Multifaglig ledelse – Hybridisering i sykehusledelse etter NPM-reformer

Abstract

The primary concern in this paper is to understand how reforms, characterized by New Public Management, NPM, affect management in hospitals. This would be considered in the light of theories of management where the term "hybrid" management is central. This term indicates a combination of management forms which "normally" do not belong together. I also apply neo-institutional theory where institutional logics are essential. The institutional logics are socially constructed patterns of cultural symbols and material practices which contribute towards meaning to daily activities for individuals and organizations. In light of profession theory professionalism is emphasized together with the professional relationship with management. I follow up how new guidelines affect management in hospitals. Research Question: How has hospital management changed after the meeting with NPM-reforms? How is management affecte whe institutional framewor condition fo organizin changes and new logics for management are introduced? Is management hybridized? How are the leading roles of doctors and nurses changed as a result of new institutional instructions? Are the leading role getting more characterized by hybrid management? The empirical material in the study is obtained from a qualitative study with interviews and observations of Norwegian and German hospital leaders. In addition, reviews of secondary and tertiary data are carried out. This has resulted in three separate articles that describe different aspects of the issue. The introductory part also sheds light on the main research question as a separate contribution. In the first approach, I examine how changes in the organization and the introduction of management logic affect an organization that previously has been dominated by professional logics in management. Through the comparison with Germany it turns out that the way management is organized and what management applications dominate has an impact on how management is practiced and understood. In Norway where there have been reforms that have introduced unitary management, as well as organizational changes with the introduction of divisional structure, management has changed. Doctors and nurses have acquired a more coherent focus on leadership. In Germany, there have not been direct management reforms, but reforms which indirectly affect management through greater emphasis on economy and increased competition. The organization of management, therefore, has not changed. When doctors lead their own profession, as seen in Germany, management is related to the organization of physician’s professional work. The equivalent is discovered amongst nurses. When doctors have unitary management positions, as can be seen in Norway, the focus of management is expanded. Corresponding findings are reported amongst Norwegian nurses. On the basis of this, I consider the German nurses and doctors in management positions as professional managers, while the Norwegians have taken a management role, but not in its pure form. I consider management in the Norwegian context as a hybrid of different types of logics. The introduction of NPM reforms have led to greater demands for planning and documenting, which have contributed to increased bureaucracy. The leaders are consequently, also characterized by a neo-bureaucratic logic. In the second approach I examine how new institutional framework conditions set out to change the management role for doctors and nurses in Norway. The introduction of unitary management has not displaced the professional logic of management, but the professional logic has changed and become something else. The professional focus extends from organizing, maintenance and development of their own profession, to include other groups they are responsible for. The focus of professional management is expanded and I have grouped this development in three; 1) the leaders’ focus on the professional development of both treatment and care, 2) maintenance and development of the competence of related staff in the unit and 3) concern of attention to quality at the system level (procedure development, discrepancy reports, complaints, etc.). The leaders have a unitary focus on management and the professional logic of management has been extended for both professional groups in the study. This can be attributed to competition for management positions amongst doctors and nurses. Both professional groups include management after the guidelines set out through the reforms to be able to participate in the contest. Due to the increasing level of academic knowledge in nursing, doctors and nurses can to a greater extent both cooperate and compete for management positions in Norwegian hospitals. The Norwegian managers are further concerned with the relational aspects of leadership. Leadership is acting as a catalyst that makes it possible to deal with the complexity of logics in management. On the background of the logics that distinguish the Norwegian and German managers, I conclude that German leaders have not changed focus after the reforms and are considered as professional managers. After the reforms with the introduction of management and structural changes with the introduction of divisional organization, management has changed in Norway. The leaders have taken on a hybrid management role. This is called a “multiprofessional management role” as an expression of multiple logics. The management logic is supplemented by professional logics and neo-bureaucratic logic. Leadership influences on the conduct and coordination of these logics.