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Decision-making power in health care organizations

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Image: Decision-making power in health care organizationsPower is not a very popular concept in health care because it refers to health care professionals' exercise of power over patients. However, health care organizations are, like any other organization, systems of power.

Organizations are complex systems of individuals and coalitions, where everyone has their own interests, beliefs, values, preferences and angles. Owing to limited resources, there is competition, which results in conflicts. The actors whose roles are more critical for the organization gain more power.

In Finland, health care services are based on public provision. As a consequence, the structures of health care organizations represent traditional organization models, such as bureaucracy and professional organization. Hospitals, for instance, are mainly seen as professional bureaucracies where the structure is bureaucratic but decentralized. The main performers are doctors, and nurses are classified as support staff.

New waves of result-based management have delegated tasks to the unit level and brought features of managerialism to health care. It has strengthened unit based thinking, but at the same time it can lead to fragmentation. As a consequence first-line management has emerged to the forefront.

Making decisions

Making decisions is at the core of management. To make the correct and rational decisions, a manager has to gather as much information as possible to be able to choose from various options and their imaginable consequences. Because not all possible consequences can be predicted, decisions can only be rational to a limited degree. Authority in organizations means legitimate power to give orders and make decisions.

Discretion is an important part of the decision-making process, and involves choosing between options. At the unit level there is greater opportunity for discretion if the top management is disintegrated, the case under consideration is not important, or the unit is sustainable. Managerial discretion depends on how managers perceive it. Perceived discretion, even if it is slight, gives managerial power. If a person does not recognize their possibilities, it is less likely they will act.

Power vested in resources is based on the fact that some resources are more critical for the organization than others. Persons who can offer resources like money, fame, legitimacy, rewards, sanctions, special skills or the ability to deal with uncertainty have power. The point is to own resources somebody else needs or desires. Scarcity and dependence are the keys to resource power. Resource allocation can also have an impact on the decision-making process as a premise for it.

"First-line managers operate at the core of the action. They deal with people as individuals rather than as groups."

Power in an organization depends on an individual's or unit's position in the official and unofficial communication networks. A formal position brings access to invisible tools of power as knowledge and membership in networks. Knowledge is also an important part of decision making. For informed decisions there must be enough information about the alternatives.

First-line management

Lower level managers are "employees who have one hierarchical level under them". In health care that means nurse and physician managers at the unit level.

First-line managers are members of two organization subsystems, the managerial structure and the unit supervised. This can cause problems if the demands of these subsystems come into conflict. The position needs balance between different values. First-line managers operate at the core of the action. They deal with people as individuals rather than as groups.

As the first-line managers work close to the operative core, the nature of their work is short-term, fluctuating and fractured. It has some regular variation in the long-term, but the lower the hierarchical position is, the more short-term the duties are. Because of the nature of the action, reactions must be immediate, and the main concern is maintaining the fluency of work processes.

Compared to other management levels, managerial roles in first-line management are the same, but the stressing of them is different. On the other hand, skills needed at higher levels may not be relevant at lower levels of management. The central point is to use the skills suitable for the relevant level. At the lowest level the most important is the implementation of policies set higher up. It can be done more or less effectively.

In the Finnish health care system, there are two managerial lines in the management structure. This also means that the two professional groups in first-line manager positions are doctors and nurses. The position of nurse managers is traditionally strong and clear. They work as leaders in their units concerning nursing operations. However, they often partake in hands-on work in their units and the proportion of managerial duties in their work varies according to the size of the unit.

On the other hand, the position of first-line physician managers is not as clear. The main focus is on clinical work, not managerial duties and the name of the position has a connection to the determination of salary, not necessarily to the content of the position. In spite of that, there are doctors working in managerial positions at the unit level.

Making space for more meaningful management

Are first-line managers' recruiting, qualification requirements and training in balance with the real conditions in the units? Do we lure first-line managers with advertisements for a job promising an innovative and development-favourable working environment, or to get higher education, causing frustration when they realize what the real conditions are? In Finland, there are no congruent competences or qualification requirements for first-line managers. In the end organizations define them themselves.

Or should the organizations revaluate their structures, responsibilities and distribution of work so that there could be space for more powerful first-line managers? If the organizations seek innovative and active managers at the unit level, they should change the organizational structure and redistribute the work so that there could be more space for meaningful management. First-line managers desire more decision-making power, not just gathering background information for somebody else.

Or do they actually have the power but do not perceive or use it? With clear frames of managerial duties, first-line managers use more discretion. With proper job descriptions first-line managers can be conscious of the possibilities and the limitations of their position and use their power effectively.

November 2011.

This is a shortened version of "Power in health care organizations: Contemplations from the first-line management perspective", which originally appeared in Journal of Health Organization and Management, Volume 25 Number 4, 2011.

The author is Ulla Isosaari.