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Moving domains: radiographers as managers in NHS
Radiography (2000) 6, 101–110 doi:10.1053/radi.2000.0246, available online at http://www.idealibrary.com on
Moving domains: radiographers as managers in NHS Tom Forbes BA (Hons), PhD, DCR, Lecturer* and Neil James Prime, MA, MPhil, DCR Principal Lecturer† *Department of Management and Organization, University of Stirling, Stirling FK9 4LA, Scotland, U.K.; †Department of Radiography, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, U.K. (Received 16 January 1999; revised 27 July 1999; second revision 27 January 2000 and accepted 3 March 2000)
Key words: radiographers; management; professionals; change; domains.
Purpose: The 1990 NHS reforms have led to a number of clinical professionals moving into management roles. This paper examines a group of radiographers who have developed management roles within the backdrop of a changing NHS. Methods: A comparative study of 25 Scottish and English radiographer managers from different NHS organizations were interviewed using semi-structured interviews. The interviews formed a number of emerging themes, which were analysed using domain theory. These themes included management, professionalism, management style, conflicts between the role of both manager and professional, and role change. Results: Radiographer managers are forming new ‘hybrid’ manager roles, which have been developing within a changing NHS. A definite tension was demonstrated in this role change. The transition from professional to manager was not easy for this group of radiographer managers. Key issues surrounded this transition which included role conflict, an emergent management style, and a lack of management development and training. Conclusion: Radiographers have shown resilience in undertaking both operational and strategic management decisions, while using their clinical background to inform their decision making. There was no difference observable between Scottish and English radiographer managers in this change process. Appropriate management training and development must be provided if radiographer managers are to contribute to the performance of their NHS organizations. © 2000 The College of Radiographers
Introduction The development of managers and management in the NHS was formally introduced by the 1983 Griffiths Report [1]. Management was introduced to all levels within the NHS with clinical professionals beginning to take on more substantial managerial roles. Research by Packwood et al. [2] indicates that acute sector hospitals began to reconfigure their internal organization with clinical directorates appearing in the late 1980s and early 1990s. The NHS and Community Care Act of 1990 set up the purchaser–provider split, established National Health Service Trusts and introduced a quasimarket into the NHS. The management freedoms of NHS Hospital Trust managers were more significant than previous hospital managers were allowed. In particular, they would have greater 1078–8174/00/020101+10 $35.00/0
responsibility in managing their own affairs without having to report to Health Authorities. This had had the effect of liberating hospital managers, both non-clinical and clinical, to make service improvements. This paper will examine the changing roles and responsibilities of a group of radiographers who have moved into management areas within their Trusts. Radiographers also have a history of developing management skills [3–6] and the College of Radiographers also offered a management diploma up until 1992. This indicates that radiographers were not only becoming involved in management, but were also studying it as a discipline. Radiographers are in a unique position in relation to other Professions Allied to Medicine (PAMs). The majority of PAMs are located within large medical or support services clinical © 2000 The College of Radiographers
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directorates, where they are managed collectively by a manager who may not be in a PAM. Radiographers are, however, incorporated into free-standing imaging or radiology clinical directorates, which are managed by radiographer managers. In many cases radiographers have also taken on the role of the directorate or business manager, although it is more common to find radiographers as radiology, radiography, or imaging service managers. These arrangements differentiate radiographers from other PAM groups and provide an opportunity for examining their personal development, as they move from a clinical to a managerial role. The development of health professionals as managers has been a major theme of the literature for several years now [7–13]. However, these studies have tended to concentrate on hospital doctors undertaking a part-time managerial role as a clinical director [14]. While still maintaining a substantial clinical role, these part-time managers often move from the managerial domain to the clinical domain after a period of time as a clinical director. While this is the case for hospital doctors, other health professionals such as radiographers have moved into full-time management and left their clinical role behind, no longer practising clinical radiography.
Methodology The NHS in Scotland (NHSiS) is structured and organized differently from the NHS in England. Scotland, at the time of the research, had 47 Trusts and 15 Health Authorities known as Area Health Boards. A comparative study was undertaken of a group of radiographer managers in the West of Scotland and North Thames/London between late spring and the summer of 1998 to ascertain if these structural and organizational differences had an effect on the developing managerial role of radiographers. A total of 25 semi-structured interviews were carried out within the two geographical areas. The sample size was relatively small to reflect the preliminary nature of the research, which if successful would lead to an application for funding to expand the study to include, as far as possible, all PAMs groups involved in management within the NHS. Radiographer managers were chosen from a variety of settings and included acute city nonteaching hospitals, acute city teaching hospitals, district general hospitals, and a breast screening
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centre. Although mainly involving radiographer managers from the diagnostic branch of the profession, two therapy managers were also interviewed. This research comes at a timely period in the development of the NHS in England and Scotland. The 1997 White Papers [15, 16] will provide the new framework for the NHS for the years ahead, including a reduction in the number of Trusts. In Scotland, this has led to a reduction in the number of Trusts from 47 to 28, and the creation of new Primary Care Trusts. The further development of community based services and Primary Care Groups in England may potentially lead to an increase in the number of radiography managers, but as yet this is unclear. These changes will provide a new challenge for existing and future radiography managers. To aid the understanding of the transition from a clinical to a management role, use will be made of Kouse and Mico’s domain theory [17] and Tannenbaum and Schmidt’s leadership style theory [18]. Kouse and Mico [17] examined service integration in what they referred to as human service organization (HSOs). HSOs have been defined as ‘the set of organizations whose primary function is to define or alter a person’s behaviour, attributes or social status in order to maintain or enhance his well being’ [19, p.1]. HSOs can be found in many areas, but have been particularly associated with the health care sector. Kouse and Mico [17] concluded from their research that there were three separate areas or spheres of influence operating within health care organizations. These spheres were subsequently adapted into three domains of policy, management and service, as each domain approached the issue of service integration differently. The domains, are illustrated in Fig. 1. Kouse and Mico [17] argued that each of the three domains saw themselves as having a legitimate role to play within their HSOs. Those in the policy domain developed policies in response to the electorate. Those in the management domain developed ways of meeting organizational goals through the effective use of scarce resources. Those in the service domain developed their practice to provide the best services they could to clients within the confines of selfautonomy and regulation based upon a set of occupational standards and ‘expert knowledge’. The service domain also affiliated to a professional culture, rather than to any specific organization. The fact that these three groups developed mechanisms to legitimize and serve their individual
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theory to the NHS, attention now turns to the radiographer manager. Managerial Domain
Political Domain
Service Domain
Figure 1. The three domains within human service organizations.
domains led to problems, which effectively set each group apart [17]. The domains promoted a separate identity and prevented a common ‘vision’, which was often seen through each domain engaging in its own direction within the HSO. Indeed, the absence of a ‘shared reality’ or vision contributed to an identify crisis and feelings of isolation as clinical professionals moved from the service domain to the management domain, with their former colleagues viewing them not as service professionals, but as managers.
Locating domain theory within the NHS Domain theory has since been modified in relation to the NHS [20]. The 1983 Griffiths report set up the ‘management’ domain within the NHS from what was essentially an administrative system [21]. From Griffiths, there was now an accepted management role for health professionals within the NHS. Domain theory was thus used to understand the move from the service, now termed ‘professional’ domain, to the new ‘management’ domain [20]. The three domains, political, managerial, and professional, pursued separate agendas which led to a ‘disconnectness’ from each other and promoted separate identities. This subsequently led to suspicions and conflicts between managers and professionals within the NHS. Having established the conceptualization and modification of domain
The professional ‘domain’ When asked whether they regarded themselves as ‘professionals’, all radiographer managers strongly identified with the term, and further questioning revealed that they understood the term ‘professional’. Definitions offered were broadly similar. Common phrases appearing in their definitions included the central issues of holding qualifications in a specific area, reaching a high level of skill, or working within a code of conduct. Radiographer managers also expressed the need for radiographers as clinical professionals to have some control in their roles and a degree of clinical autonomy. Thus in some cases professional autonomy was vitally important: ‘I would have defined it as a group of individuals who are doing a job in which they have [eventually] control over their own actions, they have responsibility for reviewing and they are self regulating in terms of what they do.’
In considering the characteristics which describe a professional, radiographer managers identified strongly with professional duties undertaken by radiographers, and had a strong sense of the values associated with clinical professionals. There was an empathy with the tasks undertaken by radiographers, which manifested itself in a number of ways. This included the views of radiographer managers who felt that it was still important to undertake clinical tasks in order to remain in touch. However, these were in the minority, with most radiographer managers commenting that their tasks were purely managerial and that they did not have sufficient time to devote to carrying out imaging examinations. This caused some of the radiographer managers to have feelings of loss, vulnerability, and uncertainty over their future, particularly those who had moved from the Whitley salary scale to senior manager salary. Despite the fact that only a few radiographer managers practised clinically, the consensus identified the importance for radiographer managers to have an in-depth understanding of the technical side of radiography. As one radiographer manager commented: ‘In terms of where I have wanted to staff my department, run my department and what staff have been allowed and encouraged to do, I have fought I would say harder on the professional issues than I would have done if I hadn’t been a radiographer myself.’
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This was seen to be particularly important in cases of equipment purchase where radiographer managers were able to both inform and influence their business or directorate manager, if not in such a role themselves, to develop a business plan for their directorate. In defining the concept of the profession, radiographer managers associated ‘professionalism’ with being broadly allied to their roots. The primary socialization of such managers was initiated as health care professionals, which then developed into a managerial role.
The management domain When asked whether they identified with the term ‘manager’ the same level of response was evoked, with interviewees not hesitating when replying. Again there was no difference in response between Scottish and English radiographer managers or with length of time in post. When asked follow-up questions for further detail on the radiographer managers understanding of the terms ‘manager’ and ‘management’ most agreed on what the terms meant. In general, it conjured up concepts of controlling and organizing resources. Key problems associated with the ‘administrative’ superintendent radiographer did not surface. Previously such roles, for example in the nursing profession, have been seen to be ‘role-locked’ [22], where such posts tended to be associated only with staff management and clinical roles. However, radiographer managers were also now taking on a new ‘managerial’ agenda associated with strategic as well as operational issues, initially surrounding their own immediate area, but subsequently expanding to the wider hospital environment. One such manager, for example was Deputy Director of services within a large teaching hospital. ‘I consider myself to be someone who looks at the strategic and operational direction of the directorate and then wider trust.’
Other keywords that emerged in the interviews as radiographer managers sought to define the term ‘manager’ included manager as controller, and manager as facilitator. ‘Control—I have hold of the word ‘‘control’’—you are controlling what is happening and you could even say controlling the service, and ensuring that it runs in an organised fashion.’ ‘I think my key role is facilitating, both between the directorate and other directorates, between the various con-
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sultant staff who have been at war for God knows how long, and to try and ensure that the whole system is running as smoothly as it can in order to achieve the overall objectives of the Trust which is to treat people.’
The interviewees thus clearly identified themselves as professionals, whilst being content with the idea of being a manager. A view also confirmed issues associated with clinical and managerial changes, and which extended to emotions associated with the transition between clinical radiographer to manager. These included problems associated with a move into management and the effect on their peer group, readiness for the role and lack of awareness of what the role included. This mirrored findings elsewhere associated with hospital doctors entering management [9]. ‘One part of this thinks we should have this, we should have more money, but the other half of you knows that you can’t. I find that quite difficult to accept, quite frustrating, but you just have to accept that as well.’
Conflict and tensions between the domains Given the ease with which radiographer managers associated with the two domains, which might traditionally be seen to be in conflict, analysis will now explore the relationship between the role of a professional and the role of a manager. Radiographer managers were first asked if they had experienced any conflicts or problems reconciling professional and managerial issues. A number of radiographer managers gave examples of where conflicts had arisen which included the management of limited resources. ‘I feel that a lot of my responsibility now is to try and get [the] message over to the radiographers, and nurses and the people that work below me to try to get them to understand why they can’t have more money for this and why they can’t have more money for that.’
There was a definite tension developing which emphasized the question of role conflict between clinical and managerial roles [23]. For example, from a professional point of view, staffing levels were important, but this had to be mediated with the managerial imperative for resource use. The radiographer managers were health care professionals first and managers second. They all wanted to provide the best care that they could for patients; however, their management roles forced them into making decisions based upon the level
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of resources available. Trying to balance the professional and managerial role resulted in an identifiable tension for which many radiographer managers were not prepared or equipped. However, other radiographer managers felt comfortable in dealing with this dichotomy. The reasons for this were probably related to personality, ability, willingness and confidence for moving out of the radiography ‘comfort zone’ of a narrower clinical focus.
Management development and training What also became apparent during the research was the fact that many of the radiographer managers were not adequately prepared by their employing organizations for the management roles expected of them. Some Trusts provided in-house training, in others it was more patchy. As a result there was no apparent unified body of management knowledge or skills being applied, rather it was a case of ‘learning by doing’. Of the radiographer managers who had undertaken formal academic management training, there appeared to be a better understanding of their roles as managers, particularly in areas outside their own directorates. Highly experienced radiographers, who had much to offer their organizations were, therefore, coming into management without adequate training and development. This is an area of particular importance and concern for the profession and employing organizations. All of the radiographer managers interviewed had indicated that training in certain areas, for example finance, human resource management and the management of change, would have been desirable. If health professionals, including radiographers are to become fully involved in management to any degree, and this is the intention of the Government [15, 16], then minimal standards for management training and development is vital if they are to make an important contribution to their organizations. Recent work by Loan-Clarke [24] has indicated that there are benefits, to both NHS organizations and health professionals, of management development and training. These include improved communications between different work areas, the proper application of organizational policies and procedures, the dissemination of ideas and concepts learned on the course to more junior members of staff, and increased loyalty to the organization. However,
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the most important benefit was seen as a better understanding, of the managerial role in providing clinical services within the context of a much larger organization. The issue of Continuing Professional Development (CPD) has been high on the agenda of many clinical health professionals, including radiographers, in the last 4–5 years. It has also been recognized by many professional bodies as essential to ensure that their membership is up-to-date in relation to professional competence. Many radiographer managers have also endorsed and indeed support the concept of CPD for their own clinical staff. These managers, however, are unlikely to maintain their own clinical CPD because they are not actively involved in radiography to any great extent. CPD is, though, becoming an important area within management [25], and it is in this field where radiographer managers should be supported by their employers because CPD is inextricably linked to management development and training. There has been increasing recognition of the contribution that effective management of human resources can make to improving organizational performance [26–27]. Within this context the contribution of training and development, particularly of the professional development of managers, is also increasingly being recognized [28]. This should be equally important for clinical managers such as radiographers. Trusts have to recognize this and provide clinical managers with the opportunities to improve their management development, which in turn would then allow them to make a significant contribution to the strategic and operational performance of the particular Trust.
The effects of background on the management role It was also important to recognise that although performing a ‘management’ role, radiographer managers could never isolate themselves from their professional roots, which often contributed to the tension between the roles. As one radiographer manager commented, ‘There are a number of issues regarding, say, purely radiographic things, for example, training, the issues of continual professional development and the plans that radiographers ought to be [pursing] combined with financial restrictions from the department. With one hat, as the senior professional of the trust in that role, I will argue
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for more money for the radiographers training, yet with the other hat on, I have to make sure that we run to budget.’
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Moving domains: professional to manager
Indeed this avenue could never be completely closed off from managerial decision making, whereas general managers with no clinical background were perceived as having an easier time. Forbes [14] encountered a situation where the senior managers of one Trust indicated that having a clinical background could in fact be a hindrance to managing a clinical service. This was because of the difficulties of ‘standing back’ and taking an overall strategic or operational view of the service after having spent several years on a much narrower clinical focus. This was not supported by this research, however, as some radiographer managers commented that being both ‘manager’ and ‘professional’ had benefits for staff and the directorate. Having a professional background allowed these radiographer managers to have an ‘edge’ in arguing for clinical issues to be taken forward, and having the knowledge and confidence to support their case. Their clinical background provided an additional insight into both managerial and clinical perspectives. There still therefore appears to be differing views on the appropriateness of health professionals developing management roles in the NHS; however, it is beyond the scope of this paper to discuss this issue further. For one radiographer manager, however, there was no question of the benefits that having a clinical background could bring to managing a hospital service,
Radiographer managers were then asked about a related aspect of this managerial/professional dichotomy, the move from a member of staff with clinical responsibilities to that of manager in overall charge of imaging services. All radiographer managers in the sample were radiographers who had either come into management via the traditional professional route as superintendent radiographer, or through service manager or business/directorate manager posts created when their respective hospitals became a Trust. In general, radiographer managers felt that they had changed, with the emphasis placed on being able to take on board more challenging decisions and of being more aware of issues that had a broader impact outside their clinical directorate. This is of significance as Kouse and Mico [17] argued that each of their ‘domains’ developed mechanisms to legitimate their own ‘patch’, with no or little shared reality or vision. Here was a group of health care professionals moving domains and developing such a vision or shared reality, but using their clinical knowledge to promote their Directorate and form a synergy with the rest of their hospital trust.
‘I think that having a professional basis, being qualified as a radiographer gives me an understanding of what the staff are experiencing. And that this actually enables me to manage the department better than if I was coming in cold with a totally different, say commercial, background— knowledge of the technicalities, pressures from experience, is helpful—that it doesn’t introduce any significant conflict.’
Some managers pointed out that ‘awareness’ had not been easy to develop. This related to the different time frames associated with the managerial role. Time frames associated with clinical issues were often much shorter than the time frames associated with managerial issues. With a clinical role, patients would be referred to the directorate, would have an imaging examination carried out, and would then go home or back to the ward. With a managerial role, decision making and the outcomes of future plans may be some weeks or months ahead. This often led to frustration on the part of some radiographer managers. As one manager commented,
Problems in reconciling the two roles could also emerge in areas such as skill mix and equipment purchase, and again the tensions reappeared between the professional and managerial agendas. ‘There are issues I think around capital replacement of equipment, for instance, where as a professional I would want to decommission very old pieces of kit, because I think the radiation dose is high or the operational issues are slowing us down, and because as a manager I know how capital is allocated in this Trust and also I am responsible for the service that they offer, then I tend to, perhaps, keep kit running longer because I can’t replace it.’
‘Yes. Of course I have [changed]. Everybody changes and learns every day. I am much tougher. And that is because you have to make difficult decisions and if you let them personally affect you all the time, you cannot actually carry through the vision of where you should be going, and where your directorate should be going. So, I am much tougher.’
‘I think I have become more aware, financially and of human resources, and tried to reconcile the two. When you are a radiographer, what you do is very tangible—you are doing this [radiography], that’s the outcome—when you are a manager, not until sometimes quite far down the line,
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do you see the outcome involved from many weeks’ work. And I think that took a wee bit of getting used to. Having come from a results area in a clinical sense to doing this [a management role], you have to have a bit of vision really to say, if I do this [management] and it all ties up, then this should be the outcome of that. I think that took a bit of getting used to, that I couldn’t produce instant results. Instant ideas, yes, but not instant results, and what they want in the NHS is results.’
A managerial outcome therefore could sometimes take longer to achieve as other factors such as staffing, contracting, and interacting with other directorates would complicate the process. The transition from clinical radiographer to clinical manager as such involved developing a much wider understanding and acceptance of the hospital as a complete organization, and the imaging directorate as a small part of that organization. ‘I think, it is part of a more wider picture than you are solely involved in being a health care professional and doing that job for which you trained. You are very much more concerned with your patients and the immediate problems surrounding them. At this level [directorate manager] you are much more aware of how you interact with the rest of the hospital and therefore there are issues of funding, contracting [and] quality of which you are not so aware, so in a sense it becomes more complicated, it has blurred the professional edges.’
Management style and changing relationships Further questioning explored the management style adopted and the changes in relationships, which were allied to the personal changes experienced by radiographer managers. The aim here was to make explicit both a changing management style and the change in domain from ‘professional’ to ‘manager’. The management style of previous incumbents could also have an effect on ‘new’ radiographer managers who wanted to have a more ‘open’ management style than the previous manager. There was the recognition that radiographer managers could no longer rely on their use of position in the hierarchical structure as a means of exercising their management role. In order to get the best results from imaging directorate staff, radiographer managers had to have a high regard for the need to encourage morale, engender team building and co-operation and a willingness to work in an increasingly demanding environment. This was demonstrated in the style of management observed and
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the degree of influence exercised by the radiographer managers in their management roles. Tannenbaum and Schmidt’s [18] work offers some help in the analysis of the management style of the radiographer managers. Tannenbaum and Schmidt identified a continuum of management behaviour, ranging from autocratic to democratic, along which particular management styles may be placed. To summarize their work, there are four styles of management which are influenced by three forces. These styles were: Telling—the manager identified a problem, chooses a decision and announces this to staff expecting them to implement it without the opportunity for participation Selling—the manager still chooses a decision but recognises the possibility of some resistance from staff faced with the decision and attempts to persuade them to accept it Consulting—the manager identifies the problem but does not choose a decision until the problem is presented to staff, and the manager has listened to the advice and solutions suggested by staff Joining—the manager defines the problem and the limits within which the decision must be chosen and then passes to the group, with the manager as a member, the right to make the decision The forces which influenced management style were: Forces within the organization—influenced by staff expectations and their relationship with the existing and previous managers Forces within the manager—influenced by personality, background, knowledge, training and experience Forces in the situation—influenced by the context and environmental pressure the manager was operated within. By using Tannenbaum and Schmidt’s continuum, it was possible to observe that almost all of the radiographer managers had begun their management roles using an autocratic or ‘telling’ style of management. As one manager indicated, ‘I think I was a bit dominant and very autocratic. I have learned to communicate more effectively. I strongly believe in communication in meetings, though I know a lot of people don’t agree with that, and I think it has improved the department immensely.’
Over time the radiographer managers moved through the continuum to either a ‘consulting’ or
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‘joining’ style of management. There were, however, constraints in adopting these management styles, as both time and staff perceptions could prevent a more open management style from being adopted. Two quotes from radiographer managers illustrate these constraints. ‘The word I would use would be democratic. I have always, certainly with the staff that I work with had a democratic style. I like to consult people and make sure that they are aware of changes and I take on board things that they say rather than telling them what to do. Unfortunately, particularly with some of the issues that we are facing at the moment, there is not the time to do that.’ ‘I like to think that any decisions that we take as a department have had input from the staff groups involved. The staff are not taking to it very well, in that it has never been the practice of the department to go to the staff and say, we might do this, how do you feel about it?, and they [other radiographers] just look at me.’
These areas were undoubtedly influenced by one or more of Tannenbaum and Schmidt’s three forces. In the examples above, forces in the situation the radiographer manager found himself in, especially environmental pressure, reduced the amount of time available for staff to debate the issue. Forces within the organization, in this case the relationship between the previous radiographer manager and the radiographers in the directorate, led to the radiographers’ unwillingness to get involved in decision making within the directorate because they had not been consulted in the past. In general though, the management style of the radiographer managers had changed primarily because they were becoming more comfortable with their new roles, the wider remit that they now had, and of course the new relationships they had formed outside their previous clinical focus. What was also apparent was the emergence of a new paradigm with the radiographer managers acting as a ‘coach’ providing a degree of leadership and inspiration to their staff and developing influencing skills to effect management decisions, rather than using an authoritarian management style to get things done. As a group, they had learned to delegate, trust subordinates, and indeed reflect upon their own experiences as radiographers. The radiographer managers also found that the degree of influence that they had in managing their service was dependent on the management style adopted. By involving staff in the decision making process (using a consulting or joining management style)
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an appropriate management decision would be arrived at for the directorate which would then be owned by staff. As one radiographer manager stated, ‘On the whole I think that they [the radiographers] understand when they ask for things, or for example, we’ve got an evening helper and when [she goes on holiday] nobody else would cover for her. When I said to them, ‘OK when she goes on holiday, you can have cover for her, but just remember that it is a financial priority, and if that is where we use the money, then there will be other areas that we can’t spend money on’. They understand that, they know at the end of the day it’s a pot of money and sometimes, even when they ask for an extra person on a public holiday, I say ‘you know it will cost £100, or whatever, is that how you want the money to be spent?’
Changing relationships The radiographer managers had faced a transitional period moving from a clinical professional to clinical manager. We have seen that over time they had become more comfortable with their new roles. This change was not without cost, sometimes personal cost. Radiographers in the directorates could have an effect on the professional and personal experiences of the radiographer managers as they moved into their new roles from the professional to the management domain. Two such managers offered different views and illustrate this role change, which for one of them was quite profound. ‘There are a lot of people who have never seen me be a radiographer and I think that is slightly sad because I was actually quite a good radiographer. And it comes across in the fact that they [inexperienced radiographers] can have a film in their hand, looking around for a superintendent to look at it, and I can be standing there, and they won’t ask me my opinion as to either whether it was ok, or how they should correct it if it wasn’t ok.’ ‘I think the biggest shock that I had when I came here was that the staff regarded me as not a radiographer. In [my] last two posts I was a working radiographer and a manager. There is quite a lot of hostility towards my [current] post and I would hate to think that it is towards me, although sometimes my paranoia is such that it feels as though it is towards me. They [the radiographers] feel that because I don’t actually go out and work [as a radiographer], I can’t understand and appreciate the problems they are having. I find that very hard to reconcile because I have been a radiographer for a long time and I don’t think that my skills are diminished by the fact that my role is different.’
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Staff therefore contributed to the manager’s transition from a clinical to a managerial function by unconsciously viewing the ‘radiographer manager’, even as a health professional, as having a different role. They could in some instances be seen as a manager, rather than as a radiographer. This led many radiographer managers to feel isolated and in some instances to have a crisis of identity in much the same way as described by Kouse and Mico [17]. This new role was almost seen as de-skilling by radiographers who were pursuing a professional agenda, and whose ‘vision’ was different to that of the ‘manager’.
Conclusion Griffiths [1] introduced a management culture into the NHS, and a number of clinical professionals have moved from a purely clinical role to a more distinctive management role. This research maps out the experiences and opinions of a group of radiographers as they took on new management roles against the backdrop of a changing NHS. No substantial differences were noted between Scottish and English radiographer managers. Both groups clearly had their roots in clinical radiography and viewed this as important for radiographer ‘managers. Domain theory has been used to inform these role changes. Although it would appear that there was a domain ‘shift’, the radiographers did not see themselves as managers, nor did they associate solely with managers. Their clinical background was reinforced again and again, they were clinicians first and managers second. Indeed many of them suggested that their clinical background made them ‘better’ managers, than if they had no clinical experience. Although there may have been a domain shift, it certainly was not completely into the ‘management’ domain, nor did they remain fully within the ‘professional domain’. Radiographer managers were undertaking management duties, but they were clinical managers rather than general managers. The domains themselves could therefore be becoming blurred, particularly between the management and professional domains. A new ‘hybrid’ manager could therefore be seen developing within the NHS, emerging due to the dynamic created firstly by Griffiths [1], and accelerated by the 1990 NHS reforms. This would imply a new domain, the ‘clinical manager’. This new domain straddles the two worlds of the
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professional or service domain and the managerial domain and indeed complements both in the rapid and changing environment of the NHS. Radiographer managers have much to offer the NHS; however, better management development and training, particularly related to their continued professional development as managers, has to be addressed by employing organizations. Radiographer managers also highlighted a range of views on management style, whilst also describing the emotions associated with the change in their role. Their management style was seen to evolve and Tannenbaum and Schmidt’s [18] management style continuum has informed the analysis of management style. Clearly radiographer managers expressed a need for consensus in decision making while indicating a change in some situations towards toughness and autocracy. However, radiographer managers equally expressed a change towards a ‘softer’ approach, which came through their increasing confidence in the position of manager. This change in management style resulted in improved staff motivation, commitment and outcomes, which undoubtedly benefited the clinical services being delivered. The research also highlights key questions surrounding what the radiography profession and the NHS can do to assist the development of radiographer managers. Not all radiographers undertaking management roles are suited to such an environment and acknowledgement has to be made of this fact. These radiographers may be better placed to use their substantial clinical and organizational skills in clinical settings, so better selection criteria may have to be developed based on the complexities of the management task in hand. Promotion has often been based on excellence in clinical and organizational abilities and can be seen as a reward for such endeavours if not the only way for a radiographer to develop his or her career. This has to be recognized both by the profession and the employing organizations—the NHS, with suitable reward strategies being put in place to encourage retention in key clinical posts, whilst allowing those radiographers with the ability and receptivity for management to flourish. Radiography as a profession has a history of being proactive in developing administrative and quasi-managerial skills via the Management Diploma of the College of Radiographers (MDCR). Given that all postgraduate education is now provided by both further and higher education institutions, the College of Radiographers could work with these
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institutions to develop management development programmes which are tailored to suit the needs of radiographer managers and the organizations in which they work. The emphasis should be on management skills per se, and not simply the collection of academic qualifications, which although not alluded to in this paper, many of the radiographer managers already possessed. Many management qualifications are generic in nature, rather than context specific and do not emphasize skills and personal development at an individual or group level. The NHS itself could also do more to support radiographers and other clinical professions entering the management arena. The Management Executive of both Scotland and England do indeed provide such support, but it is not as comprehensive as, for example, the Civil Service. Issues such as peer support, succession planning and CPD are vital areas that the NHS has to date not embraced, whilst many other organizations such as Scottish Life for example, have had such programmes for several years. Human resource management issues should be vitally important to any organization, and the NHS now has the opportunity to develop this through its Human Resources Strategy. The authors hope that the development of radiographer managers continues, but that they are given the support and encouragement that their unique place within the professions allied to medicine and wider NHS merits. Acknowledgements The authors gratefully acknowledge the financial support of the Internal Research Fund of the Faculty of Management at the University of Stirling. Thanks are also due to the many Scottish and English radiographer managers who contributed to the project.
References 1. Griffiths R. The NHS Management Enquiry. London: HMSO, 1983. 2. Packwood T, Keen J, Buxton M. Process and structure: resource management and the development of sub-unit organisational structure. Health Services Man Res 1991; 5: 66–76. 3. Thomas K. Radiographers as managers 1—how the Bristol course helped my management skills. Radiography 1993; 49: 248–50. 4. Rousell J. Planning for Change in a Department of Radiodiagnosis. Radiography 1986; 52: 47–51. 5. Yule A. Problems Facing the Profession as Result of ‘Griffiths’. Radiography 1986; 52: 139–42. 6. Gray I. Management Budgeting for Radiographers. Radiography 1986; 52: 295–98.
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7. Disken S, Dixon M, Halpern S, Shocket G. Models of Clinical Management. London: Institute of Health Service Management, 1990. 8. Fitzgerald L, Sturt J. Clinicians into management: on the change agenda or not? Health Services Man Res 1992; 5: 137–46. 9. Dopson S. Doctors in management: a challenge to established debates. In: Beyond Reason?: The National Health Service and the Limits of Management. London: Avebury, 1996: 173–87. 10. Bruce A, Hill S. Relationships between doctors and managers: the Scottish experience. J Man Med 1994; 8: 49–57. 11. Ferlie E, Pettigrew A, Asburner L, Fitzgerald L. The New Public Management in Action. Oxford: Oxford University Press, 1996. 12. Fitzgerald L. Clinical management as boundary management: a comparative analysis of Canadian and UK healthcare institutions. Int J Pub Sector Man 1997; 10: 5–20. 13. Ong B. Evolving perceptions of clinical management in acute hospitals in England. Br J Man 1998; 9: 199–210. 14. Forbes T. Strategic Management and NHS Hospital Trusts: The West of Scotland Experience 1999. Unpublished Ph.D. Thesis, University of Glasgow. 15. Department of Health. The New NHS Modern Dependable. London: HMSO, 1997. 16. Scottish Office Department of Health. Designed to Care. 1997. Edinburgh, HMSO, 1997. 17. Kouse J, Mico P. Domain Theory: An introduction to organisational behaviour in human service organisations. J Appl Behav Sci 1979; 15: 449–69. 18. Tannenbaum R, Schmidt W. How to Choose a Leadership Pattern. Harvard Business Review 1973. May/June: 162–80. 19. Hasenfield Y, English R. Human service organisations: a conceptual overview. In: Human Service Organisations Ann Arbor: University of Michigan Press, 1976. 20. Edmonstone J. If you’re not the woodcutter, what are you doing with the axe? Health Services Manpower Review 1986; 12: 8–12. 21. Harrison S. Managing the NHS: Shifting the Frontier. London, Chapman and Hall, 1988. 22. Edmonstone J, Chisnell C. Roles and Competencies of Clinical Nurse Managers and Business Managers. Wirrel: Wirrel Hospital, 1991. 23. Willcocks S. The Clinical Director in the NHS: Utilising a Role-theory Perspective. J Man Med 1994; 8: 68–76. 24. Loan-Clarke J. Health-care professionals and management development. J Man Med 1996; 10: 24–35. 25. The IPD Policy on Continuing Professional Development. London: The Institute of Personnel and Development, 1993. 26. Tyson S. Human Resource Strategy. London: Pitman, 1995. 27. Legge K. Human Resource Management: Rhetoric and Realities. Basingstoke: MacMillan Business. 28. Jones N, Robinson G. Do organisations manage continuing professional development? J Man Devl 1997; 16: 197–207.
Moving domains: radiographers as managers in NHS Tom Forbes BA (Hons), PhD, DCR, Lecturer* and Neil James Prime, MA, MPhil, DCR Principal Lecturer† *Department of Management and Organization, University of Stirling, Stirling FK9 4LA, Scotland, U.K.; †Department of Radiography, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, U.K. (Received 16 January 1999; revised 27 July 1999; second revision 27 January 2000 and accepted 3 March 2000)
Key words: radiographers; management; professionals; change; domains.
Purpose: The 1990 NHS reforms have led to a number of clinical professionals moving into management roles. This paper examines a group of radiographers who have developed management roles within the backdrop of a changing NHS. Methods: A comparative study of 25 Scottish and English radiographer managers from different NHS organizations were interviewed using semi-structured interviews. The interviews formed a number of emerging themes, which were analysed using domain theory. These themes included management, professionalism, management style, conflicts between the role of both manager and professional, and role change. Results: Radiographer managers are forming new ‘hybrid’ manager roles, which have been developing within a changing NHS. A definite tension was demonstrated in this role change. The transition from professional to manager was not easy for this group of radiographer managers. Key issues surrounded this transition which included role conflict, an emergent management style, and a lack of management development and training. Conclusion: Radiographers have shown resilience in undertaking both operational and strategic management decisions, while using their clinical background to inform their decision making. There was no difference observable between Scottish and English radiographer managers in this change process. Appropriate management training and development must be provided if radiographer managers are to contribute to the performance of their NHS organizations. © 2000 The College of Radiographers
Introduction The development of managers and management in the NHS was formally introduced by the 1983 Griffiths Report [1]. Management was introduced to all levels within the NHS with clinical professionals beginning to take on more substantial managerial roles. Research by Packwood et al. [2] indicates that acute sector hospitals began to reconfigure their internal organization with clinical directorates appearing in the late 1980s and early 1990s. The NHS and Community Care Act of 1990 set up the purchaser–provider split, established National Health Service Trusts and introduced a quasimarket into the NHS. The management freedoms of NHS Hospital Trust managers were more significant than previous hospital managers were allowed. In particular, they would have greater 1078–8174/00/020101+10 $35.00/0
responsibility in managing their own affairs without having to report to Health Authorities. This had had the effect of liberating hospital managers, both non-clinical and clinical, to make service improvements. This paper will examine the changing roles and responsibilities of a group of radiographers who have moved into management areas within their Trusts. Radiographers also have a history of developing management skills [3–6] and the College of Radiographers also offered a management diploma up until 1992. This indicates that radiographers were not only becoming involved in management, but were also studying it as a discipline. Radiographers are in a unique position in relation to other Professions Allied to Medicine (PAMs). The majority of PAMs are located within large medical or support services clinical © 2000 The College of Radiographers
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directorates, where they are managed collectively by a manager who may not be in a PAM. Radiographers are, however, incorporated into free-standing imaging or radiology clinical directorates, which are managed by radiographer managers. In many cases radiographers have also taken on the role of the directorate or business manager, although it is more common to find radiographers as radiology, radiography, or imaging service managers. These arrangements differentiate radiographers from other PAM groups and provide an opportunity for examining their personal development, as they move from a clinical to a managerial role. The development of health professionals as managers has been a major theme of the literature for several years now [7–13]. However, these studies have tended to concentrate on hospital doctors undertaking a part-time managerial role as a clinical director [14]. While still maintaining a substantial clinical role, these part-time managers often move from the managerial domain to the clinical domain after a period of time as a clinical director. While this is the case for hospital doctors, other health professionals such as radiographers have moved into full-time management and left their clinical role behind, no longer practising clinical radiography.
Methodology The NHS in Scotland (NHSiS) is structured and organized differently from the NHS in England. Scotland, at the time of the research, had 47 Trusts and 15 Health Authorities known as Area Health Boards. A comparative study was undertaken of a group of radiographer managers in the West of Scotland and North Thames/London between late spring and the summer of 1998 to ascertain if these structural and organizational differences had an effect on the developing managerial role of radiographers. A total of 25 semi-structured interviews were carried out within the two geographical areas. The sample size was relatively small to reflect the preliminary nature of the research, which if successful would lead to an application for funding to expand the study to include, as far as possible, all PAMs groups involved in management within the NHS. Radiographer managers were chosen from a variety of settings and included acute city nonteaching hospitals, acute city teaching hospitals, district general hospitals, and a breast screening
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centre. Although mainly involving radiographer managers from the diagnostic branch of the profession, two therapy managers were also interviewed. This research comes at a timely period in the development of the NHS in England and Scotland. The 1997 White Papers [15, 16] will provide the new framework for the NHS for the years ahead, including a reduction in the number of Trusts. In Scotland, this has led to a reduction in the number of Trusts from 47 to 28, and the creation of new Primary Care Trusts. The further development of community based services and Primary Care Groups in England may potentially lead to an increase in the number of radiography managers, but as yet this is unclear. These changes will provide a new challenge for existing and future radiography managers. To aid the understanding of the transition from a clinical to a management role, use will be made of Kouse and Mico’s domain theory [17] and Tannenbaum and Schmidt’s leadership style theory [18]. Kouse and Mico [17] examined service integration in what they referred to as human service organization (HSOs). HSOs have been defined as ‘the set of organizations whose primary function is to define or alter a person’s behaviour, attributes or social status in order to maintain or enhance his well being’ [19, p.1]. HSOs can be found in many areas, but have been particularly associated with the health care sector. Kouse and Mico [17] concluded from their research that there were three separate areas or spheres of influence operating within health care organizations. These spheres were subsequently adapted into three domains of policy, management and service, as each domain approached the issue of service integration differently. The domains, are illustrated in Fig. 1. Kouse and Mico [17] argued that each of the three domains saw themselves as having a legitimate role to play within their HSOs. Those in the policy domain developed policies in response to the electorate. Those in the management domain developed ways of meeting organizational goals through the effective use of scarce resources. Those in the service domain developed their practice to provide the best services they could to clients within the confines of selfautonomy and regulation based upon a set of occupational standards and ‘expert knowledge’. The service domain also affiliated to a professional culture, rather than to any specific organization. The fact that these three groups developed mechanisms to legitimize and serve their individual
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theory to the NHS, attention now turns to the radiographer manager. Managerial Domain
Political Domain
Service Domain
Figure 1. The three domains within human service organizations.
domains led to problems, which effectively set each group apart [17]. The domains promoted a separate identity and prevented a common ‘vision’, which was often seen through each domain engaging in its own direction within the HSO. Indeed, the absence of a ‘shared reality’ or vision contributed to an identify crisis and feelings of isolation as clinical professionals moved from the service domain to the management domain, with their former colleagues viewing them not as service professionals, but as managers.
Locating domain theory within the NHS Domain theory has since been modified in relation to the NHS [20]. The 1983 Griffiths report set up the ‘management’ domain within the NHS from what was essentially an administrative system [21]. From Griffiths, there was now an accepted management role for health professionals within the NHS. Domain theory was thus used to understand the move from the service, now termed ‘professional’ domain, to the new ‘management’ domain [20]. The three domains, political, managerial, and professional, pursued separate agendas which led to a ‘disconnectness’ from each other and promoted separate identities. This subsequently led to suspicions and conflicts between managers and professionals within the NHS. Having established the conceptualization and modification of domain
The professional ‘domain’ When asked whether they regarded themselves as ‘professionals’, all radiographer managers strongly identified with the term, and further questioning revealed that they understood the term ‘professional’. Definitions offered were broadly similar. Common phrases appearing in their definitions included the central issues of holding qualifications in a specific area, reaching a high level of skill, or working within a code of conduct. Radiographer managers also expressed the need for radiographers as clinical professionals to have some control in their roles and a degree of clinical autonomy. Thus in some cases professional autonomy was vitally important: ‘I would have defined it as a group of individuals who are doing a job in which they have [eventually] control over their own actions, they have responsibility for reviewing and they are self regulating in terms of what they do.’
In considering the characteristics which describe a professional, radiographer managers identified strongly with professional duties undertaken by radiographers, and had a strong sense of the values associated with clinical professionals. There was an empathy with the tasks undertaken by radiographers, which manifested itself in a number of ways. This included the views of radiographer managers who felt that it was still important to undertake clinical tasks in order to remain in touch. However, these were in the minority, with most radiographer managers commenting that their tasks were purely managerial and that they did not have sufficient time to devote to carrying out imaging examinations. This caused some of the radiographer managers to have feelings of loss, vulnerability, and uncertainty over their future, particularly those who had moved from the Whitley salary scale to senior manager salary. Despite the fact that only a few radiographer managers practised clinically, the consensus identified the importance for radiographer managers to have an in-depth understanding of the technical side of radiography. As one radiographer manager commented: ‘In terms of where I have wanted to staff my department, run my department and what staff have been allowed and encouraged to do, I have fought I would say harder on the professional issues than I would have done if I hadn’t been a radiographer myself.’
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This was seen to be particularly important in cases of equipment purchase where radiographer managers were able to both inform and influence their business or directorate manager, if not in such a role themselves, to develop a business plan for their directorate. In defining the concept of the profession, radiographer managers associated ‘professionalism’ with being broadly allied to their roots. The primary socialization of such managers was initiated as health care professionals, which then developed into a managerial role.
The management domain When asked whether they identified with the term ‘manager’ the same level of response was evoked, with interviewees not hesitating when replying. Again there was no difference in response between Scottish and English radiographer managers or with length of time in post. When asked follow-up questions for further detail on the radiographer managers understanding of the terms ‘manager’ and ‘management’ most agreed on what the terms meant. In general, it conjured up concepts of controlling and organizing resources. Key problems associated with the ‘administrative’ superintendent radiographer did not surface. Previously such roles, for example in the nursing profession, have been seen to be ‘role-locked’ [22], where such posts tended to be associated only with staff management and clinical roles. However, radiographer managers were also now taking on a new ‘managerial’ agenda associated with strategic as well as operational issues, initially surrounding their own immediate area, but subsequently expanding to the wider hospital environment. One such manager, for example was Deputy Director of services within a large teaching hospital. ‘I consider myself to be someone who looks at the strategic and operational direction of the directorate and then wider trust.’
Other keywords that emerged in the interviews as radiographer managers sought to define the term ‘manager’ included manager as controller, and manager as facilitator. ‘Control—I have hold of the word ‘‘control’’—you are controlling what is happening and you could even say controlling the service, and ensuring that it runs in an organised fashion.’ ‘I think my key role is facilitating, both between the directorate and other directorates, between the various con-
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sultant staff who have been at war for God knows how long, and to try and ensure that the whole system is running as smoothly as it can in order to achieve the overall objectives of the Trust which is to treat people.’
The interviewees thus clearly identified themselves as professionals, whilst being content with the idea of being a manager. A view also confirmed issues associated with clinical and managerial changes, and which extended to emotions associated with the transition between clinical radiographer to manager. These included problems associated with a move into management and the effect on their peer group, readiness for the role and lack of awareness of what the role included. This mirrored findings elsewhere associated with hospital doctors entering management [9]. ‘One part of this thinks we should have this, we should have more money, but the other half of you knows that you can’t. I find that quite difficult to accept, quite frustrating, but you just have to accept that as well.’
Conflict and tensions between the domains Given the ease with which radiographer managers associated with the two domains, which might traditionally be seen to be in conflict, analysis will now explore the relationship between the role of a professional and the role of a manager. Radiographer managers were first asked if they had experienced any conflicts or problems reconciling professional and managerial issues. A number of radiographer managers gave examples of where conflicts had arisen which included the management of limited resources. ‘I feel that a lot of my responsibility now is to try and get [the] message over to the radiographers, and nurses and the people that work below me to try to get them to understand why they can’t have more money for this and why they can’t have more money for that.’
There was a definite tension developing which emphasized the question of role conflict between clinical and managerial roles [23]. For example, from a professional point of view, staffing levels were important, but this had to be mediated with the managerial imperative for resource use. The radiographer managers were health care professionals first and managers second. They all wanted to provide the best care that they could for patients; however, their management roles forced them into making decisions based upon the level
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of resources available. Trying to balance the professional and managerial role resulted in an identifiable tension for which many radiographer managers were not prepared or equipped. However, other radiographer managers felt comfortable in dealing with this dichotomy. The reasons for this were probably related to personality, ability, willingness and confidence for moving out of the radiography ‘comfort zone’ of a narrower clinical focus.
Management development and training What also became apparent during the research was the fact that many of the radiographer managers were not adequately prepared by their employing organizations for the management roles expected of them. Some Trusts provided in-house training, in others it was more patchy. As a result there was no apparent unified body of management knowledge or skills being applied, rather it was a case of ‘learning by doing’. Of the radiographer managers who had undertaken formal academic management training, there appeared to be a better understanding of their roles as managers, particularly in areas outside their own directorates. Highly experienced radiographers, who had much to offer their organizations were, therefore, coming into management without adequate training and development. This is an area of particular importance and concern for the profession and employing organizations. All of the radiographer managers interviewed had indicated that training in certain areas, for example finance, human resource management and the management of change, would have been desirable. If health professionals, including radiographers are to become fully involved in management to any degree, and this is the intention of the Government [15, 16], then minimal standards for management training and development is vital if they are to make an important contribution to their organizations. Recent work by Loan-Clarke [24] has indicated that there are benefits, to both NHS organizations and health professionals, of management development and training. These include improved communications between different work areas, the proper application of organizational policies and procedures, the dissemination of ideas and concepts learned on the course to more junior members of staff, and increased loyalty to the organization. However,
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the most important benefit was seen as a better understanding, of the managerial role in providing clinical services within the context of a much larger organization. The issue of Continuing Professional Development (CPD) has been high on the agenda of many clinical health professionals, including radiographers, in the last 4–5 years. It has also been recognized by many professional bodies as essential to ensure that their membership is up-to-date in relation to professional competence. Many radiographer managers have also endorsed and indeed support the concept of CPD for their own clinical staff. These managers, however, are unlikely to maintain their own clinical CPD because they are not actively involved in radiography to any great extent. CPD is, though, becoming an important area within management [25], and it is in this field where radiographer managers should be supported by their employers because CPD is inextricably linked to management development and training. There has been increasing recognition of the contribution that effective management of human resources can make to improving organizational performance [26–27]. Within this context the contribution of training and development, particularly of the professional development of managers, is also increasingly being recognized [28]. This should be equally important for clinical managers such as radiographers. Trusts have to recognize this and provide clinical managers with the opportunities to improve their management development, which in turn would then allow them to make a significant contribution to the strategic and operational performance of the particular Trust.
The effects of background on the management role It was also important to recognise that although performing a ‘management’ role, radiographer managers could never isolate themselves from their professional roots, which often contributed to the tension between the roles. As one radiographer manager commented, ‘There are a number of issues regarding, say, purely radiographic things, for example, training, the issues of continual professional development and the plans that radiographers ought to be [pursing] combined with financial restrictions from the department. With one hat, as the senior professional of the trust in that role, I will argue
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for more money for the radiographers training, yet with the other hat on, I have to make sure that we run to budget.’
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Indeed this avenue could never be completely closed off from managerial decision making, whereas general managers with no clinical background were perceived as having an easier time. Forbes [14] encountered a situation where the senior managers of one Trust indicated that having a clinical background could in fact be a hindrance to managing a clinical service. This was because of the difficulties of ‘standing back’ and taking an overall strategic or operational view of the service after having spent several years on a much narrower clinical focus. This was not supported by this research, however, as some radiographer managers commented that being both ‘manager’ and ‘professional’ had benefits for staff and the directorate. Having a professional background allowed these radiographer managers to have an ‘edge’ in arguing for clinical issues to be taken forward, and having the knowledge and confidence to support their case. Their clinical background provided an additional insight into both managerial and clinical perspectives. There still therefore appears to be differing views on the appropriateness of health professionals developing management roles in the NHS; however, it is beyond the scope of this paper to discuss this issue further. For one radiographer manager, however, there was no question of the benefits that having a clinical background could bring to managing a hospital service,
Radiographer managers were then asked about a related aspect of this managerial/professional dichotomy, the move from a member of staff with clinical responsibilities to that of manager in overall charge of imaging services. All radiographer managers in the sample were radiographers who had either come into management via the traditional professional route as superintendent radiographer, or through service manager or business/directorate manager posts created when their respective hospitals became a Trust. In general, radiographer managers felt that they had changed, with the emphasis placed on being able to take on board more challenging decisions and of being more aware of issues that had a broader impact outside their clinical directorate. This is of significance as Kouse and Mico [17] argued that each of their ‘domains’ developed mechanisms to legitimate their own ‘patch’, with no or little shared reality or vision. Here was a group of health care professionals moving domains and developing such a vision or shared reality, but using their clinical knowledge to promote their Directorate and form a synergy with the rest of their hospital trust.
‘I think that having a professional basis, being qualified as a radiographer gives me an understanding of what the staff are experiencing. And that this actually enables me to manage the department better than if I was coming in cold with a totally different, say commercial, background— knowledge of the technicalities, pressures from experience, is helpful—that it doesn’t introduce any significant conflict.’
Some managers pointed out that ‘awareness’ had not been easy to develop. This related to the different time frames associated with the managerial role. Time frames associated with clinical issues were often much shorter than the time frames associated with managerial issues. With a clinical role, patients would be referred to the directorate, would have an imaging examination carried out, and would then go home or back to the ward. With a managerial role, decision making and the outcomes of future plans may be some weeks or months ahead. This often led to frustration on the part of some radiographer managers. As one manager commented,
Problems in reconciling the two roles could also emerge in areas such as skill mix and equipment purchase, and again the tensions reappeared between the professional and managerial agendas. ‘There are issues I think around capital replacement of equipment, for instance, where as a professional I would want to decommission very old pieces of kit, because I think the radiation dose is high or the operational issues are slowing us down, and because as a manager I know how capital is allocated in this Trust and also I am responsible for the service that they offer, then I tend to, perhaps, keep kit running longer because I can’t replace it.’
‘Yes. Of course I have [changed]. Everybody changes and learns every day. I am much tougher. And that is because you have to make difficult decisions and if you let them personally affect you all the time, you cannot actually carry through the vision of where you should be going, and where your directorate should be going. So, I am much tougher.’
‘I think I have become more aware, financially and of human resources, and tried to reconcile the two. When you are a radiographer, what you do is very tangible—you are doing this [radiography], that’s the outcome—when you are a manager, not until sometimes quite far down the line,
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do you see the outcome involved from many weeks’ work. And I think that took a wee bit of getting used to. Having come from a results area in a clinical sense to doing this [a management role], you have to have a bit of vision really to say, if I do this [management] and it all ties up, then this should be the outcome of that. I think that took a bit of getting used to, that I couldn’t produce instant results. Instant ideas, yes, but not instant results, and what they want in the NHS is results.’
A managerial outcome therefore could sometimes take longer to achieve as other factors such as staffing, contracting, and interacting with other directorates would complicate the process. The transition from clinical radiographer to clinical manager as such involved developing a much wider understanding and acceptance of the hospital as a complete organization, and the imaging directorate as a small part of that organization. ‘I think, it is part of a more wider picture than you are solely involved in being a health care professional and doing that job for which you trained. You are very much more concerned with your patients and the immediate problems surrounding them. At this level [directorate manager] you are much more aware of how you interact with the rest of the hospital and therefore there are issues of funding, contracting [and] quality of which you are not so aware, so in a sense it becomes more complicated, it has blurred the professional edges.’
Management style and changing relationships Further questioning explored the management style adopted and the changes in relationships, which were allied to the personal changes experienced by radiographer managers. The aim here was to make explicit both a changing management style and the change in domain from ‘professional’ to ‘manager’. The management style of previous incumbents could also have an effect on ‘new’ radiographer managers who wanted to have a more ‘open’ management style than the previous manager. There was the recognition that radiographer managers could no longer rely on their use of position in the hierarchical structure as a means of exercising their management role. In order to get the best results from imaging directorate staff, radiographer managers had to have a high regard for the need to encourage morale, engender team building and co-operation and a willingness to work in an increasingly demanding environment. This was demonstrated in the style of management observed and
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the degree of influence exercised by the radiographer managers in their management roles. Tannenbaum and Schmidt’s [18] work offers some help in the analysis of the management style of the radiographer managers. Tannenbaum and Schmidt identified a continuum of management behaviour, ranging from autocratic to democratic, along which particular management styles may be placed. To summarize their work, there are four styles of management which are influenced by three forces. These styles were: Telling—the manager identified a problem, chooses a decision and announces this to staff expecting them to implement it without the opportunity for participation Selling—the manager still chooses a decision but recognises the possibility of some resistance from staff faced with the decision and attempts to persuade them to accept it Consulting—the manager identifies the problem but does not choose a decision until the problem is presented to staff, and the manager has listened to the advice and solutions suggested by staff Joining—the manager defines the problem and the limits within which the decision must be chosen and then passes to the group, with the manager as a member, the right to make the decision The forces which influenced management style were: Forces within the organization—influenced by staff expectations and their relationship with the existing and previous managers Forces within the manager—influenced by personality, background, knowledge, training and experience Forces in the situation—influenced by the context and environmental pressure the manager was operated within. By using Tannenbaum and Schmidt’s continuum, it was possible to observe that almost all of the radiographer managers had begun their management roles using an autocratic or ‘telling’ style of management. As one manager indicated, ‘I think I was a bit dominant and very autocratic. I have learned to communicate more effectively. I strongly believe in communication in meetings, though I know a lot of people don’t agree with that, and I think it has improved the department immensely.’
Over time the radiographer managers moved through the continuum to either a ‘consulting’ or
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‘joining’ style of management. There were, however, constraints in adopting these management styles, as both time and staff perceptions could prevent a more open management style from being adopted. Two quotes from radiographer managers illustrate these constraints. ‘The word I would use would be democratic. I have always, certainly with the staff that I work with had a democratic style. I like to consult people and make sure that they are aware of changes and I take on board things that they say rather than telling them what to do. Unfortunately, particularly with some of the issues that we are facing at the moment, there is not the time to do that.’ ‘I like to think that any decisions that we take as a department have had input from the staff groups involved. The staff are not taking to it very well, in that it has never been the practice of the department to go to the staff and say, we might do this, how do you feel about it?, and they [other radiographers] just look at me.’
These areas were undoubtedly influenced by one or more of Tannenbaum and Schmidt’s three forces. In the examples above, forces in the situation the radiographer manager found himself in, especially environmental pressure, reduced the amount of time available for staff to debate the issue. Forces within the organization, in this case the relationship between the previous radiographer manager and the radiographers in the directorate, led to the radiographers’ unwillingness to get involved in decision making within the directorate because they had not been consulted in the past. In general though, the management style of the radiographer managers had changed primarily because they were becoming more comfortable with their new roles, the wider remit that they now had, and of course the new relationships they had formed outside their previous clinical focus. What was also apparent was the emergence of a new paradigm with the radiographer managers acting as a ‘coach’ providing a degree of leadership and inspiration to their staff and developing influencing skills to effect management decisions, rather than using an authoritarian management style to get things done. As a group, they had learned to delegate, trust subordinates, and indeed reflect upon their own experiences as radiographers. The radiographer managers also found that the degree of influence that they had in managing their service was dependent on the management style adopted. By involving staff in the decision making process (using a consulting or joining management style)
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an appropriate management decision would be arrived at for the directorate which would then be owned by staff. As one radiographer manager stated, ‘On the whole I think that they [the radiographers] understand when they ask for things, or for example, we’ve got an evening helper and when [she goes on holiday] nobody else would cover for her. When I said to them, ‘OK when she goes on holiday, you can have cover for her, but just remember that it is a financial priority, and if that is where we use the money, then there will be other areas that we can’t spend money on’. They understand that, they know at the end of the day it’s a pot of money and sometimes, even when they ask for an extra person on a public holiday, I say ‘you know it will cost £100, or whatever, is that how you want the money to be spent?’
Changing relationships The radiographer managers had faced a transitional period moving from a clinical professional to clinical manager. We have seen that over time they had become more comfortable with their new roles. This change was not without cost, sometimes personal cost. Radiographers in the directorates could have an effect on the professional and personal experiences of the radiographer managers as they moved into their new roles from the professional to the management domain. Two such managers offered different views and illustrate this role change, which for one of them was quite profound. ‘There are a lot of people who have never seen me be a radiographer and I think that is slightly sad because I was actually quite a good radiographer. And it comes across in the fact that they [inexperienced radiographers] can have a film in their hand, looking around for a superintendent to look at it, and I can be standing there, and they won’t ask me my opinion as to either whether it was ok, or how they should correct it if it wasn’t ok.’ ‘I think the biggest shock that I had when I came here was that the staff regarded me as not a radiographer. In [my] last two posts I was a working radiographer and a manager. There is quite a lot of hostility towards my [current] post and I would hate to think that it is towards me, although sometimes my paranoia is such that it feels as though it is towards me. They [the radiographers] feel that because I don’t actually go out and work [as a radiographer], I can’t understand and appreciate the problems they are having. I find that very hard to reconcile because I have been a radiographer for a long time and I don’t think that my skills are diminished by the fact that my role is different.’
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Staff therefore contributed to the manager’s transition from a clinical to a managerial function by unconsciously viewing the ‘radiographer manager’, even as a health professional, as having a different role. They could in some instances be seen as a manager, rather than as a radiographer. This led many radiographer managers to feel isolated and in some instances to have a crisis of identity in much the same way as described by Kouse and Mico [17]. This new role was almost seen as de-skilling by radiographers who were pursuing a professional agenda, and whose ‘vision’ was different to that of the ‘manager’.
Conclusion Griffiths [1] introduced a management culture into the NHS, and a number of clinical professionals have moved from a purely clinical role to a more distinctive management role. This research maps out the experiences and opinions of a group of radiographers as they took on new management roles against the backdrop of a changing NHS. No substantial differences were noted between Scottish and English radiographer managers. Both groups clearly had their roots in clinical radiography and viewed this as important for radiographer ‘managers. Domain theory has been used to inform these role changes. Although it would appear that there was a domain ‘shift’, the radiographers did not see themselves as managers, nor did they associate solely with managers. Their clinical background was reinforced again and again, they were clinicians first and managers second. Indeed many of them suggested that their clinical background made them ‘better’ managers, than if they had no clinical experience. Although there may have been a domain shift, it certainly was not completely into the ‘management’ domain, nor did they remain fully within the ‘professional domain’. Radiographer managers were undertaking management duties, but they were clinical managers rather than general managers. The domains themselves could therefore be becoming blurred, particularly between the management and professional domains. A new ‘hybrid’ manager could therefore be seen developing within the NHS, emerging due to the dynamic created firstly by Griffiths [1], and accelerated by the 1990 NHS reforms. This would imply a new domain, the ‘clinical manager’. This new domain straddles the two worlds of the
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professional or service domain and the managerial domain and indeed complements both in the rapid and changing environment of the NHS. Radiographer managers have much to offer the NHS; however, better management development and training, particularly related to their continued professional development as managers, has to be addressed by employing organizations. Radiographer managers also highlighted a range of views on management style, whilst also describing the emotions associated with the change in their role. Their management style was seen to evolve and Tannenbaum and Schmidt’s [18] management style continuum has informed the analysis of management style. Clearly radiographer managers expressed a need for consensus in decision making while indicating a change in some situations towards toughness and autocracy. However, radiographer managers equally expressed a change towards a ‘softer’ approach, which came through their increasing confidence in the position of manager. This change in management style resulted in improved staff motivation, commitment and outcomes, which undoubtedly benefited the clinical services being delivered. The research also highlights key questions surrounding what the radiography profession and the NHS can do to assist the development of radiographer managers. Not all radiographers undertaking management roles are suited to such an environment and acknowledgement has to be made of this fact. These radiographers may be better placed to use their substantial clinical and organizational skills in clinical settings, so better selection criteria may have to be developed based on the complexities of the management task in hand. Promotion has often been based on excellence in clinical and organizational abilities and can be seen as a reward for such endeavours if not the only way for a radiographer to develop his or her career. This has to be recognized both by the profession and the employing organizations—the NHS, with suitable reward strategies being put in place to encourage retention in key clinical posts, whilst allowing those radiographers with the ability and receptivity for management to flourish. Radiography as a profession has a history of being proactive in developing administrative and quasi-managerial skills via the Management Diploma of the College of Radiographers (MDCR). Given that all postgraduate education is now provided by both further and higher education institutions, the College of Radiographers could work with these
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institutions to develop management development programmes which are tailored to suit the needs of radiographer managers and the organizations in which they work. The emphasis should be on management skills per se, and not simply the collection of academic qualifications, which although not alluded to in this paper, many of the radiographer managers already possessed. Many management qualifications are generic in nature, rather than context specific and do not emphasize skills and personal development at an individual or group level. The NHS itself could also do more to support radiographers and other clinical professions entering the management arena. The Management Executive of both Scotland and England do indeed provide such support, but it is not as comprehensive as, for example, the Civil Service. Issues such as peer support, succession planning and CPD are vital areas that the NHS has to date not embraced, whilst many other organizations such as Scottish Life for example, have had such programmes for several years. Human resource management issues should be vitally important to any organization, and the NHS now has the opportunity to develop this through its Human Resources Strategy. The authors hope that the development of radiographer managers continues, but that they are given the support and encouragement that their unique place within the professions allied to medicine and wider NHS merits. Acknowledgements The authors gratefully acknowledge the financial support of the Internal Research Fund of the Faculty of Management at the University of Stirling. Thanks are also due to the many Scottish and English radiographer managers who contributed to the project.
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