Introduction

Citation

Fitzgerald, L., Mark, A. and McKee, L. (2007), "Introduction", Journal of Health Organization and Management, Vol. 21 No. 4/5. https://doi.org/10.1108/jhom.2007.02521daa.001

Introduction

This special edition of the journal looks at different aspects of power and how it affects and is affected by the people involved in health care organisation. The papers are drawn from the 5th Organization Behaviour in Health Care (OBHC) Conference held at University of Aberdeen in April 2006.

There were many excellent papers submitted for our consideration and in our selection for this special edition, we were keen to create a platform for new and young researchers and we include in this issue, papers which were chosen as award winners by the Conference participants (Anton, Bridges, Harris). This focus on the new generation of researchers is consistent with the objectives of our academic society (The Society for the Study of Organizing in Health Care), which aims to nurture and develop rising researchers.

While all the papers include in the edition met our quality criteria, we have also included papers for their collective story. There are many ways in which they could have been sequenced and a convincing narrative told, but the rationale of the selection is set out below to aid readers.

The first paper by Braithwaite et al., focuses on an examination of concepts underpinning trust and communication especially when health care encounters go wrong. Their approach is innovative and they explore whether insights from evolutionary psychology can help to explain major organisational failures leading to external inquiries. Evolutionary psychology was also identified as important in the first OBHC Conference in 1998 (Mark and Dopson, 1999). Braithwaite et al., argue that when individuals are stressed through an adverse event, many of their behaviours reveal the genetic roots of survival. By positing this theoretical view, Braitewaite et al., challenge the naivety and limitation of many adverse event models and interventions. Their powerful case helps shed light on the inclination to both tribal and political behaviour so evident in healthcare organisation and the not infrequent uses and abuse of power and trust. The paper is both novel and compelling in the way the analysis unites inquiry data from both the UK and Australia through this theoretical lens.

The second paper by Lapsley also engages with a theoretical perspective that of accountingization to explore understandings of adverse medical outcomes. The thesis that Lapsely addresses is how far accounting controls, such as clinical budgeting have affected the behaviours and rationales of doctors. Dissecting a number of medical cases with adverse outcomes, he interrogates the role of financial limits and discovers very few instants where the power of budgets has had a direct effect. His analysis illustrates the role of human frailty and suggests that the weak impact of accounting practices on medical practice is in part due to the inability of clinical budgeting to catch the imagination of doctors and the continued failure to represent financial data in a meaningful way to clinicians. Both studies suggest that management attempts to harness and direct the behaviour of clinicians either through adverse event reporting (Braithwaite et al) or accounting procedures (Lapsley) have been largely ineffectual or constrained.

In the third paper, Bridges at al., turn attention to the adequacy of traditional research methodologies by offering a longitudinal study of micro level innovation in a hospital setting. Their emphasis is on using an action learning approach to research. Action research is people focussed and acknowledges that such research cannot make assumptions about stasis and control – indeed the research results demonstrate that innovation processes are longer term and more continuous than previously conceptualised and that end descriptors are just chosen snapshots in time with which to describe this dynamic world. The focus of Bridges et al.’s study is on the novel role of inter-professional care co-ordinators and they found inattention to governance and the complexity of the innovation made this role shift difficult. Again the theme is one of unshifting power blocs and habits.

Over the past decade, the OBHC Conferences have addressed a number of continuous themes and the issue of managing innovation was central to the 2004 OBHC Conference (Casebeer et al., 2006). Picking this up again in the fifth meeting, Addicott and Ferlie have set out a very coherent explanation of their interpretation of power in reviewing the emergence of new organisational types in healthcare which are network, rather than structurally based. Their analysis suggests that even in the political priority area of cancer and with facilitation, the dominant managerialist culture cannot be adapted to accommodate potentially more expedient ways of communication and knowledge sharing. This latter point is further explored in the work of Currie et al. who look at the barriers to knowledge sharing in one of the most exciting areas of development, genetics. Their paper explores the apparent negative behaviours which, in fact, have their roots in political behaviours associated with issues of trust and uncertainty between the political, professional and managerial domains. As Lukes (2005) reminds us, the exercise of power does not require being intelligent and intentional, even though the capacity to understand it will enhance its use for good or ill. In concluding, Currie et al., look at some strategies to ameliorate these dysfunctions including incentivising behavioural change (which returns us to Lapsley’s theme); promoting new career paths and organisational development to engender the formation of trusting relationships. They conclude that behavioural change to increase collegiality depends upon a context where there is a sensitive leadership approach.

Following the themes relating to power and people, we offer a group of papers, which explore novel dimensions of HRM and HRD in health care. Again we would suggest that these aspects of organization behaviour in health care have, until recently, been relatively neglected fields of research. It is evident that the issues relating to the management of human resources are especially critical within a human service organization, such as health care and that we need to expand our understanding of the ways in which HRM/HRD can facilitate better performance (Kinnie et al. 2006). Within this group of papers, Sambrook explores the role of HRD in the NHS, using discourse analysis. This represents an illuminating and insightful approach showing how different discourses impact on professional identities. One particularly problematic transition is described, that of moving from being a nurse to becoming a manager. The different discourses that Sambrook describes are complicated by the multiple frameworks and perceptual complexity. Compounding this complexity are the ambiguities inherent in the notion of defining HRD activities and shared purposes across professional and organisational boundaries.

The next paper by Miller explores another major aspect of power inequality, this time in a Scottish context, by reviewing gender inequality in healthcare. Although the vast majority of staff employed are female, she argues that there is still a marked gender imbalance in management and a pervasive, masculine organisational culture, which she suggests rests upon the dominant power networks from which many women are excluded. The experience of Scotland does how ever differ from that of England where progress may be seen as better in terms of equality but where significant barriers still exist. In a wider UK context, it is notable that there is increasing divergence of structure and organisation in UK healthcare following the devolution of political power.

The last paper in this grouping directly addresses the theme of HRM and performance and provides a very timely review of the extant literature. There is an emerging debate in the literature on the role of Human Resource Management as a strategic player in the organisation, deriving from the work of David Ulrich (Ulrich and Brockbank, 2005). These ideas and the associated debates propose that the HR function needs to be strategic in its approach, adopt the role of business partner and provide justification for its contribution. These ideas are at the heart of the study by Harris et al. to link HR strategies and policies to outcomes in health care. The ground is complex and the links may be tenuous or context specific, resting as they do on methods which cannot confirm direct causal relationships, but can only infer patterns of relationships. However, there is clearly a basis for arguing that our understanding may be enhanced by utilising qualitative methods which display and explain the variety of context specific interconnections (Dopson and Fitzgerald, 2005) and also employing quantitative methods, which seek to identify uniform patterns (West et al., 2002).

The last pair of papers analyse and illustrate the influence of the professional bodies and finally, and by no means the least of patients and the public! Academic analysis of the perceptions, power and role of both of these, very different constituencies has been limited. The paper by Baker offers an illuminating and unique insider view of the work of a medical professional body in the UK. Baker describes the attempts to involve patients and patient representatives in the decision-making processes within a professional body. The analysis highlights that the history of prior decision making methods, coupled with accountability to their members create barriers and limits to both perception and action. The paper illustrates the struggle of the professionals to come to terms with the adoption of a more patient centred or consumerist model in healthcare. She argues that the profession of medicine has an underdeveloped understanding of its role in shaping the service and has biased its power toward a model of patient involvement that is unthreatening to professional values.

The final paper by Anton et al., focuses on the core issue of public involvement. It develops an exploration of the difficulties in involving the public, and more importantly the challenges involved in developing assessment and evaluative measures of public involvement. In Scotland, all Health Boards are having to assess their performance in relation to public involvement. This study argues that public involvement is difficult to conceptualise and is contested. The paper demonstrates the problems of identifying who should be involved, issues of representation and relevant stages for involvement. As indicated by their symbolic placement in this special edition, patients are often disempowered and placed last in the queue of those who can exercise power in health care.

This special issue provides different offerings in a number of ways. We offer novel theoretical perspectives on the exercise of power in health care and explore our themes through varied and underutilised methodologies.

A continuously reiterated finding across many of the papers is the titanic problem of shifting power across the professional and organizational boundaries. We see this expressed at the individual level, in role change and at the organizational/inter organizational levels in structural changes to networks and in professional responses to adverse events.

Another underpinning theme is the challenge of working in new ways, sharing knowledge more willingly, developing new roles, and involving professional organizations, patients and the public. We identify the crucial role which can be played by support functions in particular, HRM and HRD and emphasise the need to develop these functions into more strategic roles and activities. Many of our papers are empirically based and in offering additive new data they take up the challenge of researching these core topics relating to power and its interrelationship with people in health care.

Louise Fitzgerald, Annabelle Mark, Lorna McKeeDe Montfort University, Leicester, UK, Middlesex University, London, UK, University of Aberdeen, Aberdeen, UK