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The purpose of this paper is to explore the process of evolution of medical autonomy as an analytic and historical aspect of the medical work organization in a public bureaucracy.

The authors draw on the analytic concept of organizational contradictions (Heydebrand, 1977) to inform a dialectical approach in organizational analysis. Semi-structured interviews with 20 doctors of a Greek general public hospital were conducted and archival data were collected.

The findings suggest that the historical development of two contradictions characterize the process of medical autonomy evolution. The first contradiction tends to develop between medical autonomy, as a self-control relation, and the established division of labour through which bureaucratic control is exercised over the allocation of resources and over the distribution of healthcare service. The second contradiction tends to develop between those reified aspects of the medical work organization and the ongoing organizing activity, i.e. activity towards extending, intensifying and centralizing organizational control over labour, resources and the distribution of healthcare services. These contradictions indicate a pressure towards constraining health professionals’ power to self-define their relationship with patients and towards curtailing their discretionary domain over the use of resources.

This paper offers an empirical approach to materialist dialectics for organizational analysis towards conceptualizing change as a historical process.

Whilst significant evidence of western work-life balance (WLB) challenges exists, studies that explore Sub-Saharan Africa (SSA) are scarce. The purpose of this paper is to explore how organisational culture in Nigerian medical organisations influences doctors’ WLB and examine the implications of supportive and unsupportive cultures on doctors’ WLB.

The paper uses qualitative data gleaned from semi-structured interviews of 60 medical doctors across the six geo-political zones of Nigeria in order to elicit WLB challenges within the context of organisational culture.

The findings show that organisational culture strongly influences employees’ abilities to use WLB policies. Unsupportive culture resulting from a lack of support from managers, supervisors, and colleagues together with long working hours influenced by shift work patterns, a required physical presence in the workplace, and organisational time expectations exacerbate the challenges that Nigerian medical doctors face in coping with work demands and non-work-related responsibilities. The findings emphasise how ICT and institutions also influence WLB.

The paper addresses the underresearched SSA context of WLB and emphasises how human resource management policies and practices are influenced by the complex interaction of organisational, cultural, and institutional settings.

This paper aims at understanding how clinical guidelines' use in the labour process relates to clinical autonomy, that is, the self-control medical professionals exercise over medical practice.

Drawing on a qualitative case study research strategy, this paper explores how medical professionals use clinical guidelines in the labour process in one public general hospital of the Greek National Health System. Supplemented by an extensive study of documents, semi-structured interviews were conducted with 33 doctors of several specialties.

The analysis shows (1) how clinical autonomy, as a self-control structure, mediates the use of clinical guidelines as a knowledge tool in the labour process, and (2) how employing clinical guidelines as a means towards coordinating medical work, but also towards regulating and standardising medical practice, is exercising pressure on the individualistic character of clinical autonomy.

Advancing the analytic value of workplace control structures, this paper contributes novel theoretical understanding of emerging tendencies characterising medical work organisation and clinical autonomy, and explains how medical professionals' non-adherence to clinical practice guidelines (CPGs) relates to CPGs' role as a resource to medical practice. Finally, this research proposes a more critical approach to health policy towards addressing the challenges associated with centrally introducing clinical guidelines in healthcare organisations.

This paper aims to attempt to explore current transformations in hospital governance by tracing the evolution of medical autonomy in the Belgian hospital sector in the second half of the twentieth century.

Using published secondary sources and archive data the paper developed a historical approach to the relationship between profession and organisation, asking qualitative questions of the characteristics of professional power and knowledge.

Since World War II, two important evolutions have occurred: first, the hospital evolved into an organisational entity that is described as a “professional bureaucracy”; second, at the sectoral level the hospital adopted a position that is characterised as a “divisional structure”. Both evolutions are linked by the processes of rationalisation and bureaucratisation. The findings do not support the thesis of an overall loss of autonomy but bring into focus the transformation of medical autonomy. New forms of professional power and knowledge are emerging with the processing (bureaucracy) and pre‐processing (rationalisation) of information on medical work as key elements.

The paper explores the evolution of the medical profession's autonomy in the second half of the twentieth century. It highlights reflexivity in the changing relationship between professions and organisations and how physicians are becoming “managers of expertise” who are important for both the hospital organisation and the state.

The issue of doctors in management in the NHS is discussed and a model showing how these two key groups can work together most effectively and deal with potential conflict is offered. Four medical management styles, three management styles and three medical managerial structures are identified. When integrated into a matrix the best combinations of structure, medical and management styles can be identified. It is noted that there are only seven combinations that are likely to prove effective and that these should be taken into account when designing organisation structure in the NHS.

This paper describes how Finnish women and men pathologists account for their career choices. Finland has a gender‐balanced medical profession, but pathology has of all specialties the lowest proportion of women (28 per cent), except surgery. Nine men and nine women pathologists were interviewed in order to find out the reasons for having chosen a non‐patient specialty and if gender matters concerning performance and organisation of this occupation. In men’s accounts, the embedded character of gender rendered it invisible. The blindness of the male respondents to the related peer network and mentor system results in them supposing that their choice of specialty unfolds as though “by chance”. By contrast, the women whom we interviewed described their career choices as due to self‐selection. Women saw themselves as active agents, while men did not. A theoretical framework is presented for understanding women’s and men’s orientation to the gender division of labour and the gendered structures in medicine.

The purpose of this paper is to explore the current interest in leadership within the National Health Service (NHS), especially within medicine, as a solution to the slow rate of integration of health and social care services.

This paper is a conceptual analysis of policy documents and professional statements about leadership.

Leadership is a new common sense, promoted despite the limited evidence that it actually delivers. Leaders take risks, develop organisational vision and involve others in change using influence rather than hierarchic authority. They work together in ad hoc local networks, and, because leaders experience the work first hand, they are trusted by fellow professionals and bring to the organisation of work a flexible, immediate, policy-oriented dynamism and pragmatic adaptability.

This paper argues that the leadership movement represents a historic compromise between professionals (mostly medical) who want to shape decision making about service reconfiguration, and managers and politicians seeking ways to integrate health and social care services.

To the authors’ knowledge this conceptual analysis is the first to be applied to leadership within the NHS.

The purpose of this paper is to explain how trajectory management in hospitals is challenged by the introduction of accelerated discharge schemes. The patient trajectory is formed by short stays within health-care organizations, which requires a substantial effort for professionals to be successful in clarifying each patient's medical situation. The patients, at the same time, often have complicated illness stories, and professionals only see a limited part of the patient's trajectory.

This paper is based on extensive ethnographic studies in a newly established cardiac day unit introducing same-day discharge schemes for patients with ischemic and arrhythmic heart disease.

The findings demonstrate that the patient trajectory becomes a “temporal patient trajectory” and encounters a short-term reality, where tensions arise between admission time and the trajectory as a whole. In managing temporal patient trajectories, formal organizing and patient experiences intersect in events that emerge from conversations and span past, present and future in relation to patient treatment. Professionals engage in articulation work to maintain coherence by allowing patients to hold different events together over time.

The paper provides new insights into the challenges of managing trajectories in same-day discharge schemes where the pressure to move quickly and ensure patient discharge is intense. The paper offers a novel theoretical perspective on trajectory management as an ongoing temporal process. The analysis displays temporal tensions between patient experiences and the accelerated discharge scheme and how professionals manage to overcome these tensions by bridging the patient's long illness story and the short trajectory within the cardiac day unit.

Autonomy has long been established as a critical component of professional work. Traditionally, autonomy has been examined as the extent to which an individual or a professional group controls the decisions and knowledge used in their work. Yet, this framework does not capture the additional work activities that professionals are increasingly expected to perform. Therefore, this chapter argues for theoretically expanding our understanding of professional autonomy by bringing in the concept of articulation work. Using the case of healthcare organisational change, this study assesses how shifts in work practices impact autonomy. Data come from longitudinal ethnographic fieldwork and in-depth interviews conducted at a Neonatal Intensive Care Unit as it underwent significant structural changes. Findings show that professionals were forced to change articulation work strategies in response to new organisational structures. This included changes in the way professionals monitored, assessed, coordinated and collaborated around patient care. Furthermore, these shifts in articulation work held important implications for both workplace and professional autonomy, as professionals responded to changes in their work conditions.

The purpose of this paper is to understand how the introduction of a patient-centered model (PCM) in Italian hospitals affects the pre-existent configuration of clinical work and interacts with established intra/inter-professional relationships.

Qualitative multi-phase study based on three main sources: health policy analysis, an exploratory interview study with senior managers of eight Italian hospitals implementing the PCM, and an in-depth case study that involved managerial and clinical staff of one Italian hospital implementing the PCM.

The introduction of the PCM challenges clinical work and professional relationships, but such challenges are interpreted differently by the organisational actors involved, thus giving rise to two different “narratives of change”. The “political narrative” (the views conveyed by formal policies and senior managers) focuses on the power shifts and conflict between nurses and doctors, while the “workplace narrative” (the experiences of frontline clinicians) emphasises the problems linked to the disruption of previous discipline-based inter-professional groups.

Medical disciplines, rather than professional groupings, are the main source of identification of doctors and nurses, and represent a crucial aspect of clinicians’ professional identity. Although the need for collaboration among medical disciplines is acknowledged, creating multi-disciplinary groups in practice requires the sustaining of new aggregators and binding forces.

This study suggests further acknowledgment of the inherent complexity of the political and workplace narratives of change rather than interpreting them as the signal of irreconcilable perspectives between managers and clinicians. By addressing the specific issues regarding which the political and workplace narratives clash, relationship of trust may be developed through which problems can be identified, mutually acknowledged, articulated, and solved.