Value in the middle: cultivating middle managers in healthcare organizations

Abstract

Purpose Senior executives in healthcare organizations increasingly display preference for a closer handling of operational levels, bypassing middle managers, and de-emphasizing the need to cultivate the next cadre of leaders, creating the potential for leadership and performance gaps. The authors argue that middle managers are a vital resource for healthcare organizations and review the benefits for including them in leadership development and succession planning programs. The paper aims to discuss these issues. Design/methodology/approach Current theories and common practices in addition to data collected from government sources (e.g. BLS), business and industry surveys and reports (e.g. Moody’s, Witt/Kieffer, Deloitte, American Hospital Association) are used to classify the roles, skills, and strategic value of middle managers in healthcare organizations. Findings The combination of a greater executive span with less hierarchical depth creates a dual effect of devaluing middle management, and a decrease in middle managers’ autonomy. Healthcare middle managers who stay away or lay low further trigger perceptions of low expectations leading to low morale and high levels of stress. Others become hypereffective or develop exit strategies. Major problems are: rising turnover costs; and insufficient attention to succession planning, internal promotion, and leadership development. Practical implications The outcomes of this study are useful for management development, particularly at times of change. Practitioners and researchers can have a better understanding of the value of middle managers and their development needs as well as the factors and dynamics that can influence their motivation and affect retention. Originality/value Understanding and implementing the ideas developed in this paper by healthcare organizations and other companies can lead to a drastic change in the current perceptions of the importance of middle managers and should lead to long-term retention, well-being, and extrinsic benefits for both the company and its employees.

Healthcare middle managers’ experiences of developing capacity and capability: a systematic review and meta-synthesis

“…HMMs experienced support and feedback from their peer HMMs, but several studies described a lack of empowering support and feedback from upper management [66, 68, 75, 76, 82]. These results added to the existing knowledge describing a dominating top-down management in healthcare, HMMs’ loss of involvement and autonomy [3, 28], and the relevance of a change in leadership styles where transformative [7, 31] and relational leadership [8, 31] are argued to better relate to the present complex healthcare systems [7, 31]. Communicative rationality can only be accomplished through bottom-up social interaction, since the reality is known only to the participants of the processes [40].…”

“…In this context, HMMs have experienced a shift from professional authority to managerial values, economic stress [9], dominating top-down management and a loss of involvement and autonomy. These changes have been associated with multiple reforms beginning in the 1980s that aimed to manage public service organizations using private sector principles; these reforms are known as the New Public Management approach [3, 28]. Rather than adapting the leadership style to the tasks at hand, the staff and their previous experiences, leaders tend to favour a preferred leadership style, predominantly transactional leadership [20].…”

“…It has been argued that a dynamic, emerging, creative and intuitive view of healthcare should replace the traditional “reduce and resolve” perspective [25]. This approach involves developing new principles in healthcare leadership [21–24], accepting that some behaviours emerge self-organized, and accepting that minimum specifications [28], aims, limits and incentives [29] are better approaches than long-range plans and targets [28].…”

Constrained leader autonomy: You are the stoker in hell—No matter what you do, you are wrong!

“…Dean et al., 2010; Kälvemark et al., 2004; Kempster and Gregory, 2017). The literature on organizational change, strategy, and performance describe autonomy-related tensions and stress as arising due to the contradictory functions of formal leaders in mid-level positions who are important for the implementation of changes, strategies, and plans, but who have limited autonomy (Belasen and Belasen, 2016; Birken et al., 2012; Conway and Monks, 2011; Fleming and Spicer, 2014; Floyd and Lane, 2000; Huy, 2002; Rouleau, 2005).…”

“…As the disagreement is followed up with loyal subordination, autonomy is functionally constrained (e.g. Belasen and Belasen, 2016; Birken et al., 2012; Conway and Monks, 2011; Floyd and Lane, 2000; Huy, 2002; Rouleau, 2005).…”