This was an exploratory study done following a qualitative research approach taking into account the contextual realities of the HMs and trying to understand how clinical staff experience their managerial role.

The research was performed at Groote Schuur Hospital (GSH), a tertiary academic hospital in the WC, South Africa (SA). This hospital provides patient care across most clinical disciplines – for acute and chronic conditions. It receives referrals of high acuity patients, from clinics, district and regional hospitals.

While senior managers have a full-time management role, middle managers in this context are typically HMs who maintain significant clinical responsibilities. They generally oversee teams ranging from 5 to 50 personnel, and are accountable to senior leadership. Senior clinicians hold joint appointments, with dual accountability to the WC Department of Health and Wellness through the hospital and to the UCT. Both the hospital and the university function as complex institutions, having a wide span of functions and responsibilities. They are each governed by different administrative systems. Hybrid managers within this setting are tasked with service management, as well as engaging in research, teaching and training activities.

The study population comprised HMs at GSH who perform a managerial role alongside their direct clinical roles across the spectrum of clinical disciplines. Purposive sampling with snowballing was used to select 12 participants across different clinical departments, age groups and with a range of years of management experience. Snowballing refers to a sampling methodology whereby study participants assist in recruiting other study participants from their own networks. Inclusion criteria were clinical staff who were in a managerial position for over 12 months and who had studied medicine or were in an allied health discipline. Clinicians who had a formal diploma or higher-level training in management or who trained in Psychology, Psychiatry or the Social Work discipline were excluded, as these disciplines receive elements of emotional and social intelligence during their training. Full-time managers or those clinicians who had less than 12 months managerial experience were also excluded.

The researcher conducted in-depth interviews (IDIs) in English. The researcher was a non-clinical Medical Manager at another academic tertiary hospital in the WC. A discussion was held prior to the interview to inform participants that this was an independent research study not commissioned by the hospital. Furthermore, this research was not part of normal working arrangements, and any information obtained during the interviews would not impact on the performance management of the staff member – either negatively or positively. The participant information sheet also reinforced this. Researcher reflexivity was cultivated by the researcher documenting her own beliefs regarding the research topic, to elucidate and manage any bias that may impact on the findings. These were discussed with the researcher’s supervisor during the time of data collection, analysis and write up.

During the IDIs, an interview guide was used to assist the interviewer. Data collection was done in a confidential space and at a suitable time when they were not expected to work. To ensure credibility of the research, the researcher documented verbal and non-verbal data. All participants provided written consent for the audio recording of the interviews. A digital recorder was used to audiotape the interviews and a mobile phone application for a backup recording. Brief notes were taken. It was hoped that rich data would emerge about the insights of HMs into their management role.

The researcher began data collection in February 2020 with face-to-face interviews. Eight interviews were completed by March 2020. Each interview was 40–65 min. Thereafter the researcher could not continue with the research as the coronavirus disease 2019 (COVID-19) pandemic spread to SA and the WC. The researcher was then assigned to overseeing the COVID-19 preparedness plan and services in her hospital until the middle of September 2020. Other researchers also faced similar limitations during the pandemic.¹⁵

The researcher restarted the interviews in October 2020. Four interviews were concluded in this month – one was in person, one was online on Microsoft Teams and two were telephonic. Written consent was obtained prior to the interviews.

The researcher used the following exploratory questions in the interview guide:

For the last four interviews done during the pandemic, the researcher also asked whether the participants had to adapt any of their usual practices during the pandemic. This was an important element to bring in, as many clinicians had to work differently during the pandemic.

A transcriptionist transcribed the data verbatim after each interview. The researcher initially commenced a manual process of identifying themes. However, this process was found to be laborious, thus NVivo 12 quality data analysis software (QSR International, Melbourne, 2018) was utilised to increase efficiency and to enhance the rigour and validity of the study through systematic organisation of the data. The researcher read the transcripts and listened to the interview recordings more than once to surface new aspects.

Thematic analysis was done. Peer feedback from the supervisor was received on the first three transcripts that concurred with the initial thematic nodes that were drawn out. However, after the COVID-19 period of research absence, the researcher identified additional thematic nodes, and in some areas, multiple themes could be collapsed into one. The researcher used the NVivo 12 mind map modality to organise her thoughts about the emerging themes.

The analysis became easier with each subsequent script, and new insights reduced from the 9th script. The thematic analysis of the earlier transcripts was revisited after the break imposed by the COVID-19 lockdown.

The researcher followed the ethics principles outlined in the University of the Western Cape (UWC) Policy on Research Ethics, and approval was obtained from GSH. Ethics approval was obtained from UWC Faculty of Community and Health Sciences Higher Degrees Committee, UWC Biomedical Ethics Committee (BM19/9/11) and UCT Human Research Ethics Committee (883/2019). Written informed consent was obtained from all the participants.

Many of the HMs shared that they felt inadequate when they entered their initial managerial space. A few expressed that they would still like to receive management training and orientation to administrative tasks.

In this study, set in a tertiary academic hospital, none of the participants stepped into the role because they were drawn by the management aspects. The management responsibilities were seen as an incidental addition to their main promotion role to senior clinical staff member. This is in line with studies in other healthcare environments where different pathways into the managerial arena are described.

The managers in this study would be considered to fall into the category of ‘incidental’ HMs as opposed to ‘willing’ HMs.¹⁷ The consequence is that they are slow to embrace the managerial identity, which puts them at odds with their clinical identity.¹⁸ As shown in this study, the two roles can compete for time rather than be complementary. According to Witman et al.,¹⁹ HMs find it difficult to remain credible in the two different arenas – that of medicine and that of management – this further dilemma resonates with the findings of this research. Spehar et al.²⁰ found that in spaces where HMs felt obliged to take up the role, this affected the manner in which they tackled the management duties, as their patient-facing work was felt to be more valuable than their management tasks. If managers are ambivalent and do not fully embrace their managerial responsibilities, as described in this study, there will be an impact on the services they manage.²¹

The greater question for health systems is whether this approach to career-pathing is appropriate or if other pathways should be forged. The common practice of career progression to an HM role should perhaps be adapted, as not all clinicians and researchers make for great managers. This raises the importance of presenting management as a deliberate career path for clinicians, rather than an option for clinical promotion. A different approach would be to provide spaces where clinicians who are not yet managers could be orientated to management practices. Those who exhibit interest and show evidence of early management skills could then be upskilled with specific training and mentorship. It would also be important for leadership development in an institution to be planned taking into account its contextual environment.²²

This study purposefully excluded HMs who had formal management training, as it was interested in the experience of most HMs in this setting who, as with HMs in other countries, do not have formal management training.^23,24,25 Like many HMs reported in the literature, in this setting, and without formal training, HMs felt ill prepared and had to learn management ‘on the fly’.⁷ They shared that they would have preferred having some managerial training before taking on the role. A few of the HMs had obtained informal training after appointment, and some were fortunate to have benefited from mentoring.

In this study, most participants had more than 5 years managerial experience, with half of the participants having been in a managerial role for more than 15 years. For such a group of HMs with a fair amount of experience, training should be designed to enhance their existing technical and management skills.

Hybrid managers require upskilling, not only in technical aspects but crucially to support their ability to adapt and function in a complex health system.¹¹ Training towards a mind shift change is needed for HMs to truly embrace the managerial role as a primary function of their job. According to Mintzberg,¹² an effective manager requires three essential elements – art, craft and science:

It would be important for senior health managers to ensure that HMs are adequately equipped in these different aspects of managing.

This research study highlighted that newly appointed HMs often experience inadequate support, without effective orientation. Commonly, the post was already vacant for a while before the new HM was appointed. Any manager, whether experienced or not, would require an adjustment period as they take on a new role.¹² This would also apply for clinicians in a hospital.²⁶ Senior staff should not assume that clinical staff will be able to find their own way in a new space. Instead, it would be important to provide adequate support for clinical staff as they transition to a leadership role. The report of the UCT Enquiry into the Circumstances Surrounding Professor Bongani Mayosi’s Tenure (p. 126)²⁷ strongly reinforces this sentiment:

‘It was also emphasised that this ‘sink-or-swim’ approach has sometimes been explained as being based on the belief that university insiders do not need induction, as in the case when a staff member moves from one department to another. This short-sighted belief needs to be reviewed, given the many personal and professional variables at play in any such transition.’

Despite the lack of managerial training, many HMs in this setting were able to adapt and manage the various tasks within their role. A few indicated that being inherently resilient is a personality trait that assists them to perform better. Building up their personal resilience has been recommended as a component of HM development.²⁸ The ability to cope with the job may also be supported by the significant amount of workplace experience that these HM bring to the job in this setting. The path to being a senior clinician in a tertiary setting is long, and advanced clinical training is embedded in the workplace. The implication of this is that they have a wealth of experience to draw on in reflective workplace learning.

It was interesting to note that many of the HMs who did not themselves receive adequate support went out of their way to set up support mechanisms for their juniors. Training alone is not sufficient to equip HMs; it must be strengthened with the implementation of adequate support structures which are flexible and can assist during challenging periods.⁶. An example of a crucial element of support is mentoring and should include safe spaces where HMs feel able to reach out to more experienced managers to ‘bounce off’ ideas, without worrying about being ridiculed.²⁸

The hybrid model, if adequately supported, offers inherent opportunities to address some of the current weakness in health management in LMICs.²⁶ High staff turnover, including that of managers, has been linked to low job satisfaction. As discussed next, clinical work can boost job satisfaction. Poor performance has been linked to low staff morale fuelled by a sense that managers are disengaged from the reality of service delivery on the ground. Hybrid managers, still involved in service delivery, are in a position to demonstrate their understanding of the situation, and this gives context to their managerial action.^29,30

Hybrid managers highly value their clinical role. All participants expressed that their job satisfaction and sense of fulfilment primarily stemmed from their patient-facing responsibilities, rather than from administrative or managerial tasks. According to Witman et al.,¹⁹ the job satisfaction of HMs decreases as they perform less direct patient care. The HMs in this study exhibited a similar tendency, reporting that they did not derive job satisfaction from managerial or administrative duties. Moreover, participants noted that engaging in clinical work often served as a source of stress relief.

Hybrid managers indicated that engaging in patient-facing work enabled them to maintain a presence on the clinical floor. This helped them to understand the workspace of their subordinates and improved the quality of the supervision. It also gave them an opportunity to keep in tune to evolving clinical practices and technology. Hybrid managers can have an advantage over full-time managers in having more support from other clinicians, by virtue of their position and their perceived competency.⁸ One opportunity that emerged as important in this study is the perceived respect that HMs felt from their subordinates based on their clinical expertise and research portfolios.

The understanding of context is an essential element in developing leadership in healthcare.²⁴ Compared to their previous focus on purely clinical duties, clinicians have taken on an expanded scope of responsibilities, including management. In addition, the ‘manager’ role in healthcare has become associated with bureaucracy.¹⁸ Hybrid managers will respond differently to these demands, depending on their environment.³¹ This study showed that, while some experiences of HMs at a tertiary level hospital were similar to those described in the literature, in other settings, there are important differences.^2,32 Coordinating the three domains of research, teaching and clinical service introduces an added dimension of complexity. This specific challenge is largely absent from existing literature on HMs in LMICs, which primarily focuses on district health services. In contrast, hospital settings present a distinct and multifaceted form of complexity.^10,33 A tertiary academic hospital has even more stakeholders working in one geographical location and who are connected in various ways. In a large organisation, there are many more departments, each lead by its own head, with whom the HM needs to engage.

This study highlights a challenge that, to the researcher’s knowledge, has not yet been documented in the literature concerning LMICs – the double burden of bureaucracy that HMs have to manage in an academic hospital – that of the academic institution of a university and the service delivery institution of the Department of Health. The new HM often has to make their way through many difficult and time-consuming administrative processes in two separate organisations without any clear explanation or orientation. These parallel processes are in place, for financial, human resource and other spheres, and the HM is expected to ensure that governance is upheld in both realms.

All participants articulated the large administrative burden, somewhat accentuated by a lack of orientation to the administrative process flows within the hospital. These HMs attempted to fulfil these commitments. However, several participants reflected that so many of the tasks did not add value. Hybrid managers perceived that some of these unnecessary bureaucratic processes should be buffered by the non-clinical institutional managers, instead of just being handed down the line to HMs who are trying to balance clinical and managerial tasks. The wellbeing of clinical staff would be enhanced by the provision of appropriate administrative support.³⁴

This qualitative study did not aim for generalisability, but rather sought to elicit meaningful insights. Although the sample size was small, it still demonstrates some interesting reflections about the experiences of HMs in a tertiary hospital which may apply to other institutions in the WC tertiary academic complex, as well as in other provinces, for example, Gauteng and KwaZulu-Natal. Something that can be seen as a limitation is the fact that eight interviews took place in the first 2 months of 2020, before the COVID-19 pandemic reached SA. Thereafter, the researcher stopped data collection as the first wave commenced in March 2020 and restarted in October 2020. It is acknowledged that the experiences shared by the final four participants may have differed had the interviews been conducted prior to the onset of the COVID-19 pandemic.

A distinction should be made between clinicians who recently became HMs and seasoned HMs who have been in this role for many years. Technical and managerial skills already acquired should be acknowledged with training tailored to their particular needs.

Hybrid managers require sufficient orientation about the administrative processes and workflows within both the university and hospital environments. This should include a wide array of concepts, for example, finances, managing people including labour relations processes, organisational values and the role of the hospital within the broader provincial and national settings. An understanding of the equipment planning and procurement processes in a highly specialised service is crucial. The facility could develop a training programme including all these elements to equip staff.

Support should also be provided in a proactive manner to assist the individual with career planning. Clinicians often struggle with understanding how to move through the ad hominem academic rank promotion process. This is especially relevant in SA universities where the professoriate is on the decline.³⁵ Hybrid managers who wish to pursue academia would feel supported if they were provided with opportunities to move beyond the clinical into some managerial spaces in the hospital and university.

The more common scenario is for senior clinicians to become HMs as they are furthering their academic and clinical career. They do not usually do so because of a drive to step into a manager role. These HMs usually have no prior exposure to the managerial environment. One possible way to provide this opportunity through the creation of an enabling environment is to second interested clinicians to the management space for an allocated time to shadow a medical manager who is a full-time manager. Partnering clinicians with an appropriate mentor, with whom they feel at ease to bounce ideas off, could assist them in developing some managerial skills and start a reflective learning practice. This is currently being implemented at Red Cross War Memorial Children’s Hospital in the WC. This would provide the clinician with an on-the-job learning opportunity to begin developing the managerial skills needed when they step into an HM role further on in their career. This early exposure may assist with the development of the managerial identity.³⁶ Training towards a mind shift change is needed for HMs to fully embrace the managerial role.

In this tertiary academic context, there are certain parallels with primary health care settings – most notably, the transition of clinicians from exclusively clinical roles into managerial positions without the benefit of additional training. However, this study showed that there are additional layers of complexity. These findings may be similar in other SA academic settings and beyond. Further research should be explored in this setting.