The Multiple Middle: Managing in Healthcare

Abstract

The future of the middle manager is a much debated topic; not only in healthcare but also in other sectors. The middle manager is either viewed as an important change agent or as a relict of the past. Despite these opposing views, the underlying definition of middle management is one and the same: middle management is defined as a place somewhere ‘in the middle’ of the work floor and higher management. This spatial definition of middle management is foregrounding management activities in ‘upward’ (higher management) and ‘downward’ directions (work floor), while backgrounding other management activities. As a consequence, we only have a partial and limited view of what middle management entails. The central aim of this thesis is to open up the middle by researching the multiplicity of the middle in healthcare, thereby gaining new insights in day-to-day work of middle management and important transitions in this work. This thesis foregrounds alternative middles that so far have received little attention in literature: the middle in-between 1) conflicting values of good care; 2) different justifications used towards stakeholders; 3) professional and managerial discourses; and 4) organizational boundaries between care, welfare and housing. The empirical analysis does not only sheds light on the type of work that is conducted in these middles, but also reveals how this work is reconfigured and partially distributed to clients and professionals. Moreover, the analysis provides an answer to the main question: ‘How is the daily work of middle management enacted and reconfigured in the Dutch care sector?’ This thesis focuses particularly on care organizations for people with physical and mental limitations and neighbourhood-based care projects. These organizational settings are suitable for investigating changing responsibilities in the current care sector and welfare state. Ethnographic research methods are used to explore mundane routines and embedded perceptions of actors. By shadowing middle managers during their daily work, a clear picture was developed of what the activity of middle managing entails in practice. To deepen the empirical analysis, ethnographic observations were triangulated with semi-structured interviews and document analysis. During data collection and analysis, various sensitizing concepts from literature were used to focus on specific aspects of work, such as ‘values’, ‘justifications’ and ‘boundaries’. The result is an ethnography of managerial work that is both theory-based and inductively developed.