1. Ulla Isosaari Power in Health Care Organizations: Contemplations from the First-line Management Perspective

2. Background Aim of the study Questions
To examine public health care organisations’ power structures through unit level management
Questions
What does power mean in health care?
What power type do health care organizations represent and what factors are connected to it?

3. First-line Management in Health Care
Employees who have one hierarchical level under them
Member of two subsystems
the managerial structure
the unit supervised
In health care
Physicians (doctors as first-line managers)
Nurses (charge nurse, ward manager, first-line/unit nurse manager etc.)

4. Power The intended sphere of influence
Includes force, manipulation, persuasion and authority
Always relative and seeks balance
Can be examined in three dimensions
Structural
Individual
Interpersonal

5. Sources of power (Morgan 1990: 159)
Decision-making power
Formal authority
Control of decision processes
Discretion
Use of organizational structure, rules and regulations
Structural factors that define the stage of action
Control of resources
Control of shared resources
Ability to cope with uncertainty
Control of technology

6. Control of knowledge and networks
Control of knowledge and information
Control of boundaries
Interpersonal alliances, networks and control of ‘informal organization’
Control of counter organizations
Symbolism and the management of meaning
Gender and the management of gender relations

7. Power Configurations (Mintzberg 1983)
Instrument
Closed system
Autocracy
Missionary
Meritocracy
Political arena

8. Power configurations and sources of power
Decision-making
Discretion
Control of resources
Control of knowledge and networks
Centralized
Controlled
from
outside
Bureaucratic
Little
Standardized
goals
Strong
situations
Seeking
own interests
Inside
organization
Strictly
defined
Clear targets
Routine
operations
Rewards
bound to
success
Own
interests are
central
Control of
formal and
informal
Instrument
Closed system

9. Power configurations and sources of power
Decision-making
Discretion
Control of resources
Control of knowledge and networks
Experts make
decisions
Managers
arbitrate
Much in
expert tasks
Weak
situations
Political
bargaining
Competition
for resources
Outside
organization
(labour unions,
government)
All play along
Multiple goals
or none
instead of
expert
Extreme
discretion
Greed
Manipulation
Meritocracy
Political arena

10. Empirical study
A survey of 10 Finnish hospital districts both in specialized and primary care
Respondents :
all first-line managers (physicians and nurses)
a sample of staff members from internal disease, surgical and psychiatric units, as well as outpatient and primary care units
number of respondents: 1197
response percentage: 38
The data was analysed statistically
building sum variables
correlation analysis
Kruskall-Wallis test
table elaboration

11. Results Decision making power
In the unit, at a higher level or outside the organization?
In the unit concerning operation management and human resource management
At higher level or outside the organization concerning resources
Who makes the crucial decisions for the unit?
Nurse manager has a strong role concerning operation management and human resource management
Factors influencing the development of power
Position and competence

12. The respondents who think decisions are made inside the unit

13. Discretion
First-line managers reported more discretion than their subordinates assessed they had
Nurse managers used more discretion than physician managers
Much discretion was connected to task description in written form

14. First-line mangers’ views about discretion

15. Control of resources At average level Very little competition
Very little political games or bargaining

16. Control of knowledge and networks
Networking is a strong source of power according to
Subordinates
Primary care
Main responsibility for communication
Nurse manager
Physician managers’ role more notable
First-line managers: Specialized care, surgical units, male and physicians
Staff: Specialized care, psychiatry, male and physicians

17. Conclusions Staff: Features of meritocracy and political arena
First-line managers have lots of space and many possibilities to influence
First-line managers: Instrument
Position bounded by rules and regulations
Reaching goals set outside
Specialized care: Instrument and meritocracy
Primary care: Closed system and political arena

18. Conclusions
Surgical units: Closed system, meritocracy and political arena
Physicians: Closed system and meritocracy
Implications:
Are first-line managers’ recruiting, qualification requirements and training in balance with real conditions in the units?
Traces of effects of municipal restructuring process in primary care