The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1477-7266.htm

Power in
Power in health care health care
organizations organizations
Contemplations from the first-line
management perspective 385
Ulla Isosaari
Social and Health Management, Faculty of Public Administration,
University of Vaasa, Vaasa, Finland

Abstract
Purpose The aim of this paper is to examine health care organizations power structures from the
first-line management perspective. What liable power structures derive from the theoretical bases of
bureaucratic, professional and result based organizations, and what power type do health care
organizations represent, according to the empirical data? The paper seeks to perform an analysis using
Mintzbergs power configurations of instrument, closed system, meritocracy and political arena.
Design/methodology/approach The empirical study was executed at the end of 2005 through a
survey in ten Finnish hospital districts in both specialized and primary care. Respondents were all
first-line managers in the area and a sample of staff members from internal disease, surgical and
psychiatric units, as well as out-patient and primary care units. The number of respondents was 1,197
and the response percentage was 38. The data were analyzed statistically.
Findings As a result, it can be seen that a certain kind of organization structure supports the
generation of a certain power type. A bureaucratic organization generates an instrument or closed
system organization, a professional organization generates meritocracy and also political arena, and a
result-based organization has a connection to political arena and meritocracy. First line managers
regarded health care organizations as instruments when staff regarded them mainly as meritocracies
having features of political arena. Managers felt their position to be limited by rules, whereas staff
members regarded their position as having lots of space and influence potential.
Practical implications If the organizations seek innovative and active managers at the unit level,
they should change the organizational structure and redistribute the work so that there could be more
space for meaningful management.
Originality/value This research adds to the literature and gives helpful suggestions that will be of
interest to those in the position of first-line management in health care.
Keywords Public health care, Power, First-line management, Public health, Primary care,
Management power, Finland
Paper type Research paper

1. Introduction
Power is not a very popular concept in health care because it refers to health care
professionals exercise of power over patients. However, health care organizations are,
like any other organization, systems of power. Organizations are complex systems of
individuals and coalitions, where everyone has their own interests, beliefs, values,
preferences and angles. Owing to limited resources, there is competition, which results Journal of Health Organization and
in conflicts. The actors whose roles are more critical for the organization gain more Management
Vol. 25 No. 4, 2011
power. (Pfeffer, 1981, p. x; Shafritz and Ott, 1996, pp. 352-353). pp. 385-399
In Finland, health care services are based on public provision. As a consequence, the q Emerald Group Publishing Limited
1477-7266
structures of health care organizations represent traditional organization models, such DOI 10.1108/14777261111155029
JHOM as bureaucracy and professional organization. Hospitals, for instance, are mainly seen
25,4 as professional bureaucracies where the structure is bureaucratic but decentralized.
The main performers are doctors, and nurses are classified as support staff.
(Mintzberg, 1989, pp. 174-179.) New waves of result-based management have delegated
tasks to the unit level and brought features of managerialism to health care. It has
strengthened unit based thinking, but at the same time it can lead to fragmentation. As
386 a consequence first-line management has emerged to the forefront.
The aim of this article is to examine Finnish health care organizations power
structures from the first-line management perspective. What liable power structures
derive from the theoretical bases of bureaucratic, professional and result based
organizations? What power type do health care organizations represent according to
the empirical data, and what conclusions can be drawn from the results?

2. Power and its sources

2.1 The concept of power
The concept of power has elicited a wide range of discussion, mainly among
sociologists. Power can be seen as a potential for action through domination (Hobbes,
1999, pp. 92-93) or consensus (Arendt, 1970; Parsons, 1963; Barnes, 1988; cited in
Haugaard, 2009). On the other hand, power can be seen to manifest only in action
through concrete decision making.
The modern view of power is three-dimensional. Power can be seen as domination,
freedom or hegemony. The third dimension, hegemony, means gaining power through
shared information. It is leadership that facilitates the autonomy of the led. Successful
hegemony entails dominance through consent. Hegemony is, on the one hand, a source
of domination while, on the other hand, constitutes a form of collective will (Lukes,
2005, pp. 123-131; Haugaard, 2009, p. 242, Gramsci, 1971; cited in Haugaard, 2009,
pp. 243-245.) Flyvbjerg (1997, cited in Haugaard, 2009, p. 253) even adds a post-modern
conception, where consent is replaced with reason.
Power can also be examined in three dimensions: structural, individual and
interpersonal. Structural power creates the frame for individual power. Respectively
structural power is generated through an individual power game. Interpersonal power
becomes evident in the direct relations between individuals (Thylefors, 1992, pp. 36-37,
39.) This article concentrates on structural power.
Power is always relative and seeks balance. It can be used in legitimate and
illegitimate ways. When used in its right area it is legitimate, but when used out of its
area it can become ineffective and illegitimate (Handy, 1978, pp. 112-113, 120.)

2.2 Sources of power

In all types of power the essential question is its source. The better the sources and the
more multifaceted the use of them is, the stronger the power is (Burke, 1986, p. 61;
French and Raven, 1996, p. 375). There are several lists of sources of power. Four of
them can be seen in Table I.
Morgan (see Table I) portrays power sources especially in the organizational
context, and that is why it is used in this research. These sources can be divided into
four larger categories (Isosaari, 2008, p. 60):
(1) decision-making power;
(2) discretion;
 Power in
Handy (1978, pp. 114-121) Physical power
Reward power health care
Expert power organizations
Personal power
Negative power
Kakabadse et al. (1987, pp. 214-225) Reward power
Coercive power 387
Legitimate power
Personal power
Expert power
Information power
Connection power
French and Raven (1996, pp. 375-378, 380) Reward power
Coercive power
Legitimate power
Personal power
Expert power
Information power
Contact power
Morgan (1990, p. 159), new categorization Decision-making power
Isosaari (2008, p. 60) Formal authority
Control of decision processes
Discretion
Use of organizational structure, rules and regulations
Structural factors that define the stages of action
Control of resources
Control of shared resources
Ability to cope with uncertainty
Control of technology
Control of knowledge and networks
Control of knowledge and information
Control of boundaries
Interpersonal alliances, networks and control of
informal organization
Control of counter-organizations
Symbolism and the management of meaning Table I.
Gender and the management of gender relations Four categorizations of
The power one already has sources of power

(3) control of resources; and

(4) control of knowledge and networks.

Making decisions is at the core of management. To make the correct and rational
decisions, a manager has to gather as much information as possible to be able to choose
from various options and their imaginable consequences. Because not all possible
consequences can be predicted, decisions can only be rational to a limited degree
(Simon, 1957, pp. 67-68, 81.) Authority in organizations means legitimate power to give
orders and make decisions (Meaney, 1999, p. 335).
Discretion is an important part of the decision-making process, and involves
choosing between options. At the unit level there is greater opportunity for discretion if
the top management is disintegrated, the case under consideration is not important, or
JHOM the unit is sustainable (Krause, 2000, pp. 6-9.) Managerial discretion depends on how
25,4 managers perceive it. Perceived discretion, even if it is slight, gives managerial power.
If a person does not recognize their possibilities, it is less likely they will act (Carpenter
and Golden, 1997, pp. 192-193.)
Power vested in resources is based on the fact that some resources are more critical
for the organization than others. Persons who can offer resources like money, fame,
388 legitimacy, rewards, sanctions, special skills or the ability to deal with uncertainty
have power. The point is to own resources somebody else needs or desires. Scarcity
and dependence are the keys to resource power. Resource allocation can also have an
impact on the decision-making process as a premise for it (Pfeffer, 1981, pp. 101-115).
Power in an organization depends on an individuals or units position in the official
and unofficial communication networks. A formal position brings access to invisible
tools of power as knowledge and membership in networks (Handy, 1978, p. 117.)
Knowledge is also an important part of decision making. For informed decisions there
must be enough information about the alternatives (Pfeffer, 1981, p. 119.)
In this study these four power source categories will act as indicators of power.

2.3 Mintzbergs configurations of power

In this study, the main focus is on organization structure. In that sense the most
extensive theoretical framework for the examination of organization structure is
Mintzbergs (1983) depiction of power in organizations. Sources of power are not
effective without action. The ability to use sources of power in an effective way is
crucial. Mintzberg (1983, p. 98) divides the organization into five basic parts:
(1) strategic apex;
(2) middle line;
(3) operating core;
(4) support staff; and
(5) technostructure.

These form the internal coalition of the organization. The external coalition is
composed of owners, partners, labour organizations, and the public. Both internal and
external coalitions are part of the power play that moulds an organizations power
system. In an organization there are several power systems that can act together and
centre the power inside the organization or disperse the power when acting towards
each other. (Mintzberg, 1983, p. 219.)
Mintzberg (1983) presents six power configurations by putting together the power
structure of internal coalition and external influencers:
(1) the Instrument;
(2) the Closed System;
(3) the Autocracy;
(4) the Missionary Organization;
(5) the Meritocracy; and
(6) the Political Arena.
The Autocracy is an organization where the manager is the only centre of power. It is Power in
typical in small, young and founder-lead organizations. In a Missionary organization, health care
all activities are centred towards reaching a common goal. All tasks in the organization
have the same value and there is no control or internal structures (Mintzberg, 1983, organizations
pp. 355-366, 368-375.) The Autocracy and the Missionary organization are left aside
here, because first-line management does not have a noteworthy role in them.
When an organization acts as an Instrument, strong external influence centres the 389
power at the top of the organization. The organization is bureaucratic and hierarchical
and its goals are clear and operational. The whole organization exists for external
needs. The Closed System organization resembles an instrument having clear targets, a
stable environment, routine operative tasks and bureaucratic control. As a distinction
from instrument, external influencers are passive, causing the organization to emerge
as a system unto itself. The members of the organization are there primarily for the
inducements they can get. Because of the lack of external influence, the internal
coalition is not so centralized and the system of authority is weaker (Mintzberg, 1983,
pp. 321-323, 334-337.)
In Meritocracy, the internal system of influence diffuses power in the organization
according to the degree of expertise. Meritocracy can be divided into the federated and
collaborative types. In the federated-type, the experts apply standardized skills directly
to client needs. They can work relatively autonomously at the operational level and the
environment is quite stable and predictable. This type of Meritocracy is called
professional bureaucracy. The administration consists of representatives of experts
themselves and serves mainly to reconcile conflicts and supervise the support staff.
(Mintzberg, 1983, pp. 388-393.)
When an organizations environment is dynamic and not predictable, experts form a
collaborative type of Meritocracy. Experts combine their different knowledge and
skills working in teams. There is no predictable distribution of power since decisions
are made in many places within the structure (Mintzberg, 1983, pp. 393-395).
When an organization is a Political Arena, all the actors aim towards their own
private ends. That causes competition and conflicts. The organization as a whole has
multiple goals or none at all. No one can be sure where the power lies. The External
Coalition is divided and the Internal Coalition is largely politicized. The Internal and
External Coalitions blend into one continuous network of political activity. The
Political Arena is often a temporary configuration when an organization is in a state of
change (Mintzberg, 1983, pp. 421, 425/426).

3. First-line management
Staehle and Schirmer (1992, p. 70) have made a demarcation between an organizations
managerial levels. They describe lower level managers as employees who have one
hierarchical level under them. In health care that means nurse and physician
managers at the unit level.
First-line managers are members of two organization subsystems, the managerial
structure and the unit supervised. This can cause problems if the demands of these
subsystems come into conflict. The position needs balance between different values.
First-line managers operate at the core of the action. They deal with people as
individuals rather than as groups (Katz and Kahn, 1978, pp. 198-199; Argyris, 1990,
p. 93).
JHOM As the first-line managers work close to the operative core, the nature of their work
25,4 is short-term, fluctuating and fractured. It has some regular variation in the long-term,
but the lower the hierarchical position is, the more short-term the duties are. Because of
the nature of the action, reactions must be immediate, and the main concern is
maintaining the fluency of work processes (Mintzberg, 1980, pp. 31-35).
Compared to other management levels, managerial roles in first-line management
390 are the same, but the stressing of them is different (Mintzberg, 1980, p. 55). On the other
hand, skills needed at higher levels may not be relevant at lower levels of management.
The central point is to use the skills suitable for the relevant level. At the lowest level
the most important is the implementation of policies set higher up. It can be done more
or less effectively (Katz and Kahn, 1978, p. 538).
In the Finnish health care system, there are two managerial lines in the management
structure. This also means that the two professional groups in first-line manager
positions are doctors and nurses. The position of nurse managers is traditionally
strong and clear. They work as leaders in their units concerning nursing operations.
However, they often partake in hands-on work in their units and the proportion of
managerial duties in their work varies according to the size of the unit.
On the other hand, the position of first-line physician managers is not as clear. The
main focus is on clinical work, not managerial duties and the name of the position has a
connection to the determination of salary, not necessarily to the content of the position.
In spite of that, there are doctors working in managerial positions at the unit level.
Table II summarizes up the framework for examining the power structures of health
care organizations. It shows how sources of power indicate Mintzbergs power
configurations in first-line management.

4. Method and data of the empirical study

As mentioned earlier, the aim of this study is to examine what kind of power
configurations health care organizations represent from the first-line management
perspective. The methodological approach of the study was quantitative. Power was
examined through its sources: decision-making power, discretion, control of resources
and control of knowledge and networks, and the questions of the empirical study were
operationalized from these theoretical concepts.
The empirical study was executed through a survey in ten Finnish hospital districts
in both specialized and primary care. The hospital districts represent half of the
hospital districts in Finland. They were selected to represent the whole country
(location, size, growth of population). The survey was carried out at the end of 2005.
The respondent groups were: all the first-line managers of the chosen hospital
districts and a random sample of staff members from internal disease, surgical and
psychiatric units, as well as outpatient and primary care units. The number of
respondents was 1,197 and the response percentage was 38. The data were gathered
through an internet questionnaire (if the respondent had an e-mail address) or
traditional paper version. The answer scale was an equal distance ordinal scale.
The data were analyzed statistically by building sum variables according to
principal component analysis and examining their mean values in background
variable groups. Connections between variables were studied with correlation analysis,
the Kruskall-Wallis test, and table elaboration.
 Control of knowledge and
Decision making Discretion Control of resources networks

Instrument Influence through position Little Good governance of resources, though Communication quite effective
Decision making is centred at the top important to ensure own resources Influence is not based on control of
of the organization No competition networks
First-line managers have little
independent decision-making power
Closed Influence inside organization Little Competition Information in units is not
system emphasized
Knowledge also about informal
organization
Meritocracy Competence source of influence, Much Self-seeking Control of networks is an
position has little impact Competition important source of influence
First-line managers decision making Lack of communication
independent
Flexibility
Political Decision making does not centre Much Self-seeking Influence is based on control of
arena anywhere Competition networks
Influence in organization Lack of communication
Source: Isosaari (2008, p. 93)
organizations

first-line management
health care

configurations in
indicators of power
Sources of power as
391

Table II.
Power in
JHOM 5. Results
25,4 To find out what kind of power configurations health care organizations represent,
they were examined through four categories of power sources. There were a variety of
questions, a great deal of which were summed up in sum variables to measure each
category. Mean values vary between 0 and 4 (Likert-scale). The results are reported
only at the significant level. The final contemplation was made by comparing the
392 variable values to the theoretical framework (see Table II).

5.1 Decision-making power

The first question was whether the decision-making power was centralized or
decentralized. In other words, is the decision-making power inside the unit (first-line
managers and staff members), at a higher level in the organization (the head physician
and head nurse) or outside the organization (labour unions, public, politicians)?
As you can see in Figure 1, the units have a great deal of decision-making power
concerning operation management and a little less concerning human resource
management. When it comes to resources, decision-making power flows outside the
unit. You can see for example a low percentage in the determination of salary, although
the new performance based salary system was already in use in Finland. That is
because first-line managers only build up the bases for decisions made higher up.
There was variation among hospital districts at the stage of decentralization. In
primary care, decision making was more decentralized than in specialized care. The
psychiatric units had the weakest decision-making power.
The second target was to find out who makes the crucial decisions for the unit, the
head physician, head nurse, first-line physician manager, first-line nurse manager,
staff or somebody else. In operation management and human resource management,
the nurse manager had a strong role in the decision-making process. Looking closer at
separate respondent groups, first-line managers in all, and doctors especially, found
doctor managers to have a strong role in decision-making.
A great majority of both first-line managers (77 percent) and staff members
(68 percent) were satisfied with the amount of decision making power of the first-line

Figure 1.
Percentage of respondents
who think decisions
concerning the unit are
made inside the unit
manager, although one-fifth of both groups wanted more regarding economic Power in
resources, recruiting, amount of personnel and targets and the operation of the unit. health care
The sum variable influence inside organization depicts an estimate of a first-line
managers possibility to affect at different levels of decision-making inside the organizations
organization. The response mean of the variable at the aggregate level was low (mean
1,8). The possibility to influence was bigger in primary care (mean 1,9) compared to
specialized care (mean 1,6, KW test 15.1, df1, p , 0.001). According to first-line 393
managers they had more influence the larger the unit was r 0:21; p , 0.001). In
addition, the amount of influence was connected to the first-line managers proportion
of managerial duties at work: the more managerial duties, the more influence
r 0:12; p , 0.01).
The sum variable flexibility in human resource management depicts how willing
the first-line managers were to listen to their subordinates in work conditions related
issues, and the absence of favouritism. An examination of the sum variable means
reveals that first-line managers thought they were more flexible than their
subordinates thought they were (mean 3.6/3.0, KW 178.0, df1, p , 0.001). Staff
physicians gave higher variable values than staff nurses (3.4/2.9, KW 10.8, df1,
p , 0.01). In the first-line managers answers, primary care managers were more
flexible than managers in specialized care (3.7/3.6, KW 8.0, df1, p , 0.01) and women
and nurse managers more than men and physicians.

5.2 Discretion
The sum variable discretion depicts the first-line managers ability to choose between
options and perceive the discretion they have. This variable got rather high values in
both respondent groups. First-line managers discretion increased along with the
managers age r 0:09; p , 0.05) as well as work (r 0.14, p , 0.01) and managerial
experience r 0:13; p , 0.01) (see Figure 2). Nurse and female managers used more
discretion than men and physicians. This is interesting because hypothetically

Figure 2.
Exploration of the sum
variable discretion
means by respondents
age, experience in health
care and in managerial
duties and proportion of
managerial duties in the
first-line managers group
JHOM physicians have a lot of discretion, but apparently having a lot of discretion in clinical
25,4 work does not mean lot of discretion in managerial work. When first-line managers
work had a written description they reported more discretion rho 0:15; p , 0.001).
That is perhaps because it is easier to perceive discretion when the work has clear
frames.

394 5.3 Control of resources

In the sum variable control of resources rewarding and fairness were emphasized. The
sum variable got moderate values at the aggregate level (see Figure 3). First-line
managers opinions were slightly more positive than their subordinates. In the first-line
managers group, traces of lower control of resources could be seen the more
managerial experience they had r 20:10; p , 0.05). There were also separate
questions about competition regarding resources. Both first-line managers and staff
members considered moderate competition between units. The groups that felt most
competition were men (mean 2.3/2.9, KW 15.1, df1, p , 0.001) and physicians (mean
2.3/2.9, KW 26.1, df1, p , 0.001) (see Figure 3).
Another separate question was about gambling and bargaining concerning the
units resources. Gambling and bargaining were uncommon according to the
respondents. In the first-line managers group, the age group 35-44 years, managers
with 11-20 years of work experience in health care, and managers with management
experience over 30 years, all thought that there was more gambling and bargaining
concerning resources. In addition men and physicians felt more gambling and
bargaining (see Figure 3).

5.4 Control of knowledge and networks

The power source category of control of knowledge and networks was examined by
two sum variables and three separate questions. The sum variable control of
networks depicts the emergence of power as a result of efficient networking. The
respondents thought that networking was a moderate source of power. Networking

Figure 3.
Exploration of the sum
variable means in the
category control of
resources by sex and
profession in first-line
managers and staff
members groups
had a weaker importance in specialized care and university hospitals than in primary Power in
care and central hospitals[1]. health care
The sum variable distribution of information depicts the effectiveness of the
distribution of information. First-line managers thought that they distributed organizations
information effectively (mean 2,9) but their subordinates had a different opinion (mean
2,3)[2]. The sum variable gets higher values among female and nurse respondents than
among men and physician respondents. The variable had a connection to the first-line 395
managers proportion of managerial duties at work: the variable got highest values
when the greater part of working time went to managerial duties.
Two of the separate questions canvassed what the nurse and physician first-line
managers role in distributing information in the unit is. Both first-line mangers
themselves and staff members had the opinion that the nurse managers role was
significant. It was especially emphasized among female and nurse respondents. The
role of the physician manager was seen in the whole data as remarkably less
significant than in nurse managers. It was seen as somehow notable in specialized
care, male and physician respondent groups.
The last separate question in this category dealt with first-line managers access to
informal information in the unit. It depicts the first-line managers ability to control an
informal organization. The variable got relatively high values in both respondent
groups. There were no linear connections detected between variable and background
variables.

6. Conclusions
6.1 Organization structures connection to power structure: theoretical analysis
Putting together the existing organization structures in health care and Mintzbergs
power configurations, it seems that a certain kind of organization structure supports
the emergence of a certain kind of power structure (see Table III). When an
organization is bureaucratic, the natural power configuration is Instrument or Closed

Organization structure
Professional Result-based
Power configuration Bureaucracy organization organization

Instrument Hierarchy Professional Performance according

Rules bureaucracy to targets set outside
Limited decision-
making power
Closed system Hierarchy Emphasizing own
Rules actions
Meritocracy Professional hierarchy Focus on expert role Rivalry
Minor administrative
role
Strong labour union
influence Table III.
Political arena Decentralized decision Rivalry Connection between
making Seeking own interests organization structures in
Networking health care and
organization power
Source: Isosaari (2008, p. 202) configurations
JHOM System depending on whether there is external influence or not. A professional
25,4 organization has a connection to Meritocracy. A result-based organization can not be
connected directly to any of power configurations. The main thing is reaching the
target no matter what the organizational structure is. However, it can be connected to
Political Arena and Meritocracy.
For first-line managers working in a bureaucratic organization structure with the
396 power configuration instrument, decision-making power and discretion are limited.
They follow rules and regulations set from higher up. Their power is based on their
position in the hierarchy, where they can implement the decisions effectively or
ineffectively. In Closed Systems there are little more possibilities to act when there is no
external influence. It can lead to the overemphasis of the units own activity (Isosaari,
2008, p. 203).
In professional organizations and Meritocracy the emphasis is on expertise. The
power is vested in recognized expertise in their own speciality. The first-line managers
managerial role is not important per se. They only help experts to do their jobs. In a
result based organization the structure is decentralized. Every unit is accountable for
its results. For first-line managers this means more decision-making power and
discretion (Isosaari, 2008, p. 204).

6.2 What power type do health care organizations represent when looked through
first-line management and what factors are connected to it?
Comparing the results of the empirical study to the theoretical framework according to
subordinates, health care organizations seem to resemble a Meritocracy organization,
also having features of Political Arena. First-line managers themselves saw health care
organizations as Instruments. This means that from the first-line managers
perspective, their position is limited by rules, whereas staff members regarded their
position to have lots of space and influence potential.
Looking at organizational variables, in specialized care, the organizations power
configurations Instrument and Meritocracy come up, and respectively in primary care
the power configurations of Closed System and Political Arena. The result points out a
strong public nature and a strong need for professionalism in specialized care. In
primary care the possible effects of the ongoing turbulence in the Finnish municipal
structure can be seen, aiming at larger co-operation districts (minimum of 20,000
inhabitants) in social- and primary care. This has caused uncertainty among
employees and can lead units to turn inward (Closed System) or to try to secure their
existence with political games.
According to staff members opinions, the configurations of Closed System,
Meritocracy and Political Arena come up in surgical units. The connection to
Meritocracy is understandable, because in the surgical speciality expertise is highly
valued. In primary care ward units, staff members saw organizations as Instruments or
Closed Systems. This means quite identical units, which are distinguished by the
influence coming from outside the organization, or the lack of it. In first-line managers,
the answers revealed the Instrument and Closed System in psychiatric units. In
primary care outpatient units, the configurations of Closed System and Political Arena
were prominent.
Looking at the result at the individual level, the occupational group physicians came
up. In their opinion, organizations were closed systems or meritocracies. As physicians
are in an expert role, Meritocracy is a natural power configuration. Seeing the Power in
organization as a Closed System can mean a strong focus in their own professional health care
group, or own unit inside the organization. In the first-line managers group, extensive
experience in health care and managerial duties were connected to Meritocracy. organizations

7. Discussion
As mentioned earlier, first-line managers and their subordinates had a very different 397
view of what kind of power configurations health care organizations have when looked
at through first-line management, although it must be taken into consideration that
staff members had to evaluate somebody elses work. The result raises a question: are
first-line managers recruiting, qualification requirements and training in balance with
the real conditions in the units? Do we lure first-line managers with advertisements for
a job promising an innovative and development-favourable working environment, or
to get higher education, causing frustration when they realize what the real conditions
are? In Finland, there are no congruent competences or qualification requirements for
first-line managers. In the end organizations define them themselves. For example, the
requirements concerning education vary from higher vocational diploma to Masters
degree.
Or should the organizations revaluate their structures, responsibilities and
distribution of work so that there could be space for more powerful first-line managers?
If the organizations seek innovative and active managers at the unit level, they should
change the organizational structure and redistribute the work so that there could be
more space for meaningful management. First-line managers desire more
decision-making power, not just gathering background information for somebody else.
Or do they actually have the power but do not perceive or use it? As the results
show, with clear frames of managerial duties, first-line managers use more discretion.
With proper job descriptions first-line managers can be conscious of the possibilities
and the limitations of their position and use their power effectively.
Suggestions in brief:
.
There should be uniform qualification requirements and training for first-line
managers in health care in Finland.
.
Health care organizations should revaluate their structures and responsibilities
concerning first-line management to make the position more meaningful.
.
There should be clear job descriptions for first-line managers to use discretion
effectively.

Notes
1. Hospitals not connected to university.
2. Kruskall-Wallis test 137.8, df1 * * *.

References
Arendt, H. (1970), On Violence, Penguin, London.
Argyris, C. (1990), Integrating the Individual and the Organization, Transaction Publishers,
New Brunswick, NJ.
Barnes, B. (1988), The Nature of Power, Polity, Cambridge.
JHOM Burke, W.W. (1986), Leadership as empowering others, in Srivastva, S. (Ed.), Executive Power:
How Executives Influence People and Organizations, Jossey-Bass, San Francisco, CA,
25,4 pp. 51-77.
Carpenter, M.A. and Golden, B.R. (1997), Perceived managerial discretion: a study of cause and
effect, Strategic Management Journal, Vol. 18 No. 3, pp. 187-206.
Flyvbjerg, B. (1997), Rationality and Power, University of Chicago Press, Chicago, IL.
398 French, J.R.P. and Raven, B. (1996), The basis of social power, in Shafritz, J.M. and Ott, J.S.
(Eds), Classics of Organization Theory, 4th ed., Harcourt Brace College Publishers,
Fort Worth, TX, pp. 375-84 (originally published in 1959).
Gramsci, A. (1971), in Hoare, Q. and Nowell Smith, G. (Eds), Selections from the Prison Notebooks,
Lawrence and Wishart, London.
Handy, C.B. (1978), Understanding Organizations, Penguin, Harmondsworth.
Haugaard, M. (2009), Power and hegemony, in Clegg, S.R. and Haugaard, M. (Eds), The Sage
Handbook of Power, Sage Publications, Thousand Oaks, CA, pp. 239-55.
Hobbes, T. (1999), Leviathan eli kirkollisen ja valtiollisen yhteiskunnan aines, muoto ja valta,
Vastapaino, Tampere.
Isosaari, U. (2008), Valta ja tilivelvollisuus terveydenhuollon organisaatioissa: Tarkastelu
lahijohtamisen nakokulmasta. Acta Wasaensia 188, Vaasan yliopisto, Vaasa.
Kakabadse, A., Ludlow, R. and Vinnicombe, S. (1987), Working in Organisations, Gower,
Aldershot.
Katz, D. and Kahn, R.L. (1978), The Social Psychology of Organizations, 2nd ed., Wiley & Sons,
New York, NY.
Krause, G.A. (2000), A Positive Theory of Bureaucratic Discretion as Agency Choice, available
at: www.isr.umich.edu/cps/pewpa/archive/archive_00/20000006.pdf (accessed 8 August
2007).
Lukes, S. (2005), Power: A Radical View, 2nd ed., Palgrave Macmillan, Basingstoke.
Meaney, M.E. (1999), Authority relations in corporate medical management: toward an
organizational ethic of managed care, HEC Forum, Vol. 11 No. 4, pp. 333-44.
Mintzberg, H. (1980), The Nature of Managerial Work, Prentice Hall, Englewood Cliffs, NJ.
Mintzberg, H. (1983), Power in and around Organizations, Prentice Hall, Englewood Cliffs, NJ.
Mintzberg, H. (1989), Mintzberg on Management: Inside Our Strange World of Organizations,
Free Press, New York, NY.
Morgan, G. (1990), Images of Organization, Sage, London.
Parsons, T. (1963), On the concept of political power, Proceedings of the American Philosophical
Society, Vol. 107 (reprinted in Haugaard (2002)).
Pfeffer, J. (1981), Power in Organizations, Pitman Publishing, Marshfield, MA.
Shafritz, J.M. and Ott, J.S. (1996), Classics of Organization Theory, 4th ed., Harcourt Brace College
Publishers, Fort Worth, TX.
Simon, H. (1957), Administrative Behavior: A Study of Decision-making Process in Administrative
Organization, Macmillan, New York, NY.
Staehle, W. and Schirmer, F. (1992), Lower-level and middle-level managers as the recipients
and actors of human-resource management, International Studies of Management and
Organization, Vol. 22 No. 1, pp. 67-89.
Thylefors, I. (1992), Ledarskap i vard, omsorg och utbildning, Natur och Kultur, Stockholm.
Further reading Power in
Mintzberg, H. (1986), The five basic parts of the organization, in Shafritz, J.M. and Ott, J.S. (Eds), health care
Classics of Organization Theory, Harcourt Brace College Publishers, Fort Worth, TX,
pp. 232-44. organizations

About the author

Ulla Isosaari (PhD, admin.) is a Researcher in Social and Health Management in the Faculty of 399
Public Administration at the University of Vaasa, Finland. Her special scientific interests are
first-line management, and power and accountability questions in health care. Ulla Isosaari can
be contacted at: ulla.isosaari@gmail.com

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints