Editorial. Middle management and nursing

In 1990, a question was posed by Dopson and Stewart ‘What is happening to middle management?’ (Dopson & Stewart 1990, p. 3). Some years later, Thomas and Linstead (2002) concluded the key message from the literature was that, as a result of structural changes in both the environment and the organization, predictions over the future of middle management were profoundly pessimistic. It would seem the death knell is being sounded over the future of middle management (p. 72). This may appear to be a very negative point of departure from which to launch a journal issue specifically examining middle management, however, the purpose in acknowledging this is to emphasize the need for a fresh look at this area of management practice. In the face of such doom laden forecasts, we could be forgiven for thinking that middle management was a thing of the past. On the contrary and rather than sounding the ‘death knell’, this issue reports on the current state of middle management in nursing. Although organizations are now much less certain places for the middle managers (Clarke 1998) and they have been subject to much criticism (Balogun 2003) it appears that a wholly pessimistic outlook is inaccurate and unhelpful. Despite the gloomy predictions concerning their future, middle managers still exist because their role has changed. They are taking a more active role in strategy development (Floyd & Wooldridge 1992, 1994, 1997, Currie 1999, 2000) and serve as key players in bringing about organizational change (Moss Kanter 1982, Balogun 2003). However, the environment they are working in is much more challenging. Thomas and Dunkerley (1999) observed that although superficially many public sector organizations seem to have all the characteristics of postmodern structures, they still have strongly asserted ‘old’ forms of bureaucratic controls in place. Based on their research with middle managers in public and private sector organizations in the UK they conclude: many of the old frustrations of middle management – of being in the middle of a long line, with little say in decision-making and little discretion – are still there. But this has been exacerbated by a performance culture that pressures middle managers to achieve more and more demanding targets (p. 39). This underlines the mixed picture concerning life as a middle manager in contemporary organizations. Within the present day NHS, boundaries of structure, process, responsibility and purpose are in a state of flux. Its middle managers are caught in the tensions between the need to change and the continuity of traditional values and systems (McConville & Holden 1999). In recent years, in the NHS and organizations generally, there has been a huge emphasis on leadership development (Govier 2004, Hewison & Griffiths 2004) and service modernization (Harrison 2002) and it has become much less fashionable to talk about management. Yet middle management has not ceased to exist. In many ways, it has become hidden. Floyd and Wooldridge argue that: ‘In general the purpose of middle management is to take responsibility for, and control the managerial problem. As boundary spanners, middle managers mediate between the organization, its customers and its suppliers. As administrators, middle managers direct the organization's overall task (Floyd & Wooldridge 1997, p. 466)’. In short, they are essential and organizations will not function without them (Jackson & Humble 1995, Wall 1999). There is an added dimension to all this in the case of nursing, which can be best summed up through using the term hybrid management (Causer & Exworthy 1999). Along with the complex demands of a middle management role, there is the ‘professional responsibility’, which comes with being a nurse. The ‘hybrid’ nature of the professional nurse who is also a manager can result in fundamental conflicts for individuals who have to balance the demands and needs of the organization with those of the patients (Hewison 1994, 2004). This renders their situation slightly different to that of other middle managers. Acknowledgement of such differences is essential if our understanding of the role as a whole is to develop because middle managers do not constitute a neat homogenous group (Gleeson & Shain 1999). There are different types of management and there are varying types of middle management, yet surprisingly middle level managers have rarely been studied, despite the fact that they play a key role in implementing change policies (Keen & Scase 1996). Efforts have subsequently been made to address this situation with several studies using explicit theoretical frameworks including social constructionist approaches (Turnbull 2001, Thomas & Linstead 2002), psychoanalytic theory (Young 2000), and the notion of competing rationalities (Hewison 2002), to investigate the nature of middle management. There is also a body of work, which seeks to understand the situation from the perspective of the middle-manager (Newell & Dopson 1996, Keen 1997, Preston & Loan-Clarke 2000). Whilst this is a welcome development, there is still a dearth of evidence concerning the nature of middle management and nursing. Many middle management posts are occupied by nurses (IHSM 1995) and so consideration of the current situation for middle management in nursing is important and timely. This special issue can be broadly divided into two sections. The first four papers examine the nature of middle management itself, with three focusing specifically on nursing. The second four then report work on key issues, which fall firmly within the remit of middle managers in healthcare. In the first paper, Graeme Currie provides a useful overview of the research conducted into middle management before moving on to dispel a number of myths. He contends that middle managers are an easy target for senior managers and politicians seeking to deflect responsibility for organizational failings. The major thrust of his paper is that nursing middle managers are an untapped resource and organizations would do well to capitalize on this and demonstrate appreciation of them. In this way, the role would be enhanced and strategy implemented more effectively. In the second paper, Alison Patrick and Heather Spence Laschinger present their findings from work which investigated the effect of empowerment on middle managers’ role satisfaction. Empowerment is something of a ‘buzzword’ in contemporary management writing (Collins 2000) and so a study which engages with the term and seeks to investigate its effects is welcome. It supports much of what Graeme Currie argues for, concluding that organizations need to value and recognize the contribution of middle managers. This is vital because when it happens they are more likely to influence others to work towards achieving the goals of the organization. The research was undertaken in Canada, demonstrating that research into middle management is a concern in a number of countries. This international theme continues in a paper by Marie Carney, which reports further findings from her work in the Republic of Ireland. It seeks to address another ‘buzzword’, culture, and its influence on the strategic involvement of middle managers. Given that 50% of her sample were nurses, the findings have clear implications for nursing middle managers. It also sheds light on the ‘hybrid’ nature of such roles and how this affects the value system underpinning their actions. The final paper in this first section is by Tom Forbes and Jerry Hallier. They use Social Identity theory to inform their examination of doctors’ experiences of undertaking middle management roles. However, their findings are of interest to nurse managers because, as they suggest, all NHS health professionals will undergo similar experiences on entering management. Indeed, it is likely that many nurse managers will identify with the observations made about the lack of clarity in the roles and will recognize the various elements of organizational politicking described. Their call for more ‘fine-grained’ work to explore the role of middle management and nursing is echoed in several other papers and indicates that although the contributions in this issue are valuable, there remains a need for more to be done to increase our understanding is an area. The second half of the Journal opens with a fascinating paper by Sue Dopson and Louise Fitzgerald. Drawing on a comprehensive body of research, involving 49 case studies and more than 1400 interviews, it sheds light on the reality of implementing evidence-based healthcare. This includes an examination of the importance of organizational context, consideration of the negotiated nature of knowledge, and analysis of the role played by communities of practice. This all serves to confirm the essentially social nature of evidence-based healthcare and highlights that middle managers, as opinion leaders, have a vital role to play here. Although it is a major concern in health-care settings across the world (Niessen et al. 2000) evidence-based healthcare is just one issue on the crowded agenda of middle managers. Malcolm Lewis draws our attention to another, bullying. He argues that the social construction of bullying behaviour is a complex issue and nurse managers are probably going to be involved be it as perpetrators, victims or in dealing with the effects on staff. It is part of a continuing programme of work and it will be interesting to see the outcome of this. For now, it is clear that awareness of how bullying can occur and attention to the key issues involved in preventing and managing it are timely. By way of contrast Dean Whitehead directs our gaze to the potential that lies in creating healthy workplaces. He considers the comprehensive organizational reform that is required for the implementation of healthy workplace schemes, yet within this he outlines the different ‘layers’ of activity. This indicates where middle managers can make a contribution. Indeed the positive benefits would go a long way to offset the problem addressed by Malcolm Lewis. A series of recommendations are included to assist managers in creating healthy workplaces. Finally, Kazuyo Kusaka and his colleagues report their work on the application of the Critical Path Method as a means of reducing in-patient hospital stays for people with mental health problems. In the UK and many of the industrialized western economies, the challenge of chronic illness or the management of long-term conditions has become a central policy concern (Hudson 2005). Work of this nature, which demonstrates how acute sector beds can be used to best effect will be a useful source of information for middle managers in their efforts to play a part in meeting this challenge. The question posed by Dopson and Stewart (1990) was the starting point for this editorial. Nine years later, Wall (1999) concluded: middle managers are essential to organizations but are often unsupported by those above them and reviled by those they supervise (p. 23). What conclusions can we draw in 2006? It is evident from the work included here that middle managers are indeed essential to health-care organizations and that their potential is unrealized. They can play a strategic role if allowed to and can be the key factor in the introduction of a range of organizational initiatives including evidence-based practice, the creation of healthy workplaces and the elimination of nurse bullying. What is also clear though is that simple definitions of middle management are insufficient. Nurse managers, as middle managers, have been somewhat ‘hidden’ and the collection of papers in this issue represents an attempt to uncover their contribution. However, in doing so it has identified the need for additional work to discover more about the reality of the role and to provide further evidence of its effects. The hope is that as well as providing an insight into the current state of nursing middle management, these papers will stimulate wider debate and research.

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