meetings.

Implications

The portrayal of ‘what managers do’ helps to illuminate the construction of identities and has implications for research and practice in itself.

Managers’ work represents the behavioural aspect of identity. In our theoretical model, behaviour lies on the periphery of identity, farthest removed from the identity core (i.e. self-definition and group affiliation). Such positioning implies a possibility of only a tenuous link between the identity core and behaviour. Indeed, our analysis in Chapter 5 (see ‘Reluctant managers’: reluctant to manage or be labelled?) showed that some respondents admitted to ‘managing’ but not to ‘being a manager’. Our analytical description of managers’ work allows us to examine the extent of congruence between what the respondents did and how they defined themselves.

Our findings reflect the breadth and depth of the activities associated with management performed by the respondents. These findings support our conclusion in Chapter 5 that the low identification of the respondents with managers as a group stemmed primarily from the insufficient distinctiveness and attractiveness of the group, rather than from their behaviour (their work activities).

The implications for research stem from our fine-grained description of work groups within the broader categories of JC, MC, JNC and MNC managers. Although we do not claim to have ‘discovered’ such groups as scientist managers, managers of clinical units and managers of corporate units, we do note that to date the research on managers in health care has been predominantly based on nurse managers (including ward sisters and matrons) and doctor managers. Such selectivity may lead to a bias in the representation and assessment of the characteristics and role of NHS managers.

With regard to practice, a more inclusive picture of the NHS managers’ activities may serve to inform policy-making and media coverage. As we discussed in Chapter 5, Implications, politicians and the media seem to employ a negative stereotype of the NHS manager to scapegoat NHS management for the problems of health-care systems. Our portrayal of junior and middle NHS managers runs contrary to this stereotype. Although the vagaries of reporting did occupy a not insignificant portion of their time, none of the respondents could be fairly described as a ‘pen-pusher’. The scale, scope and sheer intensity of their work were striking, as were the challenges they coped with. The extent and importance of the functions performed by the respondents attested to the significance of their input into organisational operations. Although we obviously do not expect our findings to immediately and directly redress the situation, we hope that our research would contribute to building a more positive assessment of the managers and their work and altering political, media and public opinions.

Conceptualising effectiveness

A series of questions were asked in interview to explore managers’ self-reported effectiveness and what influences this. As befits the flexible format of semistructured interviews, not every question was asked of every respondent, but they included:

• What does being an effective manager mean to you?

• How is success as a manager measured in the trust?

• Can you identify any specific incidents that have really required you to exercise all your managerial and personal skills in managing them effectively?

Effectiveness is a multidimensional concept to do with the attainment of a range of desired outcomes. 34,35 Within the framework of NPM, it usually is associated with ‘hard’, evidential measures of clinical activity and the achievement of financial targets. 111,112 Accordingly, we anticipated that these would be vital indicators of effectiveness or the inverse for the managers, but we also expected managers to characterise effectiveness in wider and perhaps alternative terms, for the following reasons. First, in much of health care, effectiveness is accomplished through ongoing interactions between many people. In other words, it is takes place in the complex, messy, lived-reality of managerial work. Second, as discussed in Chapter 5 , many respondents construe management as what they do (managing), not that they are (a manager). Hence, they may seek to establish ‘softer’ assessments of effectiveness which have a closer fit with their sense of identity as ‘reluctant managers’. This may not always connect directly with specific transactions captured in conventional ‘hard’ outcome measures.

Two overarching sensitising concepts,108 ‘transactional effectiveness’ and ‘processual effectiveness’ were derived inductively from analysis.

• Transactional effectiveness: ‘hard’, demonstrable and visible performance measures, such as meeting an array of organisational targets, personal and team awards, and other achievements.

• Processual effectiveness: ‘softer’ and more nebulous. Evident, for example, in ‘smooth-running’ and in work ‘getting done’. Achieved by communicating and enabling others.

As we will discuss, transactional and processual effectiveness can be mutually reinforcing, but they also may be in tension.

It should also be noted that for clinical managers our focus is on effectiveness in relation to their managerial work, not their clinical activity.

Processual effectiveness

Links between processual and transactional effectiveness

As noted earlier, ideally, processual and transactional effectiveness mutually reinforce each other. The managers recognised this. For example, many JC and MC managers, in particular, doubted ‘hard’ targets could be met without due attention to the ‘softer’ processual aspects of ‘being a manager’.

Effective, I think it’s . . . being able to meet all of your targets, but also aware of staff and how they feel, and obviously the input that they have towards those targets. You need to enable to your staff as well, if they have got some good ideas, listen to them, involve them. I think if you involve your staff in decision-making . . . you are more likely to get buy-in from them.

JNC 97

This explicates how processual effectiveness should feed and nurture transactional effectiveness. However, this was not always the case. By way of illustration, a midwife consultant spoke of how the push to meet targets negatively affects crucial team building:

The culture at the minute is about hitting targets, doing things, and so it is not about team working, and setting strategies for the future, it’s almost meeting the targets already a month behind.

MC 9

As discussed in Effective management as a ‘wicked problem’, this indicates that effectiveness in one sphere may detract from effectiveness in another.

Transactional effectiveness

Box 1 lists service improvement targets and other outcomes managers contend with.

As might be expected, meeting targets is a crucial indicator of effectiveness for most managers and, conversely, not meeting them usually signals need for improvement. We recognise that these various forms of transactional effectiveness are real, ‘objective’ pressures on managers, but (as outlined in Conceptualising effectiveness) our focus is on their self-reported experience of dealing with them.

Effectiveness as collectively achieved

Most managers felt they brought something unique to their roles which they associated with certain qualities or blends of skill that enable them to mobilise others effectively. However, only a minority spoke of their personal, individual successes, such as annual internal trust awards, work within a professional association, research or publication. In fact, it was more common for them to attribute their effectiveness to the team/others they manage. This links back to the point that many felt you can only be really effective, especially in initiating change, when you ‘bring the team with you’.

Never expecting the team to do something you would not do oneself was voiced particularly, but not exclusively, by clinical managers. Thus a matron explained:

I have responsibility for ensuring quality is maintained, improved, that the operational side of things runs for wards within my area of responsibility, and also standards in a more general sense . . . Now there’s ways that you can do that isn’t there; one way to do it is to go and do it yourself, you know you go and you peer at everything and every difficult meeting you sit in on it to make sure it goes as it should. But to me you don’t . . . the thing for me, my philosophy has always been if I look after my staff they will look after the patients and in that way will look after me and will make my job work, or make it productive.

MC 68

An example relating to efficiency in project work is the Productive Ward initiative (taken up in several clinical areas in both trusts), which aims to improve ward processes and environments to release nurses for patient care (with the objective of thereby improving quality and safety). For example:

So, on the admissions ward I’m just trying to say, look when we get an acute admission in we will identify nurses with nurse 1, nurse 2, nurse 3, a bit like they would in trauma. Nurse 1 does this, nurse 2 does this, nurse 3 does this, and we all help get the patient in the bed, settled, get them on the monitor, get them monitored, get some vital signs written down. Hopefully it does lend itself then to us working a little bit more efficiently, fostering more teamwork as well.

JC 51

Conversely, personal effectiveness could be compromised by others. However, when managers – across all four primary categories – spoke about this, typically it was not in reference to their team as a collective, but to particular individuals, such as people who were obstructive or failed to provide the input or quality of input that a manager needed in order to deliver in a timely and effective manner on work of various kinds.

The contribution of feedback to effectiveness

The managers spoke of a range of constraints and enablers to the achievement of effectiveness. Most drew a strong association between communicative competence and effectiveness. The actual ways they ‘communicated for effectiveness’ and the identity constraints on this are discussed in Chapter 8 . Here we address how the ways others communicated with them, specifically in relation to feedback (sometimes also framed as support), contributed to self-reported effectiveness.

Effective communication is a recursive process: if a manager communicates effectively with others, usually this enhances their own competence. But this can be undermined if others do not communicate effectively with them. The importance of feedback is apparent in that it commonly was the first thing raised by managers in response to our questions about effectiveness.

Feedback can come from a variety of sources within the organisation, including line managers, their own staff, peers and previous line managers in the organisation, patients and relatives/visitors. It can be more formal, such as in appraisals and patient satisfaction surveys, and more informal, such as in one-to-one conversations, various meetings and e-mails.

As one might expect, positive feedback was highly valued:

If we do well on our [nursing, care quality] metrics we’ll get an e-mail to say, ‘you’ve done really well this month, that’s excellent, keep up the good work’ sort-of-thing, which I pass onto my staff, obviously.

JC 77

There is the formal [trust name] honours, so there is a staff recognition programme, but individuals within the executive team, particularly [the chief executive], will personally come and tell you when you’ve done something good. And clinical directors, I have had, you know, positive comments from clinical directors on stuff that I have done. So people are very good at giving that one-to-one feedback on how you’ve done.

MNC 42

However, many reported that line managers and others above them in the hierarchy give feedback only very infrequently or only when they have done something wrong or not right. Many managers, middle and junior, clinical and non-clinical alike, shared the frustrations evident in the following remarks:

December to May was horrendous, the worst working months of my career. And that was because of lack of support actually. So I’m quick, but often I will need to say, ‘Okay, I’m just doing this, am I on the right track?’ And all you need to do is say ‘yes’ or ‘no’. And I wasn’t getting that. So what I was doing was doing something because I wasn’t getting that and then being publicly pulled apart for having got it wrong.

MNC 11

This is regrettable; lack of feedback and poor-quality feedback have the potential to contribute to ineffectiveness by breeding uncertainty and, in some cases, the undermining of managerial and other facets of self-identities. 48 The personal uncertainties that can accumulate over time are communicated by the following middle scientist manager working in a support service:

I am managing the show now, but am I doing it right? And, you know, we don’t get patted on the head a lot, so you know my boss said to me recently, yeah he thought I was doing okay, there was nothing really he had a problem with; some things could be better, some things had gone very well. But that doesn’t really say should I in general learn something to do something else better. So I sort of feel there’s this bit of an unanswered question hanging over me, which is am I properly equipped to deliver what people expect me to deliver, do I understand what I’m expected to deliver? Because part of me feels my job is to sort of give the rugby hand-off to management as much as possible, so I can keep everything else going. But I don’t think that’s necessarily the right attitude, because I actually need not to be handing these people up, I need to be engaging with them. That’s how I feel. But then I don’t have vehicles to do that, so there’s a slight sort of worry, there’s a bit of a vacuum there in engagement, and even if I did engage what would it look like?

MC 21

However, it was also possible for managers to read something positive into lack of feedback. Perhaps on the premise that ‘no news must be good news’, some interpreted silence as indicating that they must be doing well, otherwise surely someone would have told them. However, as thoughts of this kind often were accompanied in interviews by the citing of ‘hard’ evidence of effectiveness (such as audit results), this suggests an awareness that it is risky to rely too much on this assumption.

It is also worth noting that lack of feedback, or only negative feedback, from above could be offset by positive feedback and support from below and laterally from peers in the organisation (as well as from outside). Some managers interpreted this as what ‘really matters’. For example, when asked how success was measured, a quality, safety and risk manager commented:

Lots of ways really, there’s all the targets stuff, but not just that way. There’s feedback from colleagues, formal and informal and feedback from patients and relatives. I am often in very close contact with patients and relatives. I always give relatives my number when I am dealing with them and say, ‘look if you are anxious about anything, don’t sit at home and worry, ring’, and people do and you think, well, people must have confidence then that you will do something about it.

MC 107

Thus, so far in the chapter we have considered the various ways in which the managers construe effectiveness and some of the contributors to achieving or not achieving it. We now turn to how the organisational contexts within which they work can enable and constrain the achievement of effectiveness. This also serves as a basis for the discussion of identity constraints on effectiveness in Chapter 8 .

Effective management as a ‘wicked problem’

The sheer complexity of health-care management has led to its characterisation as a ‘wicked problem’. A wicked problem is not ethically deplorable; rather it is a problem which defies easy solution because it is embedded in a complex open system (p. 160). 156 It has no quick fixes or simple solutions. 157 It is worth recalling that Cityscape and Metropolitan are among the largest in England, which one would expect to contribute to the ‘wickedness’ of managing in these organisations.

Many managers were alert to this:

I think what’s frustrating is the size of the beast. It’s that bit that you can’t just go and change anything, because there are so many different facets that are affected by any decision that you make. So we’ve been trying to improve our theatre utilisation, we can’t just say right I’ve got a surgeon, let’s go. It’s a surgeon, an anaesthetist, theatre staff, recovery staff, beds. You could do all this and then on the day we’ve had that many emergencies there are no beds, so patients get cancelled. We always say it’s a bit like treading mud really, because you know you really feel tired of getting somewhere, and then you know something else blocks it, there’s lots of blockers unfortunately that are out of your control. In effect really, nothing is directly in your control.

MNC 87

Wicked problems arose from the need to work across organisational and professional boundaries of various kinds and to varying extents, such as:

• spatial (e.g. across hospital sites)

• clinical and managerial specialisms

• professional (e.g. clinical, non-clinical)

• cultural (e.g. different working practices and emotional attachments to them).

(See also The scale of activities in Chapter 6. )

Wicked problems could be exacerbated poor communication and failures of communication (and felt lack of trust), especially from ‘above’ in the hierarchy, and by resource deficits (e.g. staff, equipment).

Effectively combining managerial and clinical work

The objective of combining clinical work and management is that by positively reinforcing each other they will increase overall effectiveness (see discussion in Chapter 2 ). Many clinical managers supported this objective. As discussed further in Chapter 8 , they spoke of mobilising their clinical expertise to get people to listen to them. A divisional head of nursing related:

People have this view that you’ve got management over here and clinical work over here, and that the two don’t meet. Actually, if you manage them well together, you’ll improve the quality and reduce cost before you have to do anything else. You don’t have to take dramatic action and change, if the two are working closely aligned you’ll improve patient care dramatically, and along the way you’ll make efficiency savings.

MC 57

Others spoke more in terms of the potential for this to happen and used specific examples (which were not the everyday norm) by way of illustration. For example, a matron (MC 72) attributed her ability to assess that a proposed skill mix on a clinical unit undergoing change would not be effective at the level of care needed to her capacity to engage in clinical work alongside her staff. The following divisional director spoke of how his clinical identity could be mobilised to convince on matters of finance and how a steely managerial stance could be employed to make clinical colleagues aware that cost savings were needed:

Even when we were having conversations about cost improvement savings, efficiency savings, as you’re still bringing a clinical aspect to that you still think ‘okay and what would that mean on the ward and stuff like that’. But, equally, there is a steel core if you like that realises that we do have to do those things. It’s like, I had a meeting with all the heads of service last week and said, look we have to close a ward, okay this is the outcome from this meeting, but we have to close a ward in a safe way, okay so we have to come up with a way of doing this, okay, that is safe. But the bottom line is that we have got to find £800,000.

MC 70

Although counterbalancing the clinical and managerial aspects of one’s role usually was challenging, the managers seemed to feel that equipoise (however shaky) could be striven for. In the eyes of many, this enabled clinical managers to work quite effectively. Even so, doing ‘two jobs’ could result in having, as a ward manager put it, ‘not have enough time to do everything, so you end up having to cut corners and doing half a job’ (JC 39). The following junior manager describes the tensions in some detail:

I’ve been working more clinically lately, I would say just over a quarter of what I’m doing in a month now is clinical, and the other three quarters is more ward manager role. But actually that’s making it quite difficult for me to feel on top of my management role, so there is always conflict. There’s been times when I’ve needed to be much more managerial, for instance, when we decamped to here and the reduction of the ward, we were increasing our beds, there was an awful lot of treatment going on, so I was constantly interviewing and shortlisting, so I wasn’t working very much clinically then. I think I might have actually got stuck in a little bit of a . . . well I don’t say stuck but so I was working then perhaps one long day a month, which was okay, but maybe not enough. It’s kind of finding that middle ground isn’t it, but I’m very conscious that when I’m working clinically out there, yes it’s great for the team, you know, I’m hopefully working as a good role model, it’s good for the patients because I’m an experienced nurse, but I’m also aware that actually, you know, I haven’t been in my emails for a week, what’s in there? [ . . . ], you do start to think about well I’m out here doing clinical shifts I’m not picking up that other work that needs to be done.

JC 51

Summary

This chapter has explored managers’ self-reported effectiveness and what contributes to and detracts from it. Through this we have contributed to our aim of determining the influence of managerial identities on organisational processes and outcomes. We have seen that ‘transactional effectiveness’; that is, ‘harder’, demonstrable measures of performance, such as organisational targets, work output, awards and other personal or collective achievements, are the visible front of a more diffuse dimension of effectiveness which we have called ‘processual’. As would be expected, we found that this enables transactional effectiveness, but we also found that some construe it as a form of effectiveness in its own right that can actually be compromised by undue attention to transactional effectiveness.

The analysis shows that communicative competence, encompassing feedback, is a key contributor to effectiveness/ineffectiveness. However, achieving effectiveness is a ‘wicked’ problem that defies easy solution because the managerial work that produces or fails to produce it is embedded in the complex open system of the hospital as an organisation. Although the managers’ span of responsibility and scope of activity (see Chapter 6 ) varied considerably according to their clinical or non-clinical status and position in the hierarchy (middle or junior and variations within this), this was something with which they all wrestled.

As outlined in Chapter 2 , identities are ‘relational and comparative‘. 39 They are learnt through identity enactment and sense-making. 110 This chapter has explored this process in relation to self-reported effectiveness. Through this we have contributed specifically to our research aim 2, of exploring how the performance of roles are shaped by identities, and aim 3, of determining the influence of managerial identities on organisational processes and outcomes (see Chapter 2 , Research aims and objectives).

We have seen that ‘transactional effectiveness’, that is, ‘harder’, demonstrable measures of performance, such as organisational targets, work output, awards and other personal or collective achievements, are the visible front of a more diffuse dimension of effectiveness which we have called ‘processual’. This brings us back to the observation first made in Chapter 5 and reiterated at the start of this chapter, that many respondents construe management as what they do (managing) not what they are (a manager). This suggests, at least for some, that knowledge of effectiveness becomes embodied through the activity of managing which has at its core engagement with others. Various values, knowledge and skills, and self-perceived ‘personal qualities’ or traits – the ‘content’ of identity – were frequently drawn together under what we have termed ‘communicative competence’. This is a highly valued as a resource for effectiveness which was often attributed by respondents to ‘leadership’ or being a good leader, a quality which was seen to have the inherent capacity to motivate or empower others to positively achieve in their work.

In Chapter 6 we reflected critically on contemporary leadership discourse, remarking, along with others,124 that it carries the risk of vesting responsibility for (in)effectiveness in individuals and individual qualities (that is, the ‘content of identity’) while deflecting it away from organisational-level causes. Yet we have seen here that respondents drew a strong connection between ‘leadership’ qualities and processual effectiveness, that is, their capacity to ‘manage’. As noted above, this can be distinguished from ‘being a manager’ (which is, perhaps, more closely associated with transactional effectiveness measures). Yet, at the same time, respondents were more or less aware (according to their work group) that the capacity of their leadership skills, communicative competence and so on, to work for them in the achievement of effectiveness was both enabled and constrained by the organisational contexts in which they worked. This has been evident in various ways in the chapter, such as in the value placed on feedback from various tiers of the organisation. Moreover, the analysis suggests an awareness, which again, varies by work group, that achieving effectiveness is a ‘wicked’ problem that defies easy solution because the managerial work that produces or fails to produce it is embedded in the complex open system of the hospital as an organisation. Although the managers’ span of responsibility and scope of activity (see Chapter 6 ) varied considerably according to their clinical or non-clinical status and position in the hierarchy (middle or junior and variations within this), this was something with which they all wrestled. We now go on to look at this in more detail in Chapter 8 which explores the behaviour of identity in relation of the managers’ capacity to ‘mobilise’ others.

Introduction

This chapter aims to capture how health-care managers mobilise their identities to exert influence in the different and various spheres in which they operate. We explore the different strategies our respondents utilise to mobilise their identities.

We define ‘mobilising identity’ as using facets of identity, such as values, knowledge and blend of skill to achieve a range of managerial objectives (as appropriate to a manager’s role, see Chapter 6 ).

The following aspects of identity mobilisation are important to bear in mind:

1. Identity mobilisation is not always immediately recognisable and is not necessarily a deliberate, pro-active process. In some instances, an identity is sufficiently strong and accepted by others for its bearer not to have to assert it as it may be embodied. Identity mobilisation also may not be conscious. Thus, a manager may interpret their managerial skill as their personal trait, such as the capacity to motivate or engage others.

2. Individual identities are socially situated and relational (see Chapters 2 and 5 ). A sense of self is developed by enacting identities and interpreting the responses to those enactments. 26 Individuals utilise different mobilising strategies depending on the context, that is, who they engage with, what they are trying to achieve, and how others perceive their identity and respond to their identity enactments.

3. The ability to mobilise identity effectively is influenced by the organisational context in which managers work most notably its power structures and the place of the individual within it in terms of position and tenure/experience (see also Chapter 7 ).

With the above points in mind, to conduct our analysis we looked at both who the respondents tried to influence (above, below, laterally) and how they mobilised or attempted to mobilise their identities. We draw on the primary typology based on two dimensions: (1) management level (junior or middle) and (2) clinical engagement (whether the manager is a member of clinical or non-clinical staff) and give consideration to key work group subcategories within them (see Table 2 ).

Junior managers of clinical units (group 5b)

Within this group we focus specifically on administrative managers who manage the work of clerical staff within a specialty in a clinical directorate or a group of services within a CBU. To recall their key features (see Chapter 6 ), most have a relatively high span of responsibility from a team, to a specialty/service, or to a group of services. The majority have cross-site responsibilities and some work with external agencies.

The content of their work, which mainly involves service delivery targets, such as managing waiting lists, requires many to mobilise ‘upward’, to influence medical consultants, and ‘downward’, to influence their line reports. Influencing upward is, however, a challenge, as their mobilisation capacity is low vis-à-vis medical consultants. Their identity is purely managerial and not very strong at that. Half do self-define as managers, but some prefer to hide behind the phrase ‘I work for the NHS/in a hospital’. Many went into work straight after school, and their education credentials (both general and managerial) are not particularly high. Their position in the organisational hierarchy, as reflected in their AfC banding is not very high, either (all band 5, except for one band 4). They are labelled ‘administrators’ rather than managers, and their work lacks visibility and is not accorded much respect:

[People] see the title of admin manager and they think you just deal with invoices or something. They have no understanding at all of what we have to deal with, very wide, broad, diverse.

JNC 24

Many spoke forcefully, and in some cases with despair, of their inability to mobilise an identity positively valued by others ‘above’. The following are fairly typical:

The consultants . . . they just swan in, swan out! Everything’s . . . happening for them . . . they just turn up and the patient is there . . . If you approach them and say, you know, you’ve got X amount of patients that you need to get in, they just say, ‘It’s not my problem, it’s management’ . . . take no responsibility.

JNC 97

Could one stand up to them? [consultants]

You wouldn’t, you wouldn’t be able to . . . you just couldn’t, no . . . ‘Consultantists’ we call it!

JNC 106

The main, if not the only, facet of their identity they seem to be able to draw on, when trying to influence ‘upward’, is knowledge and skills derived from their work experience:

I’ve got huge amounts of experience in very wide, diverse roles . . . it’s a very board skill-set you need to do these jobs, and I can do it successfully because of the broad skills I’ve got.

JNC 24

Yet, despite its advantages, skills honed from work experience outside the NHS, appears difficult to mobilise in the context of their current job. They spoke of the contrast between the NHS and the ‘real world’, where their identities were more highly valued and could be more effectively mobilised. Thus, one related that in the ‘real world’ she was used to change happening more quickly and that when she had asked someone to do something, they did it right away (JNC 24). The following incident observed during a shadowing session further illustrates the problem:

A secretary has ‘refused’ to do some allocated work and ‘walked out with stress’. The manager related that she would have liked to have told this person to ‘get your arse back here and do your job’, but she knows that HR will require her to ‘pussyfoot around’, ‘mollycoddle’ and ‘support’ the person. Also she relates that consultants develop a close relationship with ‘their’ Secretaries and ‘protect’ them. Things escalate later in the day when her line-manager (an AGM) calls to say that another member of the team has sent a text message to a consultant in the middle of a meeting to tell her about the walkout. The rest of the meeting is then hijacked by this issue, leaving the AGM with a plethora of unaddressed agenda items.

Tenure within the organisation (though not necessarily in the same job) transpires to be more valuable than ‘real world’ skills, as it allows administrative managers to build rapport with powerful individuals:

I’ve got a fantastic relationship with all of them [consultants] . . . Yes, they can come and shout at me as well, but, you know, that’s what you expect from clinicians . . . and I get on quite well with the general surgeons because the two are sort of linked together anyway, so I already knew the surgeons and now obviously I’m managing their admin service, so they already know me, I already know them. But the other areas, I know some of them, but not as well as I would like to be honest.

JNC 105

A manager of several surgical areas spoke of how, in a prior role, she had made a consultant aware of the difficulty getting patients onto lists,

[Doctors] just think you pick up the ‘phone and the patient will say yes straight away. We had a consultant in [named area] once and I said, ‘I can’t get anybody on your list’. He said, ‘Oh, I’ll try’, and he came and sat at the desk, and he goes ‘I can’t believe it’. Anyway he gave up in the end. He said, ‘you’re right, they don’t want to come in’.

Interviewee 106

Mobilising ‘downward’ is not always easy owing to pressured work environments and, sometimes, the reluctance of subordinates (e.g. to speed up or take on more work). However, administrative managers draw on a combination of management experience, their status vis-à-vis their subordinates, and their technical expertise/skills to attain their goals. Their technical skills (the ability to do the same work as their subordinates) and their affinity with their work unit allow them to identify themselves and be identified as ‘part of the team’. In turn, their interpersonal skills, refined through experience, enable them to choose the right management style when dealing with their staff:

You’ve got to keep trying to motivate your staff, we’re forever asking them to do more, and . . . as long as you’ve built up a good relationship with your staff they will help you . . . you know, they’ll moan about it and they’ll say they’re not going to do it, but then actually they do then come forward and help in the end. But I think that’s about building the kind of . . . the right relationship with your staff. I tend to be firm but fair, I’m quite friendly with everybody, I’m approachable, but they know when I’m in a bad mood also.

JNC 105

They are also skilled at employing a range of tactics – from persuasion to assertion. Explaining, cajoling and negotiating often come first, but, when it does not work, there is a need to be firm:

It’s like today, I have had to talk to somebody about time-keeping and I have actually asked them to reduce their hours because they can’t get in on time . . . and it’s not as if it’s a one off, it’s regular, three, maybe four times a week . . . and it is the third time I’ve discussed it with her and it’s everybody else’s fault but that person’s . . . You know I’m not prepared to pay you for that time that we’re losing and she has agreed you know . . . I’ve said to her . . . ‘It’s not fair to the other staff who see you coming in late on a regular basis and you’re not making the time up, how do you think they feel, you know, they think she’s getting away with it.

JNC 97

Junior nurse managers (group 2b)

Within this group we focus on the most representative case of ward managers and ward sisters. Half of them self-identified as nurses and another one-quarter as ‘50/50’ (nurse/manager), but all stressed the importance of their clinical work, which amounted to at least half (and usually more) of their time. Their dual identity as nurses and managers was their strongest asset.

Their job required ward managers and sisters to mobilise both downward (ward staff) and upward (matrons, lead nurses and medics).

In their relationship with middle nurse managers, there was a noteworthy disparity in perceptions and expectations. Middle nurse managers emphasised the continuing significance of their clinical identities and the importance of the ‘back to basics’ care [see Middle nurse managers (group 2b)], but junior nurse managers saw the clinical identity of their superiors as compromised by their lack of actual engagement in clinical practice and criticised the nursing expertise of middle nurse managers as outdated. Middle nurse managers emphasised empowering their staff, but junior nurse managers experienced this as being left to their own devices (JC 51) and described their role as ‘isolating’ and ‘lonely’ (JC 62). Junior nurse managers also saw themselves as taking a clinical perspective, whereas middle nurse managers adopted a managerial perspective (with a narrow focus on budgets and targets). Thus, junior nurse managers’ mobilising capacity vis-à-vis middle nurse managers rested on their clinical values and expertise. Yet, they also occasionally used their knowledge of and relationships with the higher ranks of the nursing hierarchy to influence their line managers. Thus, one ward sister reported that, although she would normally turn first to her matron as her line manager, she would also always liaise with the lead nurse (the matron’s line manager), with whom she had built up a strong relationship over the years of working in the trust (JC 62).

In their attempts to influence medics, junior nurse managers utilised both their clinical identity, in its facets of clinical expertise and hands-on clinical work, and their managerial identity, in its facets of job (and organisational) tenure. This particularly came out in the shadowing data. Although junior nurse managers showed deference to medics as manifested, for instance, in addressing them by their formal title (JC 56 and JC 39), they did not shy away from pressing their point, when necessary. One respondent reported complaining to a consultant about the behaviour of junior doctors on her ward who were not doing their job and creating extra work for the nursing staff (JC 6). Another used her long working relationship with a medic to speed up the confirmation of a diagnosis for a patient who had to be transferred to another ward (shadowing, JC 56). They also employed their connections with medics to influence their immediate superiors. Thus, a ward sister related that, when a series of patient operations had to be cancelled, she knew she could draw on her relationship with the clinical lead to ensure that the matron was actively involved in the situation (JC 62).

Finally, in other attempts to exert upward influence, when this influence was not directed at a particular category of staff, but at several levels of organisational structure (i.e. when trying to obtain additional resources, equipment and staff), junior nurse managers drew on their tacit organisational knowledge. They understood that, to get what they wanted, in an organisational context where decision-making processes are slow and protracted, they had to demonstrate persistence – building a case, following up requests and reinforcing messages:

A lot of . . . ward sisters have said, how do you get all the stuff you’ve got. I say . . . I just nag until they shut me up . . . I don’t give up. I’m like a terrier . . . It takes months . . . it took me two years to get a bath. Two years of nagging, chasing, . . . going through different departments . . . you’re passed from pillar to post, they’ve all got to agree . . . and it took two years.

JC 6

The downward influence was a combination of mobilising their clinical and their managerial capacities. The junior nurse managers’ involvement in patient care allowed them to influence subordinates by leading by example and modelling desired behaviours. As Bolton158 asserts, nurses are firmly attached to their professional image (however over-idealised), socialised not only to put on a uniform but also to embody whole sets of attitudes to their work and role. Indeed, mobilising their clinical identity and their commitment to a public service ethos was an important strategy to get the ward staff to do what they wanted them to do and was perceived to engender respect. Many said they could ring staff to cover at short notice and that they co-operated because the staff knew their manager would also do it as part of the team.

The managerial experience of junior nurse managers, in turn, allowed them to engage a variety of management styles relevant to the individual and the situation. They described facets of their identity as, on the one hand, being supportive, empathetic and team players and, on the other, ‘bossy’, ‘scary’ and resorting to ‘nagging’ (JC 6, JC 40, JC 51, JC 77).

Allied Health Professional managers (group 5)

The AHP managers (all AfC band 7), of whom there was only four, managed clinical teams of occupational therapists, physiotherapists or radiographers. With one exception they did not self-define as a manager and instead strongly identified with their clinical specialty. Yet, all did manage and hence possessed a dual clinical and managerial identity.

All engaged ‘upward’ with doctors and non-clinical managers and managed ‘downward’ to their teams. One (JC 90, an occupational therapist) referred to ‘lateral’ engagement with physiotherapists which she depicted as ‘strained’.

Like other clinical managers, AHP managers mobilised facets of both their clinical and managerial identity. This was especially evident in their descriptions of influencing upward, when they utilised one or the other identity depending on who they dealt with, and emphasised their clinical expertise when dealing with medics:

I’m sure certainly when it comes to any dealings I might have with our doctors because they know who I am, they don’t know who our managers are, that’s more helpful if I’m looking at altering a clinic time or if I’m saying to them, that treatment takes this length of time, you can’t refer six people in 1 day, etc. They take it from me; they wouldn’t from a non-clinical manager.

JC 13

As well as their managerial savvy when dealing with non-clinical managers:

Big brother is watching us in our clinical work. They can see how many times we saw a patient, how long we spent with them . . . I’m able to kind of defend what we’re doing through the fact that we have got outcome measures that show that things are going well.

JC 90

Allied Health Professional managers also relied on the facets of both their clinical identity when mobilising downwards, such as their continuing professional practice, which enabled them to lead by example, and their managerial identity, such as interpersonal skills:

Before I went into management . . . I always thought of . . . the power and authority to ask people to do things and them to do it for you and all that. But I’ve found the greatest challenge of management is people skills, and I think generally I’m very good with people skills. I easily . . . make a rapport with people, because I was always able to motivate others, I find it very easy to convince people to . . . I’m quite unfazed by pressure . . . I’ve got a calm personality and I found it very easy when I started this because a lot of people expected it to be a challenge for me to get people to recognise my authority, but for some reason . . . I just manage to reason with people better.

JC 94

We might advance that even though they cast these skills as a part of their personality, they actually are mobilising managerial skills honed over the years. Another important skill was to be able to translate demands from non-clinical managers ‘above’ into comprehensible and palatable messages to clinical staff ‘below’. As an occupational therapist commented, they were stuck in the middle being a ‘filter’ or ‘stop-gap’ (JC 13).

At times, it was difficult to differentiate which identity was mobilised as the managerial and clinical aspects of the work intermingled and they tried to juggle both loads. This was particularly evident in data from the shadowing of a physiotherapy manager. Over the course of the day she carried a management ‘to do’ list literally on the back of an envelope. When, at various points, the researcher asked her what she counted as management, she responded that it was difficult to define, as, for example, clinical work involved managing people and management meetings concerned service development. During the afternoon, she was working at her computer sorting out staffing cover for the outpatient clinic alongside patient numbers, but was frequently interrupted by her staff coming into the (shared) room with queries about patients, car parking and other matters. The researcher asked how often the staff came to ask for advice like this. She responded that it happened ‘all the time, it’s sort of part of the job’. To underscore the challenges of fitting in management time, when she was leaving the department, she stopped by the reception to query whether she would be able to see a patient with a junior colleague on a certain day – she could do this only if she had a management slot that she could use for it.

Middle non-clinical managers of clinical units (group 5a)

Middle non-clinical managers comprised general managers, assistant general managers and operation and service managers. For the sake of brevity we refer to them jointly as ‘general managers’.

Their responsibilities included delivering services within their respective areas within a particular financial envelope, managing performance targets and being involved in strategy planning. They also had to ensure that their staff:

Are doing what they need to do at the right time, in the right place, in the right way.

MNC 30

In contrast to the groups examined above, the main focus of identity mobilisation of general managers was neither upward nor downward but was, instead, directed laterally, as the avowed challenge of their jobs was dealing with medical consultants.

In contrast to other non-clinical managers, general managers also appeared to feel little or no disadvantage as a result of to their lack of clinical identity:

It’s not stopped me from doing anything . . . you know being non-clinical enables me to ask daft questions, and those daft questions are often useful, . . . whereas if I was clinical I’m not sure it would wash so much . . . so you know it can be an advantage.

MNC 87

Indeed, they seemed to be a perfect example of health managers as ‘outsiders’, who could serve as a link between different interest groups by virtue of such a position. 80

What did weaken their position, however, was the occupational taint associated with middle management in the NHS and the lower status of their occupation vis-à-vis that of the medical consultant. Nevertheless, general managers were highly committed to their work, stressing that they enabled the clinicians to concentrate on patients while they dealt with ‘the background issues’ (MNC 79). They also noted their responsibility for the ‘bigger picture’ and the trust as a whole (whether or not they agreed with what was been asked of them) (MNC 103). (This reflects the system-level thinking associated with effectiveness by non-clinical managers generally, discussed in Chapter 7. ) This appeared to accord with how they were perceived by their main constituents, consultants. As was evident from the interviews with consultant managers, although consultants did view management per se with suspicion, they showed respect for and appreciation of the specific general managers they worked with, recognising their expertise and acknowledging their role in sheltering themselves from the demands of senior management.

Aware of the so-called ‘them and us’ attitude that purportedly exists between doctors and managers,65 general managers understood the need to engage in long-term relationship building:

I keep my door open because my core business is the consultant staff . . . everything kind of hinges on them.

MNC 17

They believed they possessed considerable interpersonal skills, often developed through the experience of work in the private sector and through ‘learning on the job’. These skills were particularly important in dealing with medics, because general managers typically lacked both the authority to demand compliance and the status to impose their will. They therefore had to use ‘softer’ tactics of persuading, negotiating, ‘putting ideas into people’s heads’, ‘selling’ ideas98 and ‘translating’ (i.e. interpreting the ‘demands from above’ as relevant, meaningful and of value to their audience).

It would be really nice if I didn’t have to do all of this running around trying to . . . cover clinics because you have to use all of your skills of persuasion to get doctors to do something that they don’t want to do, and when . . . you’ve got patients arriving, you’ve got to get something like that covered. Sometimes you just feel like putting your hands up and saying . . . ‘I can’t be bothered . . . just do it’ . . . [but] you can’t do that.

MNC 79

Tailoring the message to a particular audience was of particular importance. Several spoke of using an evidence-based approach (facts and statistics) with medics (MNC 17, MNC 87, MNC 104); some talked about using a more ‘emotive’ language and lines of argument with the nurses.

They also spoke of utilising informal, one-to-one interactions, networking, and engaging the support of the senior clinical staff as important strategies of influencing clinicians. Thus, one general manager had circulated a paper covering the points she wanted one of her clinical leads to take on board. Alongside this, she spoke to her clinical superior (whom she knew well) and used this to tell him what to ‘feedback’ to the clinical lead (MNC P2).

Tenure in the organisation afforded general managers tacit knowledge of organisational processes and the opportunity to develop relationships. One interviewee explained that because she had worked with medics for many years, she had a strong understanding of doctor–manager relations and the power dynamics involved. She commented that she was not afraid to ‘get cross’ and mobilise her status as a general manager, when necessary (MNC 30). This mobilisation was implied rather than explicitly evoked, but it was an unspoken presence and appeared related to the general managers’ position within the upper echelons of AfC banding and their links to senior management.

Yet, the clinical respect for general managers was perceived as fragile. Some described an unspoken acceptance of poor behaviour by medics. Having been on the receiving end of such behaviour, one of the respondents intended to leave the NHS (MNC P2); and several admitted that one had to have a strong enough personality to be able to cope with medical staff.

Overall, the general middle managers appeared to draw on their tacit organisational knowledge and a set of skills and strategies that were continually utilised and developed in the enactment of ‘doing’ management. Although such skills and strategy utilisation were often taken for granted, it was clear they were presented as part of an accepted discourse of good management.

Middle nurse managers (group 2a)

Middle nurse managers were a diverse group comprising divisional heads of nursing, CBU lead nurses, nurse/midwife consultants and matrons. For this analysis, we elected to concentrate on matrons (all AfC band 8) because they sit in the middle of this group and have a key role engaging clinical staff ‘below’ (such as ward managers/sisters) and ‘above’ (consultants and more senior nurses).

Matrons were reintroduced to the NHS in the NHS Plan of 2000 and ‘intended to provide a clear focus for clinical leadership across a group of wards and a highly visible, accessible and authoritative figure on whom patients can rely to ensure that the fundamentals of care are right’ (p. 6). 159 When bolstered by experience, and their managerial position, their credibility as a ‘true’, or ‘shop floor’ nurse who embodies nursing values and practice, was a potent combination for influencing others. Their effectiveness in their role, however, very much depended on whether or not they were able to build relationships and support this credibility by interpersonal trust.

Matrons’ identity was deeply rooted in their core nursing skills, general nursing mind-set and their ‘feel’ for the ward environment. They emphasised their no-nonsense, ‘back to basics’ approach; some contrasted that with their image of other ‘new’ nurses, who were ‘too posh to wash’ and did not ‘believe that they should be in the sluice and emptying commodes, doing bed baths and washing’ (MC 55). Yet, as discussed in Junior nurse managers (group 2b), junior nurse managers often were sceptical of the matrons’ expertise because they no longer directly practiced nursing.

One of the key words describing the matron’s role was visibility. They were expected to be ‘visible’ to patients and their relatives and to provide a point of contact and a sense of reassurance. Visibility was also essential for influencing their subordinates. Their time-consuming managerial work, however, made it difficult to achieve this visibility:

We’ve had one or two operational things pulled away from us, so that we don’t spend as much time managing beds, which we’d got heavily involved in, and actually it was loathe, hate and abhor. So now we’re trying to get back to our roots, the visible, being able to help people. So you go round, you meet people, you try to answer their questions, just see how things are going.

MC 68

As their managerial work made it impossible for them to be directly ‘watching over’ their subordinates, they strived to:

Put time into people at the front end . . . showing people that I trust them to do things and to develop.

MC 68

They also placed a high value on being approachable and communicating with staff they line managed.

In mobilising upward, building relationships was also important:

One of the things I dreaded when I had to move was to form those new relationships with the consultants in particular. The junior doctors are fine, but I do . . . it’s a confidence thing . . . But having said that, the ophthalmologists love me, and they all talk to me and they’re fine, and I’m with them. But I haven’t made great strides to meet the others, to meet ENT or plastics or maxfax, if I’m totally honest . . . I know that I need to make that effort to get in there, because if I want to influence anything they’ve got to know who I am and what I’m capable of, and you know that I’ve got some credibility, but I do find it difficult.

MC 55

Their identity, in a sense, was not strong enough to carry them and they had to ‘prove’ that they were capable of performing their role.

One matron who had a track record as someone willing to take risks and prepared to deal with contingencies related how she was asked by senior management to open an additional unstaffed ward during a winter bed crisis and had to ‘rattle some very senior cages’ in order to obtain the necessary staff and equipment. Her reputation as ‘reasonable’ lent credence to her demands, but she opined that one could not be seen to cry wolf too often (MC 68).

Thus, matrons’ identities as ‘shop floor nurses’ allowed them to connect with their subordinates and to influence upwards, but these identities had to be bolstered by actions that supported this claim.

Middle scientist managers (group 3a)

The middle scientist managers interviewed were heads of services and defined themselves as ‘scientists’ rather than managers:

I am a clinical scientist in the health service. The fact that I don’t get to do much science anymore is unfortunate, but where I come from is being a scientist.

MC 32

Alongside the daily responsibilities in their particular service areas, scientist managers were involved in national committees and national auditing.

Describing themselves as ‘the link between the laboratory and the clinicians and the outside world’ (MC 14), scientist managers may be seen as organisational ‘boundary spanners’. 30 They were primarily involved in mobilising ‘down’ (their team of scientists, which often included laboratory workers, administrators and/or nurses) and ‘laterally’ (with consultants throughout the trust and the general manager for their service area).

In attempting to influence downward, all emphasised the importance of their ongoing clinical involvement, which also informed the managerial side of their work:

If I don’t do [science] then . . . I have lost what I came in for and I have lost some of the information or . . . feedback which is . . . important to my managerial work. I wouldn’t be working on the shop floor anymore and I would have lost some of that contact . . . it is useful to know, not just what you’re telling people to do, but to experience some of the consequences of what you are telling them and asking people to do.

MC 32

All appeared less confident in enacting their managerial identity and, unlike most other work groups, directly spoke of their lack of management training and experience as hampering their work:

I don’t know whether this is where my lack of management training shows. I perhaps could manage these things better if I had more training or experience simply in management.

MC 32

Those who had received some management training highlighted the need to support managerial knowledge with skills, which had to be honed through experience:

Well . . . when you get out . . . actually doing it and being ground down by too much to do, a lot of that stuff goes out of my head and it’s not embedded well enough to be part of [my] normal working.

MC 21

Although the managers in other work groups emphasised their strong interpersonal skills, scientist managers appeared to be in the process of developing those, but lamented the time and organisational constraints that prevented them from doing so:

Increasingly what would be nice is to have the time to engage people . . . to gradually build a case, but of course I don’t have the time to go and meet with everyone. I would like to bump into people more often and that’s an issue about site location. Some of the people I need to influence as opposed to bludgeon, are over at [the other site] and I don’t see them . . . It’s about just getting out there and talking to people, in some ways I’m getting better at it, in others because the trust has become bigger I’m less good . . .

MC 21

In attempting to influence upward, scientist managers appeared to be on a more secure ground. Their interactions with medical consultants were on equal terms, because of the parity in clinical status and expertise. Thus, a consultant scientist spoke of being sufficiently medically trained:

To know what a clinician is going to be doing with their patients, what they are worried about, what they won’t understand, what they won’t or what they will be able to do with the results . . .

MC 14

Indeed, he reported needing to ‘translate’ science for medics and commented that, although he understood their job, they did not have the scientific training to understand his.

They also had considerable experience of dealing with medics, were unfazed by ‘tantrums and shouting’, and knew how to utilise their established relationships with consultants:

If I need support or help in moving things forward I tend to talk to the clinicians that are in charge of the services, that use our service. So for example we’ve got one of the lead consultants who sends us patients . . . so he’s a useful contact . . . if you need support in a particular area . . . And there’s a few other clinicians like that . . .

MC 15

Their interactions with general managers were less amicable. They derided them as ‘NHS managers, not real managers’ (MC 15), criticised ‘needless management’ (MC 32), and commented that they had a tendency to ‘say one thing and do another’ (MC 21). They were also frustrated by the general managers’ lack of clinical knowledge and perceived that this hampered their ability to ‘sell’ scientific ideas to senior managers. Yet, similar to consultant managers, scientist managers were grateful to their immediate general managers for sheltering them from the pressures of senior management.

Consultant managers (group 1)

Consultant managers had a wide span of responsibility and typically managed large numbers of staff. Like most other clinical managers, they defined themselves primarily as clinicians:

At the heart of it I am a doctor. Although I do management, at the heart of what I do I am still a doctor . . . in terms of everything I do, it comes from the context of being a doctor.

MC 70

Often they had taken on the management role because they were ‘passionate’ about developing their service and/or felt the time was ‘ripe for change’ more generally. The managerial role was portrayed as a demanding and time consuming ‘add-on’ to their core identities as clinicians and clinical leaders. Yet they saw no fundamental opposition between their clinical and their managerial role:

So, the core identity is being a physician . . . but part of being a physician is about determining best patient care, practice, pathways, and those sorts of things, and I suppose one could argue that you cannot do that in a void . . . So, one manages the team so the rest of the doctors in the team, associated with the nurses, the admin people, has a responsibility . . . I suppose that one of the responsibilities of being a clinician, a senior clinician, is to facilitate change, benefit, positivity, and all those sort of things.

MC 59

Unlike most other work groups who primarily had to exercise influence downward and upward, consultant managers were mainly engaged in managing their former peers (other consultants), i.e. laterally. Another distinctive characteristic was that those former peers were likely to become actual peers again, as most consultant managers took on the managerial job only temporarily. (In contrast, other clinical managers, both junior and middle, had worked their way up to a management role and were likely either to stay in it or move up to a higher post.) The upshot of this was that the identity of consultant managers was ‘suspended’, hovering precariously over the ‘pool’ of their peers, into which they would eventually ‘drop back’. This created a challenge to mobilising their identity for lateral influence:

Taking the team with you is very difficult because . . . you’re basically up there to be shot at . . . [It’s] extremely tricky, because at some point I’ll give this role up, and then you just pop down to being one of the team again.

MC P4

If you continue in this role too long, you almost get to the point where you can’t move forward, can’t move anything forward, and everyone is hating you. Then you drop back in and then you feel despised and hated and not part of a team and someone else has to take it over.

MC 47

Although it seems an oxymoron to suggest that the consultant manager’s identity is vulnerable, this is, in fact, an apt way to describe it. On the clinical side, they feared loss of credibility among their peers, the very people whom they looked to for confirmation of a valued identity and who now thought that they had:

. . . Gone over to dark side . . .

[A consultant once] stood at the door at my office and said, ‘I’m not coming in because that is management carpet and I’m on workers’ lino.’ And he was a friend, but at that moment I had my clinical director hat on in his mind and therefore I was management on the carpet.

MC 49

On the managerial side, they lacked the authority to sanction, because their consultant peers were powerful enough to refuse both to listen and to act:

I can’t tell my consultant colleagues to do anything because they just go: ‘Make me!’

MC P4

To counteract these vulnerabilities, consultant managers had to press the valued aspects of their identity to the fore by continuing to carry the clinical load to show that they stood:

‘Shoulder-to-shoulder’ and saying ‘Why would I want to shaft us because actually I’m shafting myself as well as you’.

MC 47

Another way of countering these vulnerabilities was to espouse a system- or trust-level view, which placed them more effectively as outsiders to their peer group:

You are in a role which people understand that you’re not part of the team. So I’m coming in as clinical director, but actually I’m going to provide a service for you as well . . . I am now going to come to you and explain the costs of that service that you are missing, because I am providing the costs and it gives me a very different lever than if I had been a cardiologist.

MC 49

However, this view was not easily digested by their peers, who, as several respondents recounted, were heavily inclined to see the individual picture rather than the wider perspective.

Finally, consultant managers tried to draw on their management team (e.g. general managers and matrons) to counterbalance the force of peer consultants. Also, one consultant manager recalled using nursing staff as a lever to achieve the successful merger of services across two sites:

The rotation of nursing staff [between sites] has been the catalyst . . . It doesn’t matter how much resistance my consultant colleagues put up, if the nurses are doing it, it’s going to happen . . . I talk to them, I talk to them, I spend hours doing walk around management, because it is incredibly time consuming, but it is also just so important . . . I try to give them my vision, if you like, and try to encourage them and show them the advantages. But most of them are really receptive . . . and take it on and you don’t really need to push . . . The give was much more obvious.

Interviewee 47

In conclusion, consultant managers struggled to mobilise their dual or hybrid identity as clinicians and as managers to influence their peers, because, for their peers, this undermined their credibility. Yet, consultant managers developed strategies to bolster their influence, by strengthening both their clinical identity (through continuing engagement in clinical practice) and their managerial identity (such as by espousing a systems view and trying to communicate their vision to the subordinates).

Summary

In this chapter we have been concerned with the ‘behaviour of identity’ (see Figure 1 , Chapter 1 ), that is, the ways in which various work group subcategories mobilise facets of their identity to achieve their managerial objectives. We have focused on the ‘who’ and the ‘how’ of identity mobilisation, bearing in mind our overarching approach to identity which emphasises its contextual and relational features.

The analysis shows that, in terms of ‘who’ respondents tried to influence, there was evidence of mobilising their identities to influence downward (their subordinates), upward (their superiors) and laterally (colleagues operating at the same or similar level of the organisational hierarchy).

In terms of the ‘how’ of identity mobilisation, the analysis shows a combination of:

• mobilisation capacity, i.e. the facets of identity that a manager could draw on in trying to influence others (e.g. continuing engagement in clinical practice, tacit organisational knowledge derived from the tenure in the job or the organisation), and

• mobilisation strategy, i.e. the enactment of this capacity in interaction with others (e.g. leading by example, building trust).

Respondents mobilised both their managerial identities and their ‘other’ ‘core’ professional self-identities [clinical (e.g. nurse) or non-clinical (e.g. accountant)]. In comparison with the mobilisation capacities of other identities, which were fairly explicit, a key finding is that the mobilisation capacity of managerial identity was more veiled and often appeared ‘in disguise’, referenced by the respondents as their personal characteristics (i.e. ‘content of identity’). Thus, they frequently referred to their experience, or tenure, within the organisation as a resource they used to influence others. Yet we wish to emphasise that their notion of experience actually implied skilled knowledge of organisational context (e.g. decision-making structures) that had been honed over time. Indeed, the problem that managers faced when they did not have these kinds of skill was evident in the not uncommon reference to the challenges of being new to a role and not yet having built up the valuable personal connections and insider knowledge that come with experience in the specific work environment. Similarly, as also seen in Chapter 7 , managers often cited their ability to communicate with others as their personality trait. Yet, on closer examination, this encompassed a plethora of specific skills associated with the management profession, such as the skill of translating specific demands placed on their subordinates by the organisation (e.g. adherence to targets) in terms that were clear and meaningful to their audience.

In Chapter 6 we considered the variation in the span of responsibility and scope of activity of managers according to their clinical or non-clinical status and position in the hierarchy (middle or junior and variations within this). In Chapter 7 we saw how the achievement of self-defined effectiveness is enabled and constrained by the organisational context within which the managers work. These two points have been drawn together in the present chapter in our analysis of the constraints that hierarchies of various kinds (both within and between work subgroups) place on the capacity of managers to mobilise others in pursuit of their objectives, thereby further contributing to our research aim of determining the influence of managerial identities on organisational process and outcomes (see Chapter 2, Identity). As highlighted throughout this report, there were significant differences in identity (its core, content and behaviour) both between and within the four primary categories of managers. As the analysis shows, the ‘who’ and the ‘how’ of mobilising identities also varied. Table 21 summarises the overall findings of the chapter.

Introduction

Little research attention has been given to the identities of managers within the health sector generally or in hospitals specifically, and even less to how their identities may influence their work and their effectiveness.

The category ‘NHS manager’ is internally broad and diverse. Managers are situated at different organisational levels in a variety of clinical and non-clinical roles. Their work calls for them to engage with an array of other organisational members. In an attempt to capture this diversity in a way that could reasonably be operationalised for empirical research, we employed a primary typology of managers based on the two dimensions: management level (middle or junior managers) and clinical engagement (whether the manager is counted as clinical or non-clinical staff). This generated four primary categories of managers: MC, JC, MNC and JNC. During the data analysis it became apparent that a finer-grained categorisation according to ‘work groups’ (which maps back onto the four primary groups) would be useful to elucidate some components of their work. We hoped to discover whether managers from different clinical and non-clinical backgrounds and at middle and junior levels have different sources of identification, leading to different identities, which might shape their interpretations of their roles and the ways in which they performed them.

On the premise that the work managers do is facilitated and constrained by organisational contexts and processes, we elected to take a case study approach focusing on two acute hospital trusts. The original intention was to interview 12 managers in each of the four primary categories in each trust, making an overall total of 96. (In actuality 91 respondents were recruited; see Chapter 3. ) The interviews were supplemented by the shadowing of a number of respondents and the observation of meetings.

In this final chapter we return to the original questions of the research and summarise the main findings from Chapters 5–8 . We also reflect on the strengths and limitations of the research and the challenges we experienced in conducting the research and analysing the data. Finally we draw out some implications for practice and make recommendations for future research.

Research questions and analytical approach

Main findings

The research generated a rich, complex and wide-ranging body of data. The extent to which the findings can be extrapolated beyond the two case study trusts is difficult to assess. On the one hand, as emphasised in Chapter 2 and elsewhere, it is important to appreciate that identities are formed in interaction with others and can alter in their emphasis according to the interaction context in which individuals are engaged. Thus the specific organisational contexts of these two trusts are likely to be important. On the other hand, as noted in Chapter 3, The two research sites, we found that the organisational factors affecting the work of the managers in the study were of a broadly similar order across the two sites, even though the trusts’ organisational structures were somewhat different (see Chapter 4, Organisational structures), this suggests that many of the findings are theoretically generalisable to other sites. That said, a cautionary note is called for as these two trusts are among the largest in England, and each has more than one physical site, which may make them more complex than other trusts.

The four preceding chapters presented the research findings. We recap on these in what follows.

Facets of identity

In relation to facets of identity, Chapter 5 showed that cleavages ran between all four primary categories (JC, JNC, MC and MNC). It was found that:

1. The professional identity of respondents as managers was not particularly strong (almost half did not self-define as managers). The main dividing line was between non-clinical managers, who were more likely to define themselves as managers, and clinical managers, who tended to espouse their ‘primary’ clinical identity and distance themselves from the managerial identity.

2. Those respondents who had higher education qualifications in management were more likely to define themselves as managers, as were those who had previously worked outside the NHS.

3. Those who defined themselves as managers were more likely to identify with individuals or a work team than with a peer group (i.e. people at the same level as themselves).

4. Our results paint a more nuanced portrait of a ‘reluctant manager’ than conveyed to date and indicate that this is a more widely spread phenomenon than hitherto reported, restricted neither to middle management nor to managers with clinical backgrounds.

Effectiveness

Our analysis of self-reported effectiveness revealed that ‘hard’, demonstrable measures of performance, which we call ‘transactional effectiveness’, were important to all four primary groups of managers and hence to organisational processes and outcomes. However, many were also concerned with ‘softer’ indicators of their personal effectiveness, which we call ‘processual effectiveness’, involving activities such as enabling others, supporting and developing a team. The analysis showed that:

• managers felt that ‘processual effectiveness’ contributed to ‘transactional effectiveness’; however, for some, it was a form of effectiveness in its own right that could be compromised by undue attention to ‘transactional effectiveness’

• ‘processual effectiveness’ was especially relevant to managers with smaller spans of responsibility (it was not, for example, so significant to middle managers of corporate units)

• being a skilled or competent communicator was viewed as a key contributor to effectiveness generally

• personal feedback was a gauge of effectiveness for most categories of manager; however, many reported that feedback from their own managers was lacking and/or that the only feedback that they got was of a negative kind

• personal effectiveness could be challenged by the sheer size and complicity of the hospital as an organisation, effectiveness in one area could be compromised by ‘knock-on’ or ‘ripple-effects’ from another

• the objective of combining clinical work and management is that they positively reinforce each other and thereby increase overall effectiveness; however, lack of time and volume of work often made this a potential more than a reality.

Strengths and limitations

To our knowledge, this is the first study to explore the associations between managers’ self-identity and how it is mobilised to achieve their goals (i.e. for effectiveness in the course of their daily work in interaction with other staff).

To some extent the strengths of this research are also its limitations. The interview data were rich and nuanced. They provided a textured and complex picture of each manager’s work and their experience of it. However, the sheer variety and complexity of issues raised meant they were a challenge to analyse comparatively by primary category. As discussed in Chapter 3 , we used the method of ‘quantitising’, or the ‘numerical translation, transformation, or conversion of qualitative data’121 to explore patterns which otherwise might not have been so readily apparent in qualitative data. However, given the flexibility of qualitative interviews not all questions were asked of all respondents and this meant that data were not available for all tabulations, particularly in respect of the content of work and scale of activities.

Quite early on in the research it became apparent that the sheer scope of the sample would raise a question mark over the validity of the four primary categories for some aspects of the analysis. Although breaking the sample down into the ‘work groups’ helped to deal with this during the data analysis, it was not a complete solution as some work groups had quite small numbers and there was internal variation even within those. On the one hand, as outlined in Main findings, this points to what appears to be a valuable finding – and, hence, a strength of the research – that there are more differences within and commonalities across the four primary categories than we had anticipated. Yet on the other hand, we cannot be sure that this is not an artefact of small numbers.

As outlined in Chapter 3 , it had been our original intention to study two similar organisations to enable us to identify whether or not the association between identity and work activity was common for managers in two hospital trusts, thus enhancing the potential reliability of the findings. This was impeded by organisational restructuring at one site (Cityscape). However, we found that the two trusts faced similar dynamics such as multisite working, year-on-year efficiency savings, cost improvement programmes and mergers of services, which seems to be mirrored by hospital trusts across the country. Moreover, challenges of recruiting respondents such as ours who have pressured and busy jobs meant that we could not balance categories of respondents across the trusts. For example, all of the matrons were from one trust and all of the scientist managers were from the other. Hence we did not seek to compare the two trusts but rather combined the two sets of data for analysis to generate cross-case theoretical generalisations.

A related analytical challenge came from the variability of the issues raised in the interviews. Although the topic guides (see Appendices 4 and 5 ) were lengthy in the number of questions, the interview transcripts show that we soon settled on a common core. Yet, even so, as befits semistructured interviews, respondents varied in what they focused on most; in other words, on what mattered to them, and hence what was most important for us to capture. However, this did make it hard to compare them on some facets of their identity and on the ‘content’ and ‘form’ of their work.

The key research concepts, namely, identity, mobilising identity and effectiveness, are ‘slippery concepts’ that are difficult to operationalise in research terms. In fact, respondents largely seemed to find it relatively easy to talk about their identities as managers, clinicians, colleagues and so on. However, it was far more difficult to capture how they mobilised facets of their identities in their work and especially how this might contribute to effectiveness. Many found it hard to give concrete examples of being ‘effective’ and even more difficult to account for how they had achieved this, although we have, of course, been able to draw inferences ourselves on this from issues raised across each interview. The shadowing data were useful in helping us to tease out some elements of how those concerned mobilised their identities in the course of their everyday work. Within the limitations of word length we have employed some of these in Chapter 8 . We had anticipated that observations of meetings would be similarly useful in seeing identities ‘in action’, but as remarked on in Chapter 3 , they proved less useful than we had hoped because (in large meetings in particular) many participants were not actively engaged (e.g. in briefing meetings). Even so, the meetings were useful in providing us with a rich insight into the organisational structures and processes of the two study sites and the issues they faced at the time of the research. This assisted us in the interpretation of the issues raised in the interviews.

Implications for practice

As remarked on in Chapter 1 , the period during which this research was conceived and accomplished has been one of quite rapid change for NHS management, particularly in the wake of the White Paper Equity and Excellence: Liberating the NHS 11 and subsequent changes following the Health and Social Care Act of 2012. 17 Although the bedding in of the reforms and the recommendations of the Francis Report11,13,14 post-date the conduct of the research presented in this report (and hence did not directly inform the analysis) our findings do have implications for some of the issues that they raise. We incorporate some of these into the discussions of implications for practice that now follow.

Recommendations for further research

Our primary recommendation follows from the exploratory nature of this study. Given the variation not only across but also within primary categories and work groups, it would be valuable to extend the research with larger numbers of respondents. There is also scope to explore each of the work groups in greater detail in their own right than has been possible here. This particularly applies to hitherto under-researched ‘work groups’, such as scientist managers and AHP managers.

Given the exploratory nature of the research most of our implications for practice (see Implications for practice) are suggestive rather than definitive. Hence our recommendations for further research are a call for additional investigation into these areas. Briefly, they are as follows.

An over-riding finding from which most others follow is that many respondents were struggling with their identities as managers. To recap, most were not reluctant to manage but to self-identify as ‘a manager’. Given that a strong identity is associated with uncertainty reduction and employee strengthening, we advocate for more research on how positive managerial identities can be enabled within specific organisational contexts and at different levels within the organisation. This applies not only to managers’ self-identities but also to identities conferred on them by others, such as other NHS staff groups and the general public. In particular, since our study focused on managers themselves and their own perception of their identities, it would be valuable to complement the study by examining how different groups of managers are perceived by other organisational members.

Following on from this, we propose that more research knowledge is needed on how ‘veiled’ skills, such as those that derive from tenure and experience and are often framed as personal traits (the ‘content of identity’), in the workplace seem to function as skills that enable effective managing (the ‘behaviour of identity’), even though they are not recognised as such. To the extent that they are effective enablers, further research should be able to discover how they may be re-envisaged as skill and facilitated in management education, training and development.

As recapped in Implications for practice, we have found that less than one-third of the respondents had recognised management qualifications and that the qualifications that they did have were not necessarily commensurate with their current positions. We have suggested that management qualifications might foster stronger identification of NHS managers with management. However, our study did not set out to directly research this issue. Hence we would recommend further study of managers’ own perceptions of this issue and how it might be tackled, something which may vary across work categories and finer-grained work groups. The same point applies to the issue of professional association.

Finally, we have found that the managers generally felt that the mobilising capacity of work group identity was inhibited by other work groups (upwards, downwards and laterally in the organisation). There is, therefore, considerable need to explore the perceptions that staff groups have of the work that other staff groups do (including non-managers) and, if inaccuracies exist, to identify how they might be overcome to enable more effective working between groups. It is also of note that although feedback from above was valued, many managers reported that it was infrequent and tended to occur only when there was a problem. More detailed research on both vertical and horizontal feedback channels might profitably identify how feedback can be improved and whether this in turn can enhance managerial effectiveness.

Contributions of authors

Dr Janet Harvey (Senior Research Fellow, Health Services Research, University of Leicester, and for majority of the project, Assistant Director at the Centre for Research in Social Policy, Loughborough University). Principal investigator for the first 3 years of the project, leading on project design and contributing to the literature review, data collection and ongoing data analysis. Dr Harvey also contributed to the early stages of writing this report and latterly acted as an advisor to the team, giving critical advice covering content both factual and intellectual, and contributed to the revision of draft report and preparation of final report.

Professor Ellen Annandale (Professor of Sociology, University of York). Principal investigator from July 2012 to completion of final report in June 2013. Contributed to development of the proposal, literature review, fieldwork, development of coding frame, NVivo data coding, NVivo data analysis (see Chapters 6–8 ), writing of Chapters 3 and 7–9 , commented on all chapter drafts, edited complete report, and contributed to the revision of draft report and preparation of final report.

John Loan-Clarke (Senior Lecturer in Organisational Development, Loughborough University). Contributed to development of the proposal, literature review, fieldwork, development of coding frame, NVivo data analysis (see Chapter 4 ), writing of Chapters 1, 2 and 4 , commented on some aspects of draft chapters.

Dr Olga Suhomlinova (Lecturer in Management, University of Leicester). Contributed to, development of the proposal, literature review, fieldwork, development of coding frame, NVivo data analysis (see Chapters 5 and 6 ), writing of Chapters 2, 4–6 and 8 , commented on all chapter drafts, and contributed to the revision of draft report and preparation of final report.

Dr Nina Teasdale (Research Fellow, University of Leicester). Contributed to fieldwork, literature review, development of coding frame, NVivo data coding, NVivo data analysis (see Chapters 6 and 8 ), writing of Chapters 2, 4, 6 and 8 , commented on all chapter drafts, and contributed to the revision of draft report and preparation of final report.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

PROJECT INFORMATION SHEET

Project title

Project description

It is now well-recognised that managers play a central role in leadership, organisation and service delivery in the public sector. Middle managers, in particular, have been identified as ‘key strategic actors’ in terms of how effectively organisations operate and, in many organisations, the number and variety of the roles they play has steadily increased. Currently, little consideration has been given to the accounts of managers themselves, particularly at the middle and junior levels, concerning how and why they operate in particular ways and what affects their professional backgrounds and identities play in this process.

The purpose of the research, therefore, is to investigate the working lives of middle and junior managers in the NHS. It will look at managers who are medically/clinically trained, and those who are not but who come from a general management or other backgrounds; in order to identify the similarities and differences in the way that they operate. The research will also explore the identities held by middle and junior managers and the effect these identities have on the way they conduct their work and how they relate to others with whom they come into contact in the workplace. It will then look at how this feeds into the performance of their roles and influences leadership effectiveness.

This will build on existing research that has described the working lives of managers more generally and will help to increase our specific knowledge about middle and junior managers, about whom relatively little is known. It will also tell us about these groups in the health-care setting. This will provide valuable learning to the NHS and groups, such as patients, who use its services, about what goals, values and beliefs motivate middle and junior managers and how this may relate to the performance of their roles.

How the research will be conducted?

To conduct the research we are using a range of methods that include:

1. One-to-one Interviews We will interview both middle and junior managers to gather accounts of managers’ daily working lives and their own sense of personal and professional identity and how this is may influence the ways in which they work to achieve personal and organisational goals. Interviews will last approximately 1 hour and with the participants’ consent, these will be recorded and fully transcribed. Prior to the interviews, we will ask interviewees to keep a brief, simple schematic diary of their meetings, tasks, activities and contacts for the previous 3 working days.

2. Observation and Shadowing We will observe managers’ work in action; that is, carrying out the work that they regularly undertake. This will involve shadowing a small number of middle and junior managers over a 2-day period and the observation of some directorate, departmental and unit meetings.

Whom we would like to participate

We intend to interview both women and men, middle and junior managers, from both clinical and non-clinical backgrounds and from a variety of different departments, specialisms and directorates. Individuals have been randomly selected for interview according to these criteria’ from the Human Resource directorate.

Anonymity, confidentiality and right to withdraw

All participants who agree to take part will be asked to sign a consent form. They will be guaranteed both anonymity and confidentiality, and will have the right withdraw their participation at any stage of the research. All data will be treated as personal data under the 1998 Data Protection Act and stored securely for a period of 5 years.

Research outcomes

Both preliminary and overall findings will be presented to participating hospitals and the findings will also be presented at conferences and published in scientific journals.

Project team

Dr J Harvey, (Principal Investigator) Assistant Director, Centre for Research in Social Policy, Loughborough University

Dr E. Annandale, Reader in Sociology, Department of Sociology, University of Leicester

Mr J Loan-Clarke, Senior Lecturer in Organisational Development, Business School, Loughborough University

Dr O Suhomlinova, Lecturer in Management, School of Management, University of Leicester

Dr E. Kuhlmann, Senior Lecturer in Sociology, University of Bath

Dr J Goode, Senior Research Associate, Centre for Research in Social Policy, Loughborough University; and

Dr N Teasdale, Research Associate, Department of Sociology, University of Leicester.

If you require more information or to discuss the research further please contact:

Dr J Harvey

Centre for Research in Social Policy; Loughborough University (contact details provided)

PARTICIPANT CONSENT FORM

Mobilising identities: the shape and reality of middle and junior managers’ working lives

Purpose of the study The purpose of the research is to investigate the working lives of middle and junior managers in the NHS. It is funded by the NHS R&D SDO.

It will look at managers who are medically/clinically trained and those who are not but who come from a general management background; in order to identify the similarities and differences in the way that they operate. The research will also explore the identities held by middle and junior managers and the effect these identities might have on the way they conduct their work and how they relate to other groups with whom they come into contact in the workplace. It will then look at how this feeds into the performance of their roles and influences the achievement of personal and organisational goals as a result of their work.

Participant consent form

Name of research participant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of research participant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .

Research team

Dr J Harvey, (Principal Investigator) Assistant Director, Centre for Research in Social Policy, Loughborough University

Dr E Annandale, Reader, Sociology Department, University of Leicester

Mr J Loan-Clarke, Senior Lecturer in Organisational Development, Business School, Loughborough University

Dr O Suhomlinova, Lecturer in Management, School of Management, University of Leicester

Dr E Kuhlmann, Senior Lecturer in Sociology, University of Bath

Dr J Goode, Senior Research Associate, Centre for Research in Social Policy, Loughborough University; and

Dr N Teasdale, Research Associate, Sociology Department, University of Leicester.

If you require more information or to discuss the research further, please contact:

Dr J Harvey

Centre for Research in Social Policy (CRSP)

Loughborough University

Telephone: (removed for report), e-mail: (removed for report)

1. Current role

1.1 What is your current job title(s)?

1.2 How long have you occupied your current post?

1.3 Can tell me about your main duties, responsibilities and areas of jurisdiction; including (roughly) the number and categories of staff you manage?

2. Professional background

2.1 Can you tell me briefly about your professional background and qualifications?

2.2 Have you ever worked outside of the NHS? (If ‘yes’: Do you think this has influenced your management practice?)

2.2 What management training have you undertaken (if any)?

2.3 Are you a member of any professional association or network? (It maybe that there are ‘expected’ as managers to belong to certain networks, for example.)

3. Day-to-day work

3.1 What are your main activities during a working day?

3.2 Can we talk about the diary you completed? Can you talk me through 1 day of it in more detail (researcher to choose the day – ask how the respondent felt about various issues/events)?

3.3 Are these documented diary-days typical days for you in terms of the components of work involved? (Why? Why not?)

3.4 Roughly how much time do you spend in meetings? What meetings do you regularly attend?

3.6 What’s a good day like? What’s a bad day like?

4. Management work

4.1 Why did you choose to get involved in a management role in the NHS?

4.2 What are the main challenges of being in a management role in the NHS? Greatest satisfactions? Greatest downsides?

4.3 Are you directly involved in strategy within the trust – that is in terms of implementing strategy and/or the formulation of strategy? (If ‘yes’: At what level?)

4.4 What are your goals/targets as a manager? (Prompt: Are these set by you/by others? How much discretion do you have?)

4.5 How do you go about achieving these goals/targets? (Prompt: Are there particular skills, tactics or strategies you deploy to further these goals? How far do these goals coincide or diverge from your own professionally derived goals?)

4.6 How do the current organisational structures affect the way you work?

4.7 Is there a body of knowledge you can call upon to inform your role as a manager? (Prompt: Are there identifiable skills involved?)

5. Effectiveness/accountability

5.1 What does being an effective manager mean to you? (Prompt: How do you create and judge success in your role?)

5.2 How is success as a manager measured in the trust? Criteria of effective performance (e.g. performance targets, annual ‘quality’ account and other metrics, financial targets of various kinds, organisational and national priorities)?

5.3 Is success incentivised? Are there any sanctions imposed for not achieving targets/success?

5.4 If there were two things you could change to help you more effectively achieve your management goals, what would they be?

5.5 From what sources do you derive support in doing your job effectively?

5.6 Who are the people you get on with the best in your work? (Prompt: Why is this?)

5.6 Can you identify any specific incidents that have really required you to exercise all your managerial and personal skills in managing them effectively? (Can you talk me through such an incident?).

5.7 Are there some areas of your work where you find it easier to exercise influence than others? (Prompt: What does this depend on?)

5.8 How do you get people to act in the ways you want them to? Get them to do what you want them to?

6. Mobilising identity (using particular identity-derived elements of professional and individual background to create influence and leverage advantage in an occupational situation)

6.1 Can you tell me about something you have achieved in the organisation of which you are particularly proud, why you felt this was important and how you achieved the result you wanted?

6.2 Conversely, can you tell me about something in which you were involved in the trust that you felt turned out badly and caused you some concern? (Prompt: Why did this particularly concern you? What did you try to do about it?)

6.3 What things do you fall back on when the going gets tough?

6.4 Multidisciplinary teams seem to be an increasing feature of the NHS – how well do people from different professional backgrounds work together? (Prompt: Do you find some groups easier to work with than others?)

6.5 In your view, are there differences in the way managers from clinical (medicine, nursing, etc.) and non-clinical (general management) backgrounds operate? What about managers at different levels of the organisation, do they operate differently? How well do the different levels of management relate to each other? (Prompt: Is communication good between them?)

6.6 How far do you see yourself operating within the wider hospital trust or do you operate more locally at the level of the ward or department? (Prompt: What are your operating boundaries here?)

7. Identity

7.1 How much does your work define you as a person?

7.2 Do you think of yourself primarily as a ‘manager’? (If ‘yes’: Get them to expand on this. If ‘no’: Why not?).

7.3 (For clinical managers only.) Which are you first – a clinician or a manager? (Are the lines between ‘clinician’ and manager blurring?)

7.4 (For clinical managers only.) Have there been occasions when being a clinician as well as a manager has helped you to resolve management issues?

7.5 (For non-clinicians only.) Given that this is predominantly a clinical environment, has it ever felt difficult that you don’t have a clinical background?

7.6 (For non-clinicians only.) Are there times in your management role where not being a clinician has helped you?

7.7 What motivates you in your role as manager? (Prompt: What values do you bring to your role as a manager?)

7.8 How would you describe your management style?

7.9 What ethical issues do you face in a management role in the NHS (Prompt: Where do you derive your ethical compass from?)

7.10 (Dis-identification.) What alienates and frustrates you within this organization? (Incentives.) What energies and excites you about this organization? (Prompt: Which part of your work do you most enjoy/least enjoy?)

7.11 Are there particular aspects of your work that you particularly hold dear/that are particularly important to you (to a greater degree than other aspects)? (Prompt: What? Why?)

7.12 If you have to leave/jettison certain aspects of the job, what goes first and why?

7.13 Who do you most closely identify with in the trust, as having the most in common with you? (Prompt: Whose goals do you see as most aligned with your own?)

7.14 Would you say you have a strong sense of self-identity? How does this express/manifest itself? (Prompt: Does this express itself in your work?)

7.15 How do you envisage your long-term career? Do you see yourself continuing in a managerial role in the NHS?

7.16 Is there anything else you would like to say about the issues we have discussed?

1. Current role

1.1 What is your current job title(s)?

1.2 How long have you occupied your current post?

1.3 Can tell me about your main duties, responsibilities and areas of jurisdiction; including (roughly) the number and categories of staff you manage?

2. Occupational background

2.1 Can you tell me briefly about your job history and qualifications?

2.2 Have you ever worked outside of the NHS? (If ‘yes’: Do you think this has influenced the way you work in this job?)

2.3 Have you had any management training for this job?

2.4 Are you a member of any professional association or network? (It maybe that there are ‘expected’ as managers to belong to certain networks, for example.)

3. Day-to-day work

3.1 What are your main activities during a working day?

3.2 Can we talk about the diary you completed? Can you talk me through 1 day of it in more detail (researcher to choose the day – ask how the respondent felt about various issues/events)?

3.3 Are these documented diary-days typical days for you in terms of the components of work involved? (Why? Why not?)

3.4 Is attending meetings part of your job? (If ‘yes’: What meetings do you attend regularly?)

3.5 What’s a good day like? What’s a bad day like?

4. Management work

4.1 How and why did you become involved in a management role in the NHS?

4.2 What are the main challenges of your job? Greatest satisfactions? Greatest down-sides?

4.3 What are your goals in your job? (How far are these set by you and how far by others? If others: Who?) How do these goals impact on your job? How much discretion do you have?

4.4 How do you go about achieving these goals? (Prompt: Are there particular skills, tactics or strategies you deploy to further these goals? How do you feel about the goals you have to meet?)

4.5 What proportion of your work is routine and how much of it involves responding to events as they unfold?

4.6 What sort of skills do you need to do your job? How do you gain these?

5. Effectiveness/accountability

5.1 What are the targets/performance indicators for the group/unit you manage/people you supervise? Who sets them and how often are they monitored? How far do they coincide or diverge from your own views of what is important?

5.2 What does being an effective manager/supervisor mean to you? (Prompt: How do you create and judge success in your role?)

5.3 Are you specifically rewarded for success? Are there any sanctions imposed on you for not achieving targets/success?

5.4 If there were two things you could change to help you more effectively achieve your work goals, what would they be?

5.5 Where do you go for support if you need it to get your job done?

5.6 Can you identify any specific incidents that have really required you to exercise all your skills in managing them effectively?

5.7 Who are the people you get on with the best in your work? (Prompt: Why is this?)

5.8 Are there some areas of your work where you find it easier to exercise influence than others? (Prompt: What does this depend on?)

5.9 How do you get people to act in the ways you want them to?/get them to do what you want them to?

6. Mobilising identity (using particular identity-derived elements of professional and individual background to create influence and leverage advantage in an occupational situation)

6.1 In your view, are there differences in the way clinical and non-clinical (general management) managers at your level operate?

6.2 How well do people with different professional backgrounds work together? (Prompt: Do you identify more with some groups than others/find some groups easier to work with than others?)

6.3 Can you tell me about something you have achieved in the organisation that you are particularly proud of, why you felt this was important and how you achieved the result you wanted?

6.4 Conversely, can you tell me about something you were involved with in the trust that you felt turned out badly and caused you some concern? (Prompt: Why did this particularly concern you? What did you try to do about it?)

6.5 What do you fall back on when the going gets tough?

6.6 In your view, are there differences in the way managers from clinical (medicine, nursing, etc.) and non-clinical (general management) backgrounds operate? What about managers at different levels of the organisation, do they operate differently? How well do the different levels of management relate to each other? (Prompt: Is communication good between them?)

6.7 How far do you see yourself as a part of the wider hospital trust or do you operate more locally at the level of the ward or the department? (Prompt: What are your operating boundaries here?)

7. Identity

7.1 How much does your job define you as a person?

7.2 Do you think of yourself primarily as a ‘manager’? Why/Why not? (Probe if this is a term they would use to describe themselves.)

7.3 (For clinical managers only.) Which are you first – a clinician or a manager? (Are the lines between ‘clinician’ and manager blurring?)

7.4 (For clinical managers only.) Have there been occasions when being a clinician has helped you resolve management issues? (Prompt: Does this ever hinder you?)

7.5 (For non-clinicians only.) Given that this is predominantly a clinical environment, has it ever felt difficult that you don’t have a clinical background, when trying to get across your point of view?

7.6 (For non-clinicians only.) Are there times when not being a clinician has helped you as a manager?

7.7 What motivates you in this job?

7.8 How would you describe your management style?

7.9 What ethical issues do you face in your role? (Where do you derive your ethical ‘compass’ from?)

7.10 (Dis-identification.) What alienates and frustrates you within this organisation? (Incentives.) What energies and excites you about this organisation? Which part of your work do you most enjoy/least enjoy?

7.11 Are there particular aspects of your work that you particularly hold dear/that are particularly important to you (to a greater degree than other aspects)? (Prompt: What? Why?)

7.12 If you have to leave/jettison certain aspects of the job, what goes first and why?

7.13 Who do you most closely identify with in the trust as having most in common with you? (Prompt: Whose goals do you see as most aligned with your own?)

7.14 Would you say you have a strong sense of self-identity? How does this express/manifest itself? (Prompt: Does this express itself in your work?)

7.15 Do you see yourself continuing in a managerial role in the NHS in the future?

7.16 Is there anything else you would like to say about the issues we have discussed?

Who

What

How work is experienced

Identity

Mobilising identity

Organisation