Clinicians and the governance of hospitals: A cross-cultural perspective on relations between profession and management

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Abstract

This paper explores similarities and differences in the value stances of clinicians and hospital managers in Australia, England, New Zealand and China, and provides some new insights into how we theorise about the health profession and its relations with management. The paper draws on data derived from a closed-ended questionnaire administered to 2637 hospital-based medical, nursing and managerial staff. We examine variations between the countries in the value orientations of doctors, nurses and managers by considering their assessments of issues that are the focus of reform. In particular, we examine the ways in which the Chinese findings differ from those of the other countries. Whereas the results from the Commonwealth hospitals showed a marked division between clinicians and managers about issues that can affect clinical autonomy, this was not the case in the Chinese hospitals. The concluding discussion traces these differences to a number of cultural, organisational and policy-based factors. The implications of our findings on how we conceive the relationship between professionals and organisations are then discussed, as are further lines of research.

Section snippets

Overview

The view that there is a conflict between professionalism and organisation employment, particularly state employment, has long been discarded in favour of a more subtle thesis. This recognises how professionals are able to construct a role for themselves in ways that ensure that their interests and conceptions of their tasks are dominant (Johnson, 1972). Within most industrial societies, organisational forms have emerged in which professionals are autonomous from management and accountable

Method

The studies were undertaken in Australia and England (Degeling, Kennedy, Hill, Carnegie, & Holt, 1998), New Zealand (Degeling, Sage, Kennedy, & Perkins, 1999) and in China in 2000. The hospitals included in the study in each country were selected to be comparable in terms of size, type and clinical role. Selection was restricted to not-for-profit teaching hospitals and large general hospitals located in major urban areas. The hospitals in China operated at provincial and county levels. The

Findings

The most striking feature of Fig. 1 is the across-country stability in the patterns of how occupations were positioned on the two dimensions. This finding suggests that the hospital studies, whether in Australia, New Zealand, England or China, are characterised by the underlying consistency in the patterned set of differences between the occupation-based sub-cultures of medicine, nursing and management that populate them.

Notwithstanding this finding, Fig. 1 also describes the extent to which

Discussion

The studies in Commonwealth countries revealed two marked occupational differences that were absent in the Chinese sample. The first referenced occupation-based differences on matters that can affect the standing of medical clinicians in the performance of clinical work. These differences were illustrated in the strong support of the Commonwealth general managers and nurse managers for efforts to strengthen the systematisation and team-based nature of clinical work. Equally, the data showed how

Conclusions

Our starting point was the long-running Western debate on the extent to which the relationship between professionalism and organisations is akin to what Klein (1990) memorably describes as ‘the politics of the double bed’. Here, the interests of clinicians and managers are united in a commitment to the viability of a health service but opposed on how dilemmas about scarce resources, clinical autonomy and accountability might be addressed. Against this background, we examined extraordinary

Acknowledgements

The authors acknowledge their indebtedness to C.K. Wong, Victor Wong, Jonathan Erskine, Andrew Gray and John Kennedy. They also thank the three reviewers for their valuable comments on an earlier draft.

References (48)

  • Z.X. Chen et al.

    Employee demography, organizational commitment and turnover intentions in China: Do cultural differences matter?

    Human Relations

    (2000)
  • Z.X. Chen et al.

    Loyalty to supervisor vs. organizational commitment: Relationships to employee performance in China

    Journal of Occupational and Organizational Psychology

    (2002)
  • P. Degeling

    Policy as the accomplishment of an implementation structure: Hospital restructuring in Australia

  • P. Degeling

    Reconsidering clinical accountability: An examination of some dilemmas inherent in efforts to bolster clinician accountability

    International Journal of Health Planning and Management

    (2000)
  • P. Degeling et al.

    Mediating the cultural boundaries between medicine, nursing and management—The central challenge of hospital reform

    Health Services Management Research

    (2001)
  • P. Degeling et al.

    A cross-national study of differences in the identities of nursing in England and Australia and how this has affected nurses’ capacity to respond to hospital reform

    Nursing Inquiry

    (2000)
  • P. Degeling et al.

    Professional sub-cultures and hospital reform

    (1998)
  • P. Degeling et al.

    Making clinical governance work

    British Medical Journal

    (2004)
  • P. Degeling et al.

    The impact of reform on hospital-based professional subcultures-a comparison of some Australian and New Zealand hospitals

    Australia Health Review

    (1999)
  • W. Dong

    Health care reform in urban China. Comparative program on health and society

    (2001–02)
  • J.-L. Farh et al.

    The influence of relational demography and Guanxi: The Chinese case

    Organization Science

    (1998)
  • R.B. Fetter et al.

    Diagnosis related groups: Product line management for hospitals

    Academy of Management Review

    (1986)
  • E. Freidson

    The theory of professions: State of the art

  • T. Gao et al.

    Medical education in China for the 21st century

    Medical Education

    (1999)

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