The role of hybrid professionals in the public sector: a review and research synthesis

ABSTRACT

Professionals appointed with managerial roles working in public organizations are expected to act as the junction between the professional and managerial domains, and to add value by spanning organizational and professional boundaries. At the same time, their role urges them to cope with conflicts emerging from such complex organizational contexts. In the last decades, a wide variety of approaches have enlivened the debate on this topic, mainly – but not exclusively – with regard to the role of hybrid roles in the health-care sector. Through descriptive investigations, the paper explores the results of a systematic literature review and propose a classification of the emerging approaches.

KEYWORDS:

• Hybrid professionals
• institutional logics
• hybrid role
• literature review
• public sector

Introduction

Public sector organizations characterized by knowledge-intensive work have often been described as professional bureaucracies (Mintzberg 1989), with different professionals working together and delivering complex services such as education, social services and health care (Noordegraaf 2007). Over the past decades, public administrations, particularly those in Western countries, have faced reform processes that changed their organizational structures, routines and management styles shifting from traditional models descending from Weberian approach to management-like (Dunleavy and Hood 1994) and governance-like ones (Bovaird and Elke 2009).

On this trend – far more complex and less linear than often depicted (Christensen and Per 2011) – professions have evolved accordingly. Professionals in the public sector are indeed paramount in turning planned change into reality: their capacity to mediate top-down demands and spread them across the organization plays an important role in the implementation process of policy-driven innovation (Ackroyd, Kirkpatrick, and Walker 2007; Ongaro and Valotti 2008). As professional bureaucracies (Mintzberg 1989) in the public sector have become managerialized, professionals with a managerial status have then been asked to reshape their role in order to align professional tasks with managerial goals.

Nowadays, multiple sources of complexity are challenging public sector organizations (Christensen and Per 2011) with ‘wicked’ rather than ‘tame’ problems (Head and Alford 2015), such as increasing service demands against shrinking fiscal constraints (Cepiku, Mussari, and Giordano 2016), citizens and clients’ changing needs (Benington and Moore 2010) and post-crisis governance redefinition (Peters, Pierre, and Randma-Liiv 2011), just to cite a few. Advancing public sector human resource management, particularly by enacting the potential of professionals, is therefore necessary to ensure the long-term sustainability of the system. This is particularly true in contexts such as health care, with a great part of the expenditure being governed by clinicians by means of knowledge-driven, and yet discretionary, choices (e.g. clinical prescription). Indeed, prescription behaviour is an area where clinicians’ decisions influence to a great extent prioritization in the budgeting process; this results in a peculiar power configuration that makes health a context in which the fundamental characteristics of professional bureaucracies are being further exalted, thus raising the question of professionals’ participation in the design of organizational decisions (Abernethy and Stoelwinder 1995; Nuti and Vainieri 2016). Exploring hybrid professionalism aims then to understand how fundamentally different principles or value systems may coexist, interact and mutually influence each other, leading to new configurations of roles for professionals and enabling them to exploit their ‘two-windows’ position (Llewellyn 2001) in order to increase public organizations’ capacity to create value for their stakeholders. However, though management scholars have recently revitalized the topic of ‘hybrid professionalism’, the increasing amount of theoretical and empirical works still calls for systematization (Denis, Ferlie, and Van Gestel 2015).

A literature review is carried out in order to analyse how hybrid professionals’ role is being played in public sector organizations and to systematize emerging approaches and definitions. The review followed the PRISMA approach (Moher et al. 2009) and was developed searching three electronic databases: ISI Web of Science, Scopus and Business Source Complete (EBSCO). Both theoretical and empirical studies published in international academic journals up to mid-2018 were considered. Every article appearing in at least one of these databases which matched the keywords algorithm was selected for analysis via further selection procedures. Through descriptive investigations, the paper explores the results of the review and propose a classification of the emerging approaches.

Methods

The author conducted a systematic literature review of academic articles published between 1990 and mid-2018 on the role and identity of hybrid professionals in the public sector. Extant research was explored in order to systematize recurring theoretical approaches and emerging insights highlighted by scholars when studying the topic of role hybridity within the public sector. From this, the following research question (RQ) is derived:

1. How is the process of role and identity hybridization framed and interpreted in public sector organizations?

This study also aims to investigate why professionals working in the public domain take on managerial roles and, when they do it, how they exert them. From this follows:

• (2) What purposes professionals pursue when taking on managerial roles and by what means they exert them?

Last, the literature review explores what organizational conditions tend to facilitate professionals in hybridizing their role; the following RQ then arises:

• (3) What conditions enable the effective enactment of hybrid roles?

Systematic reviews, in order to ensure research rigor and replicability, follow transparent protocol for the search and appraisal of literature that aims to minimize bias, together with inclusion and exclusion criteria for selecting publications, as well as prescriptions for how to assess and synthesize the resulting evidence (Tranfield, Denyer, and Smart 2003). Three reviewers independently read abstracts and full papers, sharing common criteria for their selection; one of the three members checked the extraction and the respect for inclusion criteria to ensure consistency and accuracy of the work; any differences in opinion, regarding the papers’ eligibility, were discussed and resolved by the reviewers during the reading process.

A five-step procedure to identify and select eligible papers was then followed. The steps of the procedure are explained in further detail in the following paragraphs and reported in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart diagram (Figure 1).

Figure 1. Literature search flow diagram.

The protocol followed as much as possible the PRISMA guidelines, originally developed for reporting reviews evaluating randomized clinical trials (Moher et al. 2009). Social science research cannot be considered fully compatible with all the steps of the PRISMA approach, because of the nature of the objects of analysis and the relevance of interpretive approaches; nonetheless, its systematic nature can contribute to the advancement of the insights of this study, by ensuring ‘transparent and complete reporting’ (Voorberg, Bekkers, and Tummers 2014), and it has been largely applied to management research (Ianniello et al. 2018; Cinar, Trott, and Simms 2018).

Search strategy

Since the analysis focused on studies dealing with hybrid professionalism in the public sector, the review started with a scoping study, in order to provide focus and input for the development of our classification schemes of hybrid professionalism, theoretical perspectives and core concepts. Five papers (Appendix 1) were selected based on the author’s familiarity with leading public management scholars in the field. The scoping study clearly suggested a cross-disciplinary treatment of the topic. Therefore, the search strategy was quite broad.

Firstly, the author conducted a primary search on three databases to identify relevant peer-reviewed and English language works published to mid-2018: an electronic search was carried out in databases powered by EBSCOHost (Business Source Complete), Thomson Reuters (Web of Science) and Elsevier (Scopus), using the following keywords algorithm:

(‘hybrid professional*’ OR ‘hybrid manager*’ OR ‘hybrid role*’ OR ‘hybrid middle manager*’ OR ‘hybrid physician manager*’ OR ‘hybrid nurse manager*’ OR ‘hybrid clinician manager*’ OR ‘hybrid middle level manager*’ OR ‘doctors managers’ OR ‘clinician manager*’ OR ‘clinical manager*’ OR (hybrid AND professionalism) OR (managerialism AND professionalism)) AND (role OR identity) AND (‘public sector’ OR ‘public administration’ OR ‘public services’ OR ‘health*’ OR ‘education’ OR ‘universit*’ OR ‘justice’ OR ‘court’).

The keywords concerning the health-care sector (e.g. ‘clinical managers’) were included to account for the vast scholarship dealing with the role of health-care professionals entrusted with a managerial role (Powell and Davies 2016), which was likely to outnumber studies conducted in other fields. Indeed, health-care professionals represent ‘the extreme end of the spectrum of professional and expert formation, the archetypal model of professional power and disciplinary knowledge’ (Ashburner and Fitzgerald 1996, 190). However, in order not to ignore the existing scholarship on hybrid management in other professional bureaucracies, also keywords concerning university and justice were considered in the ‘context’ component of the algorithm.

A pilot search was constructed to identify articles where any of the above combinations appeared in the title, abstract or keywords discussing hybrid professionalism in the public domain. The abstracts of the first 30 articles resulting in each database, sorted by relevance, were analysed to verify whether the selected keywords allowed to retrieve contributions in line with the purpose of the review.

After this first screening process, aimed at assessing the relevance of the contributions, a form of snowball strategy was used to identify additional papers not resulting from this structured search but relevant to the topic. This second step consisted of a search based on recurring keywords emerging from the preliminary screening phase, but not included in the original algorithm. An additional search, on the same electronic databases, was then performed in order to supplement the results of the first step:

(‘knowledge broker*’ OR ‘boundary span*’) AND (‘role’ OR ‘identity’) AND (‘public sector’ OR ‘public administration’ OR ‘public services’).

These first two steps of the search identified a total of 614 results, distributed as following: WoS 1st step: n = 315; Scopus 1st step:186; EBSCO 1st step: n = 114; WoS 2nd step: n = 10; Scopus 2nd step: n = 19; EBSCO 2nd step: n = 10. The total number of articles was reduced to 468 after deleting duplicated results.

Eligibility of articles

Based on PRISMA approach (Moher et al. 2009), eligible studies were selected to be included in the review when meeting the following six criteria:

• Topic: The papers should narrowly address hybrid professionalism, in order to ensure an in-depth analysis of comparable studies. Some papers, for instance, Clark (2012), dealt with professionalism but did not predominantly investigate the hybridization process with regard to role and identity, and were hence excluded. This was aimed at limiting an otherwise excessively large subject for the scope of the review.

• Field: Articles should study hybrid professionalism in the public sector. We define the public sector from a functionalist perspective (Borgonovi 2005), whatever the provider, in order to account for possible cross-country dissimilarities in definition and boundaries (Jackson 2004).

• Study design: Both empirical and theoretical studies were included. The varied approaches adopted by scholars from several research field urged the author to account for both the empirical evidence and the emerging theoretical frameworks, in order to effectively synthetize the scientific contributions on hybrid professionalism.

• Source: The review included only papers published in international peer-reviewed academic journals. A systematic review is characterized by the quality assessment of the papers. However, since applying any quality assessment to the articles may introduce an interpretative bias, researchers usually rely on the assessment of the source (Tranfield, Denyer, and Smart 2003). Thus, unpublished papers, grey literature and books were not included in the review.

• Language: Only English written papers were selected, which is common for systematic reviews, given the practical difficulties of translation and replicability.

• Time frame: The review included papers published from 1990 to mid-2018. The year 1990 was chosen as it represents a conventional starting point for the NPM era (Hood and Peters 2004) and, therefore, a rough and yet widespread reference term for the hybridization of professionalism and managerialism.

Records selection

In order to identify suitable studies to contribute to the purpose of the review, we then carefully read the titles and abstracts of the resulting 468 articles and selected those that met all the aforementioned six inclusion criteria, with specific attention paid to topic and field. This third step led to the selection of 71 suitable papers.

In step four these works were further screened and categorized through full-text reading and deeper analysis, in order to attain a more focused selection of papers. The main reason for exclusions in this step was a loose focus on the role of hybrid professionals, the latter only being a contextual or marginal factor.

Finally, the remaining 57 articles were considered eligible for the review and analysed. All of them focused on hybrid professionalism, with particular reference to their role and identity. The next section describes the results of the review.

Results

Before answering the research questions of the study, some characteristics of the selected records are addressed. Data were charted using an ad hoc extraction protocol that included the following dimensions:

• Baseline information, i.e. author/s, year of publication and journal of publication;

• Context information, i.e. policy field and country/ies. This information helped the author accounting for the relevant contextual factors;

• Research method, which is the data-collection and methodological approaches used. As for empirical studies, the adopted the following three broad categories: qualitative studies, quantitative studies and mixed-methods studies. However, as already noted, also theoretical studies were included;

• Theoretical framework, which refers to the use of a clearly identifiable prevailing theory, the reference to multiple theoretical approaches combined, or a lack of explicit theoretical reference. Though simplifying, this classification has been previously adopted by other public management scholars (Mauro, Cinquini, and Grossi 2016) and allowed to distinguish those works aiming to contribute to theoretical advancements and those more inclined to nurture practice-based insights.

The 57 works were published in the 1992–2018 (Figure 2) volumes of 28 different journals. The publication trend in time highlights an increased interest towards the topic of hybrid professionals after 2014, with more than half studies (53%) published from this year on. The reason seems to be partially due to the foundation, in 2013, of a journal expressly focused on professional organizations (Journal of Professions and Organization), which published itself intensively on the topic of the review and contributed to raising scientific interest around it.

Figure 2. Number of papers included in the review by year of publication.

The four journals providing the greatest coverage of the topic were: Journal of Professions and Organization (n = 6), Journal of Health Organization and Management (n = 6), Public Administration (n = 4) and International Journal of Public Sector Management (n = 4). The sharp fragmentation of the publication sources mirrors a rooting of the studies in very differentiated research fields.

As for contextual information, the selected articles showed more cohesion. Out of 57 studies, 43 concerned the health-care sector, three studies were conducted in the education or higher education field and four in other public policy areas. Three papers regarded cross-policy studies. Four studies received no classification in this regard as they dealt with theoretical speculation. From a geographical perspective, UK-based studies unsurprisingly outnumbered all other countries, counting 37% of the total articles. Studies from Scandinavian countries (including Denmark) registered also a relevant amount of scientific production, with 11 contributions, whereas papers from Australia counted four records. Studies from other countries were numerically less represented. Three cross-country comparison studies were also included.

Regarding the methods, out of the 51 selected empirical studies, 45 were found to adopt qualitative inquiries, three used a mixed-method approach and only three based their insights on quantitative analyses; the remaining six papers were theoretical studies. The overwhelming prevalence of a qualitative approach is not surprising: the nature of the object of analysis, as well as the need to foster the emergence of perceptions and interpretations of concepts such as role and identity, made inductive qualitative research more suitable to engender finer-grained evidence.

As for theoretical background, about one-half of the reviewed studies (27 out of 57) draws on a single clear theoretical background, whereas nine studies adopt a combination of multiple theoretical references and 15 declare no explicit theoretical affiliation. This criterion has not been applied to those studies conducting literature reviews and research synthesis, based on their peculiar scope of analysis.

In Appendix 2, the final database showing the literature review results is displayed.

Discussion

The emerging results are presented and discussed in the following sections, based on a classification of the perspective of analysis adopted in the studies. Three main approaches emerged in this regard: studies contributing to an institutional logics perspective (Thornton and Ocasio 2008; Reay and Hinings 2009), studies advancing insights on identity work perspective (Creed, Dejordy, and Lok 2010) and studies investigating enabling conditions for hybrid professionals to exert effectively their role (Mintzberg 1998). By streamlining the contributions that proved to be insightful to the three perspectives, the author will answer the corresponding research questions (RQs): institutional logics perspective studies then contribute to RQ 1, scholarship on identity work tries to answer RQ 2 and studies devoted to the enabling conditions perspective enrich the debate posited by RQ 3.

As already highlighted by other scholars (Meyer et al. 2014), these perspectives are, actually, closely intertwined and it would be very difficult, in day-to-day organizational experience, to identify the border points between one and the others: indeed, professionalism operates ‘both as an ideology or a belief system at the macro level and as a control mechanism of individual practitioners at the micro level’ (Evetts 2003). This continuum, indeed, is mirrored by the fact that most of the reviewed studies simultaneously contributed to multiple perspectives. In these cases, a prevalence criterion was used when classifying the emerging insights.

The institutional logics perspective

An institutional logic is defined as ‘a set of material practices and symbolic constructions constituting organizing principles which are available to organizations and individuals to elaborate’ (Friedland and Alford 1991, 248). In other words, institutional logics set the frames of reference defining actors’ choices for sense-making and their sense of self and identity (Thornton and Ocasio 2008). A large part of the reviewed studies adopted this concept to explain the nature of hybrid professionalism, viewed as a form of institutional complexity (Greenwood et al. 2010) with incompatible prescriptions from multiple institutional logics coming together. Beside institutional logics, a dialectic approach is also adopted by those scholars applying Foucauldian lenses: without digging into a discussion that would be outside the scope of this review, the concept of ‘technologies of power’ as the belief systems within which individuals construct the self and exert agency seems very much associable with institutional logics.

The studies included in the review adopted the perspective of an interplay between two (Olakivi and Niska 2017; Noordegraaf 2007, 2015, 2013; Hendrikx and van Gestel 2017) or more (Blomgren and Waks 2015; Byrkjeflot and Jespersen 2014; Pettersen and Solstad 2014) institutional logics, with public sector reform processes questioning traditional professionalism in the public domain, by conveying managerialism norms and values. At its core, professionalism is indeed defined by autonomy or, in other words, ‘controlled content’ (Noordegraaf 2007): as it is a matter of learning, knowing and doing certain things (content) and being part of professional communities entitled to define and assess how the content should be exerted (control), its encounter with managerialism as a source of external control is likely to question its very bases. Whereas professionalism has been defined as a ‘logic of appropriateness’, managerialism has been referred to as a ‘logic of consequentiality’ (March and Olsen 2010). More nuanced interplays have been assumed by some scholars, by bringing in also political (Pettersen and Solstad 2014), democratic and market (Blomgren and Waks 2015) logics.

Several possible results of combined logics have been outlined (Numerato, Salvatore, and Fattore 2012), accordingly mirrored by different professionals’ strategies, from resistance and protection (Doolin 2001), to bureaucratization (Kitchener 2000), to interactive exploitation (Kolsaker 2008), to connection (Noordegraaf 2013) and – under specific conditions – even to opportunistic role-escape (Currie, Tuck, and Morrell 2015). Challenging a traditional conflict perspective (Scott 2008), which allude to processes of ‘deprofessionalization’, ‘proletarianization’ or ‘post-professionalization’ (Randall and Kindiak 2008), discourse-based studies have suggested a less clear-cut situation about how managerialism and professionalism interface. In this view, hybridization processes are described as ‘negotiation’ (Ainsworth, Grant, and Iedema 2009) and ‘articulation’ (Thomas and Hewitt 2011).

In line with the trend to account more and more for the inherent complexity of these roles, several scholars warn against the tendency to apply simplistic or one-size-fits-all approaches to institutional logic-based research. Noordegraaf’s fundamental work (Noordegraaf 2007, 2013, 2015) claims for a finer-grained approach to the topic of professional hybridization and proposes a fourfold conceptualization of it: whereas pure professionalism aims at protecting and restoring a traditional professional logic, controlled professionalism disciplines professional work within organizational settings and structures, managed professionalism actually hybridizes professional and organizational logics, and – ‘beyond hybridity’ (Noordegraaf 2015) – organizing professionalism embeds organizing roles and capacities within professional action.

All in all, a trend in scholarship switching from competing logics to overlapping discourses (Olakivi and Niska 2017) is not in question. By applying a stretched definition of ‘profession’, Røiseland, Pierre, and Gustavsen (2015) have explored how different systems of norms, intended as principles of control and accountability, interact from the standpoint of Scandinavian local government leaders. Their analysis shows that, surprisingly, professionalism is a strong predictor of positive attitudes toward managerialism, thus reframing the two logics as complementary, rather than competing, control arrangements.

Contextual factors may also play a great role in shaping the specific character of hybridization, both at the systemic (Bode and Maerker 2014), sectorial (Currie, Burgess, and Tuck 2016; Hendrikx and van Gestel 2017), organizational (Fitzgerald and Ferlie 2000) and occupational (Burgess and Currie 2013) level. These nuanced effects have drawn extensive attention in the literature in the frame of role theory, as that roles act as cogs in the transmission between the macro level of institutional logics and the microprocesses of individual behaviours. This process is further discussed in the following paragraph.

The identity work perspective

In order to answer the second research question of the study, in this paragraph are summarized contributions dealing with identity work, as the processes engaging individuals in ‘forming, repairing, maintaining, strengthening or revising the constructions that are productive of a sense of coherence and distinctiveness’ (Sveningsson and Alvesson 2003) and, particularly, with role claiming and role use (Creed, Dejordy, and Lok 2010). Roles are indeed fundamental building blocks in defining the sense of organizational self (i.e. organizational identification); though their definition would go beyond the scope of this study, at the very least they can be defined as social positions carrying along expectations for behaviour and obligations to other actors.

Within these defining points, role claiming refers to the motivation to embrace a certain role, whereas role use defines the purpose towards which the role is exerted (Creed, Dejordy, and Lok 2010). Below are then reviewed the studies advancing insights about why professionals embrace hybrid roles and how they play them.

Hybrid professionals are pivotal to support policy-driven aspiration for change, due to their ability to view organizational issues through ‘two-way windows’ (Llewellyn 2001): this metaphor has been widely used to indicate transparency between the boundaries of different domains, implying open communication between logics being previously considered opaque to each other. Building on the case of clinical directorates in UK, Llewellyn depicts the role of the hybrid professional as the organizational actor who makes different domains mutually visible, thanks to ‘Janusian thinking’ capacity (Llewellyn 2001, 594). This process has also been referred to as boundary work (Ong 1998), knowledge brokering (Burgess and Currie 2013; Kislov, Hodgson, and Boaden 2015; Currie, Burgess, and Hayton 2015) or translational work (Spyridonidis and Currie 2016), suggesting that hybrids can use their in-between positions to support change through connecting, recombining and translating managerial and professional knowledge across different individuals and groups within and outside the organization.

Burgess and Currie (2013) focused on middle-level managers in the health-care sector to describe this knowledge-brokering role: by crossing professional frontline and managerial domains, these actors are ‘capable of brokering both exogenous and endogenous knowledge within and across professions, departments and organizations for service development’ (Burgess and Currie 2013, 140). However, this should not be intended as a deterministic process: knowledge-brokering is indeed a collective phenomenon which is only possible when ‘external knowledge is spread within the organization through internal knowledge brokering embedded in collective practice’ (Kislov, Hodgson, and Boaden 2015, 484). This needs other actors, beside ‘designated’ hybrids, to emerge as additional knowledge-brokers and configure effective ‘broker chains’ (Waring et al. 2013).

This role of institutional bridge has been also explained by Blomgren and Waks (2015): based on their study in the Swedish health-care sector, the authors observed that hybrid professionals can bridge conflicting institutional logics by providing ‘translation work’ (e.g. constructing and sharing data to monitor health-care performance) and building practical solution that aligned with the different logics at play. Indeed, their embeddedness in different logics makes hybrid professionals able to function ‘as linking pins between different world views’ (Blomgren and Waks 2015, 97) and ‘make the work done’ (ibidem).

However, scholars do not unanimously agree in considering such a proactive role use. A more conservative view is presented by Doolin (2001) in his study on a clinical leadership strategy carried out in New Zealand in the mid-Nineties: here, doctors-managers seem to stick to the traditional concept of managerialism as ‘the dark side’ and see the hybridization process as a risk to betray their profession. This results in a process of decoupling: while accepting the organizational changes for external legitimation purposes, organizational actors resist the implementation of the changes in internal operational activities. Very similar processes, labelled as ‘delegating’ and ‘buffering’, are discussed by Jain, George, and Maltarich (2009) when exploring role identity modifications of (reluctant) academics involved in commercialization activity. Individual expectations on the managerial role can actually polarize the commitment of professionals towards management, forging ‘investors’ and ‘reluctant’ types (Forbes, Hallier, and Kelly 2004): ‘investors’ come into management with a specific agenda and seeing potential opportunities, whereas ‘reluctants’ accept the dual role based on the willingness to exert organizational and professional resistance or defence.

Even if inclined to exert a hybrid role, professionals may encounter practical sources of role conflict, such as time constraints and work overload: O’Riordan and McDermott (2012), for instance, described general practitioners-managers in Ireland facing tension in balancing their primary professional identity with their secondary business role, with work encroaching into personal time and thus limiting their possibility to attend training. Braithwaite (2004), in a grounded description of clinician-managers’ behavioural routines in the Australian context, reinforced this ‘stuck-in-between’ position depicting them as ‘embedded in webs of complex relationships’ (ibidem, p. 249), with demands and pressures on both the vertical and horizontal organizational planes. Clinicians-managers indeed are required to mobilize influence, develop networks and alliances and support their structures, coping with expectations descending from different logics.

From a different but compatible theoretical perspective, Ainsworth, Grant, and Iedema (2009) investigate this very topic under the lenses of spatial discourse: drawing on Lefebvrian conceptualization of space, these scholars apply metaphor in discourse as a tool to interpret organization and managerial phenomena and generate insight into the behaviour and attitudes of individuals. By analysing the role of hybrid middle-managers through their spatial imagery (i.e. the material and metaphorical spatial concepts that help individual making sense of their positioning and relationship within an organizational context), these authors highlight this role as balancing the tension, inherently present in a reforming organization, between competing and contradictory spatial logics of fixity and flow. Rather than inserting into a managerial hierarchy whose main scope is to dictate, control or persuade, the authors suggest that these hybrid roles ‘require to be involved in more intense forms of contact and communication with their immediate co-workers’ (Ainsworth, Grant, and Iedema 2009, 5). Drawing as well on a spatial metaphor (i.e. distance vs. closeness), Sørensen, Delmar, and Pedersen (2011) conceptualize nurses-managers’ role as a navigation between clinical activities and management. Croft et al. (Croft, Currie, and Lockett 2015) build on the concept of ‘liminal space’ to question the naïve idea of hybrids as conflict managers and identity crafters: on the contrary, they highlight the risk, inherent to their position, of identity turbulence and conflict.

Role use can also aim to protect or redefine the boundaries of occupational power: this is explained by Carvalho (2012, 2014) when showing that nurses in Portugal use managerialism as a strategy to legitimate their position in the organizational context and to maintain control over their profession. By emphasizing care as their core function, nurses seem to include managerialism as a role-enhancing trait of their profession. This point is also explored by Currie and Croft (2015): in their research note, they highlight that nurses-managers, compared to ‘higher-status roles’ such as doctors-managers, are likely to respond differently to the demands of their managerial role, as also discussed by Spehar, Frich and Kjekshus (2015).

Drawing on identity work concepts, Cascón-Pereira et al. (Cascón-Pereira, Chillas, and Hallier 2016) explore how the construction of particular role-meanings influence role identities of doctors-manager in the Spanish health-care sector. In their study, role-meanings are shown to work as ‘the very fabric with which the sensemaking process of identification is developed’ and ‘the means by which institutional discourses and interpersonal relations […] operate and influence role identities’ (Cascón-Pereira, Chillas, and Hallier 2016, 23). In highlighting the contribution of their study to the understanding of role claiming and role use, these authors also comment on a study conducted by Mcgivern et al. (2015). In this study, the authors identify two hybrid types: ‘incidental hybrids’ use hybrid roles to represent, protect and maintain traditional institutionalized professionalism; on the contrary, ‘willing hybrids’ develop authentic hybrid identities throughout formative identity work. Differentiated coping strategies have been also emphasized by Spyridonidis, Hendy and Barlow (2015) among clinical managers in UK (i.e. the innovators, the sceptics and the late majority), and by Breit, Fossestol and Andreassen (2018) in the Norwegian labour and welfare administration (i.e. hybridization, commodification and protection). The chance for the process of hybridization to actually take place depends indeed on contingent factors, both at the organizational and individual level, which can result in very different reactive approaches. Whatever the actual outcome of the navigation across diverse discourses, Machin (2018) highlight that ‘through hybridity there is the potential to configure non-exclusive, blended and shifting […] identities which cross-cut multiple discourses’ (p. 14).

In line with this view, Spehar, Frich and Kjekshus (2012) discuss clinicians’ experiences in entering management roles by drawing on qualitative data gathered in the Norwegian health-care sector: challenging the scholarships rooted in sociological theories of profession and general management theories, the authors show that a broad variety of reasons nested in the organization may exist for professional to take on managerial roles, bringing path-dependency in the debate.

In a recent study comparing education and health care, Hendrikx and van Gestel (2017) construe professionalism through historical lenses. The authors present professional role use as reflecting different public management archetypes: Traditional Public Administration, New Public Management and New Public Governance (Christensen and Per 2011) are mirrored, respectively, by professionals as guardians, service providers and network partners. However, waves of reform should not be considered sequential, but rather intertwined and ‘layered’ (Christensen and Per 2011; Iacovino, Barsanti, and Cinquini 2015); likewise, professionalism can take different forms because of contextual factors (such as sectors), as the action of professional communities matters as a mediating factor in a complex mutual relationship with reform processes. As shown by Sartirana, Prenestini and Lega (2014) as well as Kuhlmann, Rangnitt and Von Knorring (2016), respectively, in the Italian and Swedish health-care sectors, the successful (or unsuccessful) reshaping of professionals’ role and identity cannot be contemplated without considering the supportive (or restraining) organizational environments in which this process takes place.

The ‘enabling conditions’ perspective

Henry Mintzberg, describing the interplay between profession and management, stated that ‘professionals require little direction and supervision. What they need is […] support’ (Mintzberg 1998, 146). Telling a parallel with the world of music, he emphasizes that professionals – just as musicians of an orchestra – do not need to be empowered; rather, they need to be enabled in their work.

In a recent study on institutional complexity, Martin et al. (2017) investigated how divergent outcomes in individual responses (e.g. domination, resistance, transformation) to multiple institutional configurations can arise from both individual agency and organizational level factors. The authors questioned the idea that contrasting responses in practice can actually result from either the constellation of logics in the field or the action of focal organizational actors alone; on the contrary, they ascribed such a variability to ‘the confluence of micro- and macro-level circumstances, mediated at the meso (organizational) level’ (ibidem, p. 114). In other words, organizational factors act as a prism between the macro and the micro levels, transmitting ‘institutional prescriptions into micro-level constraints’ (ibidem, p. 125) and explaining why ‘institutional repertoires that were accessible and held legitimacy in some cases were beyond the reach of focal actors in others’ (ibidem, p. 114).

This approach is discussed by Quartz-Topp, Sanne and Pöstges (2018) in a comparative study on Dutch and Swedish hospitals dealing with quality improvement initiatives: as they moved away from the mentality of clash towards a more pragmatic approach, managers could support professionals self-efficacy via a series of hybrid forums (e.g. meetings, training), tools (e.g. monitoring systems) and roles, blending managerial and professional knowledge. This integration proved to generate new practices that have the potential to support professionals in their efforts to align different demands. A paramount role of meetings as ‘managerial vehicles’ is also highlighted by Braithwaite (2004), who describes the nature of management work as essentially communicative: the hybrid manager’s activity is ‘centred on ongoing interaction, coordinating work with and through others, influencing people and the constant creation and dismantling of relationships and teams’ (ibidem, p. 252).

The enactment of a range of support strategies with training and role development activities is being since long considered conducive to overcoming the traditional reluctance of professionals to engage with management (Fitzgerald and Sturt 1992); this kind of resistance is rooted into a cultural clash between the scientific provenance of the historically formed professional habitus, based on evidence-based individualistic decision-making, and managerialism, often perceived as ‘a technical procedure that can be learnt by rote’ (Fitzgerald and Sturt 1992, 138). However, over time professionals have become increasingly aware that taking on dual roles requires specific skills and competences: Kippist and Fitzgerald (2009), for instance, report that reluctance itself may actually arise from feeling unfit for the managerial role, based on a perception of lacking training.

Burgess et al. (2015) discuss, under the lenses of organizational ambidexterity (Lavie, Stettner, and Tushman 2010), contingencies that shape the ability of hybrid middle managers to mediate tensions and conflicts arising from the inter-organizational and intra-organizational context (Kippist and Fitzgerald 2009) and ‘forge workable compromises’ (Burgess et al. 2015, 88). In their study, the authors found that hybrid middle managers are more likely to span professional boundaries when having appropriate social linkages and a holistic (rather than a specialist) professional background.

As regards management Macinati, Bozzi and Rizzo (2016, 2017) show, through multi-method investigation in the Italian health-care sector, that participative budgeting enhances hybrid professionals’ self-efficacy and, indirectly, their capacity to contribute to performance: this nexus takes action by offering information that strengths hybrids’ cognitive and emotional investment in managerial tasks by supporting their belief to ‘have the capability and resources to perform successfully in managerial tasks’ (Macinati, Bozzi, and Rizzo 2016, 1020).

However, the adoption of management control practices can be conducive to very differentiated effects on the absorption of accounting knowledge by medical professionals (Østergren 2009), accordingly mirrored by different interpretation of the hybrid role. Østergren highlights the risk for hybrids role to experience an ever-increasing need for accounting knowledge, which could eventually lead them to information overload and, by this mean, hinder their capacity to decode and translate top management directives. Use of information, in the shape of performance management, emerged as a fundamental aspect of hybrid professionals’ boundary work also in Fitzgerald and Dufour’s (1997) comparative study on Canadian and UK clinical management: performance information can be framed as a tool for brokering knowledge, through which translational processes can be directed. Shand and Callen (2003) reinforce this view and show, based on a questionnaire-based research conducted among Australian health-care professionals, that management information supports the hybrid role of the clinicians-managers if they are timely, graphically interpretable and comparative.

Organizational configuration, as well as professional status and hierarchy can define conditions for professional action, as ‘the scope of professional work is somehow dependent on organizational processes’ (Correia and Denis 2016): however, this may result in paradoxical scenarios, with professionals taking advantage of incumbent roles to exploit re-stratification, thus ‘balkanizing’ (Correia and Denis 2016, 81) organized professionalism, or exacerbating existing power differentials, as in the case of nurses-managers compared to doctors-managers (Currie, Finn, and Martin 2008; Currie, Burgess, and Hayton 2015).

Conclusions and directions for future research

Professionals’ capacity to mediate top-down demands plays an important role in the implementation process of policy-driven change (Ackroyd, Kirkpatrick, and Walker 2007). As waves of public sector come to a various extent and time in different parts of the world, similarly hybrid professionalism also varies in strength across domains and systems, as well as the sequence of its emergence and development. Scholars have long been addressing the theme of contingency in public management (Ongaro 2009; Meyer and Hammerschmid 2010) and thoroughly questioned the one-size-fits-all approach: on this line, research on hybrid professionalism provided findings that prove to be strongly context-dependent: normative, institutional, administrative, sectorial and occupational factors – just to cite a few – make the difference, and have to be accounted for. As for conceptualization issues, however, it is to note that hybridity often ends up being a ‘blanket term’ (Fulop 2012) used to cover phenomena which are ‘no more’ something (e.g. pure professionalism) and ‘not yet’ something else (e.g. managerialism). However, in order to provide useful insights for public management research and practice, the in-between space needs to be questioned, understood and explained. Recently, several scholars (Noordegraaf 2015) have challenged the dichotomous and maybe simplistic perspective provided by the mentality of clash, and advanced both empirical and theoretical insights and conceptualization, where institutional and organizational complexities (the plural being significant) are accounted for.

Reviewing professionalism as intertwined with public sector reforms, as recently suggested by some scholars in public management (Røiseland, Pierre, and Gustavsen 2015; Hendrikx and van Gestel 2017), offers noticeable potential for research in the field. It is indeed reasonable that the macro-modifications of the public sector impact the nature of roles and the ways of acting of professionals; these, in turn, are likely to contribute to determining the (positive or negative) outcome of change and reform implementation, by means of their translational work. Another avenue for research could be therefore that of microprocesses of institutional complexity. This research space, however, seems not as disregarded as a number of scholars suggest (Cascón-Pereira, Chillas, and Hallier 2016; Blomgren and Waks 2015): most of the papers reviewed, on the contrary, drew on both institutional logics and identity work to explore this very topic. Based on the results of this study, a far more niche and underdeveloped avenue for research seems to be related to the enabling conditions and managerial levers that help professionals exert hybrid roles: this seems to be a promising avenue for public management research to come.

As for methods, the overwhelming prevalence of qualitative approaches – though consistent with the nature of the topic – might be questioned, in order to understand whether different designs could better address the scope of research on hybrid professionalism. Mixed-method designs are currently gaining traction in public sector research (Pandey 2017): though several barriers have to be considered when combining methodological approaches (Creswell and Plano Clark 2017), scholars underline (Tashakkori and Teddlie 2003; Yang, Zhang, and Holzer 2008) that mixed-method studies can generally answer research questions that other approaches cannot, provide better inferences and mitigate threats stemming from a mono-method approach. A few studies included in this review actually adopted a mixed-method approach (Macinati, Bozzi, and Rizzo 2016), providing promising insights: further research should be promoted in this strand.

Acknowledgments

The author wishes to acknowledge helpful feedbacks from the scholars of MeS Lab (Scuola Superiore Sant’Anna) and, in particular, Prof. Sabina Nuti, Prof. Milena Vainieri, Nicola Bellè and Anna Maria Murante for their precious comments on a previous version of the paper.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Giorgio Giacomelli

Giorgio Giacomelli (PhD) is Postdoctoral research fellow at Laboratorio Management e Sanità (MeS), Institute of Management of Scuola Superiore Sant’Anna in Pisa. His primary research interests are in performance management and human resource management in the public sector. He has a Master’s Degree in Economics and Management of Public Administrations and International Institutions and a PhD in Management.

Appendix 1.

Database of the scoping study (records displayed by authors’ alphabetical order)

Table

Authors	Title	Year	Journal
Croft, C.; Currie, G.; Lockett, A.	Broken ‘two‐way windows’? An exploration of professional hybrids	2015	Public Administration
Fitzgerald L., Ferlie E.	Professionals: back to the future?	2000	Human Relations
Llewellyn, S.	‘Two-way windows’: Clinicians as medical managers	2001	Organization Studies
McGivern, G.; Currie, G.; Ferlie, E.; Fitzgerald, L.; Waring, J.	Hybrid manager-professionals’ identity work: the maintenance and hybridization of medical professionalism in managerial contexts	2015	Public Administration
Noordegraaf, M.	From ‘pure’ to ‘hybrid’ professionalism - Present-day professionalism in ambiguous public domains	2007	Administration and Society

Appendix 2.

Database of the selected papers (records displayed by first author’s alphabetical order)

Table

Authors	Title	Year	Journal	Methods	Country	Policy field	Theoretical background
Ainsworth S., Grant D., Iedema R.	Keeping things moving’: space and the construction of middle management identity in a post-NPM organization	2009	Discourse and Communication	Qualitative	Australia	Health care	Single prevailing theory
Blomgren, M; Waks, C	Coping with contradictions: hybrid professionals managing institutional complexity	2015	Journal of Professions and Organization	Qualitative	Sweden	Health care	Single prevailing theory
Bode I., Maerker M.	Management in medicine or medics in management? The changing role of doctors in German hospitals	2014	International Journal of Public Sector Management	Qualitative	Germany	Health care	Multiple theoretical approaches combined
Braithwaite J.	An empirically-based model for clinician-managers’ behavioural routines	2004	Journal of Health Organization and Management	Qualitative	Australia	Health care	No declared theoretical affiliation
Breit, E.; Fossestol, K.; Andreassen, T.A.	From pure to hybrid professionalism in post-NPM activation reform: the institutional work of frontline managers	2018	Journal of Professions and Organization	Qualitative	Norway	Cross-policy analysis	Single prevailing theory
Burgess N., Currie G.	The knowledge brokering role of the hybrid middle level manager: the case of healthcare	2013	British Journal of Management	Qualitative	UK	Health care	Single prevailing theory
Burgess, N. Strauss, K. Currie, G. Wood, G.	Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals	2015	Human Resource Management	Qualitative	UK	Health care	Single prevailing theory
Byrkjeflot H., Jespersen P.K.	Three conceptualizations of hybrid management in hospitals	2014	International Journal of Public Sector Management	Theoretical	NA	Health care	NA
Carvalho T.	Managerialism and professional strategies: A case from nurses in Portugal	2012	Journal of health organization and management	Qualitative	Portugal	Health care	No declared theoretical affiliation
Carvalho, T.	Changing connections between professionalism and managerialism: a case study of nursing in Portugal.	2014	Journal of Professions and Organization	Qualitative	Portugal	Health care	No declared theoretical affiliation
Cascón-Pereira R., Chillas S., Hallier J.	Role-meanings as a critical factor in understanding doctor managers’ identity work and different role identities	2016	Social Science and Medicine	Qualitative	Spain	Health care	Single prevailing theory
Correia T., Denis J.L.	Hybrid management, organizational configuration, and medical professionalism: Evidence from the establishment of a clinical directorate in Portugal	2016	BMC Health Services Research	Qualitative	Portugal	Health care	No declared theoretical affiliation
Croft, C.; Currie, G.; Lockett, A.	Broken ‘two‐way windows’? An exploration of professional hybrids	2015	Public Administration	Qualitative	UK	Health care	Single prevailing theory
Currie G., Croft C.	Examining hybrid nurse managers as a case of identity transition in healthcare: Developing a balanced research agenda	2015	Work, Employment and Society	Theoretical	NA	NA	NA
Currie G., Tuck P., Morrell K.	How hybrid managers act as ‘canny customers’ to accelerate policy reform. A case study of regulator-regulatee relationships in the UK’s tax agency	2015	Accounting, Auditing and Accountability Journal	Qualitative	UK	Taxation	Single prevailing theory
Currie, G. Burgess, N. Tuck, P.	The (un)desirability of hybrid managers as ‘controlled’ professionals: comparative cases of tax and healthcare professionals	2016	Journal of Professions and Organization	Qualitative	UK	Cross-policy analysis	No declared theoretical affiliation
Currie, G.; Burgess, N.; Hayton, J.C.	HR practices and knowledge brokering by hybrid middle managers in hospital settings: the influence of professional hierarchy	2015	Human Resource Management	Qualitative	UK	Health care	Single prevailing theory
Currie, G; Finn, R; Martin, G	Accounting for the ‘dark side’ of new organizational forms: The case of healthcare professionals	2008	Human Relations	Qualitative	UK	Health care	No declared theoretical affiliation
Doolin B.	Doctors as managers: New public management in a New Zealand hospital	2001	Public Management Review	Qualitative	New Zealand	Health care	No declared theoretical affiliation
Fitzgerald L., Dufour Y.	Clinical management as boundary management – A comparative analysis of Canadian and UK health-care institutions	1997	International Journal of Public Sector Management	Qualitative	UK and Canada	Health care	Single prevailing theory
Fitzgerald L., Ferlie E.	Professionals: back to the future?	2000	Human Relations	Qualitative	UK	Health care	No declared theoretical affiliation
Fitzgerald L., Sturt J.	Clinicians into management: on the change agenda or not?	1992	Health Services Management Research	Theoretical	UK	Health care	NA
Forbes T., Hallier J., Kelly L.	Doctors as managers: Investors and reluctants in a dual role	2004	Health Services Management Research	Qualitative	UK	Health care	Multiple theoretical approaches combined
Hendrikx, W. van Gestel, N.	The emergence of hybrid professional roles: GPs and secondary school teachers in a context of public sector reform	2017	Public Management Review	Qualitative	Netherlands	Cross-policy analysis	Multiple theoretical approaches combined
Jain, S; George, G; Maltarich, M	Academics or entrepreneurs? Investigating role identity modification of university scientists involved in commercialization activity	2009	Research Policy	Qualitative	USA	Education/University	Single prevailing theory
Kippist L., Fitzgerald A.	Organisational professional conflict and hybrid clinician managers: The effects of dual roles in Australian health-care organisations	2009	Journal of Health Organization and Management	Qualitative	Australia	Health care	Multiple theoretical approaches combined
Kislov R., Hodgson D., Boaden R.	Professionals as knowledge brokers: the limits of authority in health-care collaboration	2016	Public Administration	Qualitative	UK	Health care	Single prevailing theory
Kitchener M.	The ‘bureaucratization’ of professional roles: the case of clinical directors in UK hospitals	2000	Organization	Qualitative	UK	Health care	Single prevailing theory
Kolsaker A.	Academic professionalism in the managerialist era: a study of English universities	2008	Studies in Higher Education	Mixed-method	UK	Education/University	Single prevailing theory
Kuhlmann, E.; Rangnitt, Y.; von Knorring, M.	Medicine and management: looking inside the box of changing hospital governance	2016	BMC Health Services Research	Qualitative	Sweden	Health care	No declared theoretical affiliation
Kurunmaki, L.	A hybrid profession – the acquisition of management accounting expertise by medical professionals	2004	Accounting, organizations and society	Qualitative	Finland	Health care	No declared theoretical affiliation
Llewellyn, S.	‘Two-way windows’: Clinicians as medical managers	2001	Organization Studies	Qualitative	UK	Health care	Multiple theoretical approaches combined
Machin, D.	The hybrid professional: an examination of how educational leaders relate to, with and through managerialism	2018	British Journal of Sociology of Education	Qualitative	UK	Education/University	Single prevailing theory
Macinati M.S., Cantaluppi G., Rizzo M.G.	Medical managers’ managerial self-efficacy and role clarity: how do they bridge the budgetary participation–performance link?	2017	Health Services Management Research	Quantitative	Italy	Health care	Single prevailing theory
Macinati, M.S.; Bozzi, S.; Rizzo, M.G.	Budgetary participation and performance: the mediating effects of medical managers’ job engagement and self-efficacy	2016	Health Policy	Mixed-method	Italy	Health care	Single prevailing theory
Martin G., Currie G., Weaver S., Finn R., McDonald R.	Institutional complexity and individual responses: delineating the boundaries of partial autonomy	2017	Organization Studies	Qualitative	UK	Health care	Single prevailing theory
McGivern, G.; Currie, G.; Ferlie, E.; Fitzgerald, L.; Waring, J.	Hybrid manager-professionals’ identity work: the maintenance and hybridization of medical professionalism in managerial contexts	2015	Public Administration	Qualitative	UK	Health care	Single prevailing theory
Noordegraaf, M.	From ‘pure’ to ‘hybrid’ professionalism – Present-day professionalism in ambiguous public domains	2007	Administration and Society	Theoretical	NA	NA	NA
Noordegraaf, M.	Reconfiguring professional work: changing forms of professionalism in public services	2013	Administration and Society	Theoretical	NA	NA	NA
Noordegraaf, M.	Hybrid professionalism and beyond: (New) Forms of public professionalism in changing organizational and societal contexts	2015	Journal of Professions and Organization	Theoretical	NA	NA	NA
Olakivi, A.; Niska, M.	Rethinking managerialism in professional work: from competing logics to overlapping discourses	2017	Journal of Professions and Organization	Qualitative	Finland	Welfare/Social care	Multiple theoretical approaches combined
Ong, B.N.	Evolving perceptions of clinical management in acute hospitals in England.	1998	British Journal of Management	Qualitative	UK	Health care	Single prevailing theory
O’Riordan C., McDermott A.	Clinical managers in the primary care sector: do the benefits stack up?	2012	Journal of Health Organization and Management	Qualitative	Ireland	Health care	No declared theoretical affiliation
Østergren, K.	Management control practices and clinician managers: the case of the norwegian health sector.	2009	Financial Accountability and Management	Qualitative	Norway	Health care	Single prevailing theory
Pettersen, I.J; Solstad, E.	Managerialism and profession-based logic: the use of accounting information in changing hospitals	2014	Financial Accountability and Management	Mixed-method	Norway	Health care	Multiple theoretical approaches combined
Quartz-Topp, J.; Sanne, J.M.; Postges, H.	Hybrid practices as a means to implement quality improvement: a comparative qualitative study in a Dutch and Swedish hospital	2018	Health Care Management Review	Qualitative	Sweden and Netherlands	Health care	No declared theoretical affiliation
Randall G.E., Kindiak D.H.	Deprofessionalization or postprofessionalization? Reflections on the state of social work as a profession	2008	Social Work in Health Care	Qualitative	Canada	Welfare/Social care	No declared theoretical affiliation*
Røiseland A., Pierre J., Gustavsen A.	Accountability by professionalism or managerialism? Exploring attitudes among Swedish and Norwegian local government leaders	2015	International Journal of Public Administration	Quantitative	Sweden and Norway	Local government	Multiple theoretical approaches combined
Sartirana M., Prenestini A., Lega F.	Medical management: hostage to its own history? the case of Italian clinical directors	2014	International Journal of Public Sector Management	Qualitative	Italy	Health care	Single prevailing theory
Shand S., Callen J.	Management information needs of clinician managers in a metropolitan teaching hospital	2003	Health Information Management	Quantitative	Australia	Health care	NA
Sørensen E.E., Delmar C., Pedersen B.D.	Leading nurses in dire straits: Head nurses’ navigation between nursing and leadership roles	2011	Journal of Nursing Management	Qualitative	Denmark	Health care	No declared theoretical affiliation
Spehar I., Frich J.C., Kjekshus L.E.	Clinicians’ experiences of becoming a clinical manager: a qualitative study.	2012	BMC health services research	Qualitative	Norway	Health care	Multiple theoretical approaches combined
Spehar, I.; Frich, J.C.; Kjekshus, L.E.	Professional identity and role transitions in clinical managers	2015	Journal of Health Organization and Management	Qualitative	Norway	Health care	Single prevailing theory
Spyridonidis D., Currie G.	The translational role of hybrid nurse middle managers in implementing clinical guidelines: effect of, and upon, professional and managerial hierarchies	2016	British Journal of Management	Qualitative	UK	Health care	Single prevailing theory
Spyridonidis D., Hendy J., Barlow J.	Understanding hybrid roles: The role of identity processes amongst physicians	2014	Public Administration	Qualitative	UK	Health care	Single prevailing theory
Thomas, P.; Hewitt, J.	Managerial organization and professional autonomy: a discourse-based conceptualization	2011	Organization Studies	Qualitative	UK	Health care	Single prevailing theory
Waring, J.; Currie, G.; Crompton, A.; Bishop, S.	An exploratory study of knowledge brokering in hospital settings: Facilitating knowledge sharing and learning for patient safety?	2013	Social Science and Medicine	Qualitative	UK	Health care	Single prevailing theory