Lower-status experts' influence on health-care managers' decision-making

Introduction

In public organizations, there has been an expansion of support functions in staff positions due to new public management (Ackroyd et al., 2007). In health-care organizations, human resource (HR) experts and other quality experts in staff positions have been added to the organization (Wadmann et al., 2019). Including experts is supposed to strengthen the line managers' ability to improve the performance of public organizations (Andrews et al., 2009; Rosenberg Hansen and Ferlie, 2016). Relationships between line managers and experts in staff positions constitute a pertinent area of study regarding the structure of public organizations (Weber, 1946; Dalton, 1950; Mintzberg, 1979; Sapir et al., 2016). Experts in staff positions have extensive knowledge or abilities in specific areas, based on research, experience or occupation (Styhre et al., 2010, pp. 159–160). Both experts and line managers may have extensive knowledge and be professionals. However, not all experts may be professionals. Professionals have exclusive rights to perform work associated with their specific area of scientifically-grounded theory, acknowledged in professional licensing and legislation (Abbot, 1988). Different professionals hold different statuses, depending on their authority in relation to other professionals (Freidson, 2001). New professionals may hold relatively lower status than established ones, such as physicians (Abbott, 1988; Freidson, 2001). Experts may differ from line managers, who may well have extensive knowledge, and be professionals. Experts in staff positions constitute part of the external environment of line managers working in the primary operations. Given that this staff position exists alongside positions in the line organization, we assume that staff experts lack formal authority to exert power over the line managers' actions and decision-making (Crozier and Friedberg, 1980).

Researchers (McGuire et al., 2008; Thilander, 2013) have indicated that the main problem with experts is their inability to influence the line managers' operational and strategic decision-making, whereas the managers' main difficulty is underdeveloped control over or collaboration with the experts. Line managers consider the staff experts' knowledge to be inadequate and interfere in their attempt to achieve their core goals (Sapir et al., 2016; DiBenigno, 2019). Line managers do not value the experts' knowledge and believe that it is harmful to follow their recommendations (Huising, 2015; Valentine, 2018).

We claim that a consequence of the increased number of experts in health care organizations is increased organizational complexity for managers in governing, as long as experts and line managers have difficulties cooperating.

Previous research on cooperation difficulties have addressed the need for experts to connect with line managers' organizational knowledge (Freidson, 1970; Truss, 2009; Arena et al., 2010) to make their problem-solving methods visible and to demonstrate their unique competence in a relationship with the managers' problem definitions (Dutton et al., 2001; Mikes, 2009; Hall et al., 2015). In these studies, and others concerning cooperation between experts and mangers, similarity in knowledge or perspective between cooperating actors concerning the experts' alignment with management's processes and strategies is presented as a success factor (Ashford et al., 1998; Dutton et al., 2001; Howard-Grenville, 2007). An explanation for the importance of the experts' alignment in previous studies may be that the experts have recognized knowledge and skill to exercise their expertise, but one that is difficult for the managers to understand. Experts have difficulty exerting influence because staff experts play peripheral roles, lack the opportunity to offer advice and lack the relational foundation that line experts rely upon to identify strategic management questions (DiBenigno, 2019). Peripheral experts face difficulties gaining respect as equal to the managers and are not regarded as strategic assets (Sandholz et al., 2019, p. 1,350). According to DiBenigno (2019, p. 29), peripheral experts who take advantage of windows of opportunity early in the relationship exert influence over line manager's decision-making in a “rapid relationality.”

The recipients of the advice present additional difficulties with staff experts in their attempts to exert influence; line managers may regard themselves as having extensive knowledge based on scientifically grounded theories that are superior to the staff experts' pretensions on expertise. However, if the manager depends on the advice (Kellogg, 2019, pp. 950–951), if the advice supersedes the managers' knowledge, or if it is central to the workflow (Black et al., 2004, pp. 600–601), then the manager regards the expert's knowledge as adequate. These studies highlight the need for experts to identify and provide their indispensable knowledge and skills to the managers' core tasks. Experts are considered as belonging to lower-status occupational groups than the line managers, who regard the experts as representing a lower level of professional status than the line managers see themselves as occupying (Black et al., 2004). They consider the staff experts as peripheral, lower-status experts.

There have been studies on the barriers faced by experts, such as lack of formal authority (Crozier and Friedberg, 1980); lack of relevant knowledge of the core processes (Arena et al., 2010) and, given the boundaries between staff and line, lack of a relational foundation (DiBenigno, 2019). However, there is still a need to examine how peripheral experts with lower professional status exert influence over the decisions made by line managers with higher professional status, as in the relation between physicians and staff experts in health care organizations.

The aim of this study is to investigate and to provide a theoretical explanation on how line managers and lower-status experts work together in public health care organizations. Hence, we explore how lower-status experts influence line managers' decision-making, and task prioritizing, in order to guide staff experts' cooperation and performance improvements. This is of special interest since many new categories of experts have been added to public organizations, including health-care organizations, with high expectations that they will improve these organizations; at the same time, we know from previous studies that this is difficult for experts in general. It may be assumed that these difficulties could be pronounced for experts with a lower professional status than that of the line managers. This study aims to contribute to a theoretical understanding of how such lower status experts act and can gain influence.

Through interviews, we followed the efforts of occupational health service (OHS) experts such as company physicians, nurses, physiotherapists/ergonomists, behavioral/organizational consultants, health pedagogues and engineers in an occupational health unit as they attempted to influence the line managers' decision-making in health care organizations in matters affecting occupational healthcare. All these OHS experts may be regarded as peripheral to their staff positions, and, except for the company physicians, may be regarded as lower-professional-status experts in relation to the line-manager physicians in this study. This assumption is in line with Freidson's (2007) theory on professional dominance in healthcare, whereby physicians enjoy the highest prestige of all professions.

How the OHS experts in this study influenced line managers in providing rehabilitation services is a reference point for the degree to which the experts were able to exert influence in the services they provided from a lower-status position. The study's setting offered the opportunity to investigate the impact of experts in a lower-status position, regardless of other possible influencing conditions.

A theoretical approach of expert identity positioning, in terms of similarities and differences, enabled us to analyze the interaction between managers and experts. The experts in our study struggled to become more influential vis-à-vis the managers' decision-making by mobilizing positioning acts related to how they simultaneously upheld both differences and similarities in their interactions with the managers. Therefore, we contribute to the literature by (1) identifying the experts' patterns of interactions with line managers associated with positioning acts related to the line managers' operative decision-making and (2) theorizing about experts' positioning acts in interaction with line managers and their patterns of similarities and differences.

Previous explanations for how experts become influential

Although few studies have specifically addressed how peripheral, lower-status, occupational experts become influential, there are studies on technicians and physicians (e.g. Black et al., 2004), technical writers and engineers (Sapir et al., 2016), and HR strategists, and line managers (Sandholz et al., 2019). According to Black et al. (2004), lower-status (their computed tomography (CT)-scan technicians were called “lower-power experts”) may influence line managers (their physicians were called “higher-power experts”) if they have superior knowledge or technical skills that higher-power experts depend on for their operations. As Black et al. (2004) demonstrated, however, if these physicians believed technicians were dominating the technology, they withdrew from interactions with technicians in the CT-scanning activity. The hierarchical position of the physicians' diagnostic authority superseding the technician's technological authority was upheld although the boundary between the two categories was blurred when the technicians acquired some diagnostic competence and the physicians gained some technological competence. However, when the physicians gained more knowledge of CT technology than the technicians, physicians relegated the technicians to a minor role and the traditional pattern of professional dominance occurred. Black et al.'s overall conclusion was to recognize that “a balance of expertise across occupational boundaries in operating the technology creates a pattern in which the benefits of the new technology are likely to be realized most rapidly” (p. 572).

Sapir et al. (2016) studied the interaction of peripheral and core experts in creating new cross-occupational knowledge through such dialogical mechanisms as learning, inquiry, negotiation and knowledge sharing. They concluded that a fruitful interaction mechanism created a bond between the actors, allowing for “tolerance and mutual attentiveness on the part of the participants” (p. 33), creating new knowledge through mutual respect. However, Sandholz et al. (2019) showed that it is difficult for professionals (HR experts in their study) to redefine their profession to higher-status work through what Sandholz et al. call jurisdictional entrenchment. They claimed that acknowledged professional jurisdiction by the surrounding actors' results has positive and negative consequences: It serves as a protection of the professional domain and an obstacle to its revitalization. Pate et al. (2010, pp. 208–211) argue that for lower-status professionals, there is even a counteracting mechanism between achieving professional identification and interprofessional partnership. Comeau-Vallée and Langley (2019, p. 1,668) express a nuanced view in explaining lack of success in interprofessional relations' lower-power professionals, meaning they will have difficulties in reaching consensus within its group, which in turn increases the difficulties in gaining interprofessional recognition.

A contextual framework

How experts exert influence has been studied previously. Dutton et al. (2001), for example, demonstrated the process whereby various experts influenced the strategic agenda of top management through “issue selling” – moves that include packaging, involvement and timing. Packaging comprises alignment of the message to the company's business plan and presentation of facts in the correct order and form; involvement requires the coordination of similar targets of interest to the right people; and timing involves waiting for the right moment to raise an agenda item (p. 732). Dutton et al. emphasized that managers with an area of expertise can become influential only if they “move” (process) based on an understanding of the thought patterns of innovations (strategy and managerial skill).

Accordingly, the process in the interaction between experts and top management matters, but the strategic dimension is also central if it serves as an “internal engine” for change and innovation in the strategic decision-making of top management. Dutton et al. (2001) suggested that successful issue sellers draw on relational, normative and strategic contextual knowledge, using various moves to achieve their objectives, including a characterization of their appeal as a rational incremental step tied to key organizational goals and priorities. Early in the process, they involve a wide range of colleagues, particularly people at or above their level. They keep their bosses informed and persist in their selling efforts, while taking advantage of timing to help them decide when to sell their ideas and when to hold back.

Hall et al.'s (2015) study also elaborated on issue selling, developing an understanding of situated interactions between experts and managers. They showed that the central role of toolmaking is “structural arrangements and interpersonal connections when explaining how functional experts can become influential” (p. 3), arguing that accuracy of information is not critical for exerting influence, but that “communicability” and “experts' personal involvement” are essential (p. 19). Thus, experts become influential through formal procedures such as meetings and informal procedures such as trust in interpersonal relationships. According to Hall et al. (2015) and similar to Dutton et al. (2001), the first condition is the process by which toolmaking is used in order to align the experts' information or area of expertise in relation to the managers' operations: “the process by which experts adopt, adjust and reconfigure tools that embody their (and others') expertise – plays a vital role” in explaining how experts may become influential in relation to managers (Hall et al., 2015, pp. 18–19). The second condition is strategic and is described as how experts become influential in relation to managers' strategic agenda, by aligning their area of expertise/information to that of the managers in their strategic decisions, “where experts may (or may not) find the ‘privileged moments' to interact with business managers, whether in compliance roles, discretionary strategic decisions, or in performance evaluation and planning” (Hall et al., 2015, p. 19).

Pritchard (2010) observed that earlier efforts to examine experts' attempts at becoming strategic have usually taken a role perspective. According to Pritchard (2010, p. 185), the experts' pursuit of influence could be regarded as an active performance of identity work rather than a changing role description or new tasks framed as a new job specification. She suggests that focusing on expert identity positioning in the conversations and interactions of everyday work activities should guide the research on experts' ability to gain influence. Since this approach concerning the experts' professional identity seems especially adequate in a study concerning lower-status experts, we followed her recommendation.

Positioning and concepts used in exploring experts' positioning acts

Czarniawska (2013) suggested a theoretical approach for positioning acts, which could serve as a useful frame for analyzing organizational events in terms of social dynamics. This approach highlights an interactive production of selves, comprising ongoing positioning acts – in organizing practices with various outcomes, for example, in which experts can simultaneously stress their similarities and differences in managerial concerns and problems in achieving recognition and influence (Czarniawska, 2013). The concepts of similarity and difference are fundamental to the dialectic of positioning acts. As Jenkins (2008) asserted, “Taken, as they can only be – together – similarity and difference are the dynamic principles of identification, and are at the heart of the human world” (p. 15). This process has been attributed to self-positioning, defined by Sveningsson and Alvesson (2003) as “forming, repairing, maintaining, strengthening or revising the constructions [of self] that are productive of a sense of coherence and distinctiveness” (p. 1,165). It can be assumed there is an inherent tension in striving for both similarities and differences (Lewis, 2000; Jenkins, 2008).

In the study of OHS experts' positioning acts and in agreement with Kreiner et al. (2006), we have assumed that people's search for a balance between similarities (“belonging,” in the Kreiner et al.'s terminology) and differences (“uniqueness” for Kreiner et al.) must be negotiated within a social structure in which we include practice and place – plus discourse. Similarities and differences must be negotiated in the social structures of work groups and departments at various managerial levels, and in their external relationships.

We combined Dutton et al.'s (2001) concept of issue selling with Hall et al.'s (2015) concept of common construction of tools. Both concepts concern different ways of constructing similarities. We identified two categories of similarities for our analysis: strategic alignment, including packaging; and process alignment, with its two sub-categories: communicativeness/meaning-creation and common toolmaking.

1. Strategic alignment refers to experts' involvement in an organization's strategic business plan and alignment of the message in relation thereto – experts' participation in specific situations or specific issues of interest to managers, for example.

2. Process alignment refers to experts' personal involvement in an experts' approach in convincing managers to use their methods when the managers try to understand the context and conditions of the relevant strategic activities, allowing the experts to exhibit their competence and demonstrate their actions and achievements. This approach includes common toolmaking, in which timing is a key element.

Based on Freidson's (1970, 2001) work, we identified two categories of differences: use of technical skills and professional attributes.

1. Use of technical skills refers to the adoption of theoretically based models and conceptualizations of knowledge in practice (e.g. evidence-based methods).

2. Professional attributes refer to the use of professional, institutionalized jargon and external factors (e.g. study rooms, dress codes and such exercises of authority as medical responsibility).

Thus, starting with Czarniawska's (2013) idea that identity builds on both similarities and differences, we have found in the existing literature what has been regarded as important similarities in the relationship between line managers. These relate to the use of strategic alignment, including packaging and process alignment with its two sub-categories: communicativeness/meaning creation and common toolmaking to create similarities (see Dutton et al., 2001; Hall et al., 2015). Similarly, we found in the existing literature (See Freidson, 1970, 2001) that the use of technical skills and professional attributes creates differences between experts and line managers. We examine how the use of technical skills and professional attributes creates differences (See Freidson, 1970, 2001.)

Because similarities and difference are continuous rather than discrete variables, we examined the degree of each. We also examined the extent to which the actors achieved a balance in their similarities and differences using attributive positioning and self-positioning (Czarniawska, 2013). Czarniawska concluded that negotiations about the “self” arise mainly from two types of positioning acts: attributive positioning (in this case, how managers acknowledge experts' position) and self-positioning (how the experts position themselves). The two key outcomes of an individual's positioning activities are acceptance or rejection of the self-positioning.

Occupational health services: the study's setting

The occupational health unit is an internal organization within a large regional organization (RVG (Region Västra Götaland)) in Sweden, mainly comprising several hospitals and health centers, to which the occupational health unit should provide services. Hospital managers, recipients of the OHS experts' advice, are traditionally physicians, with their own high pretensions on expertise. The occupational health unit has a reputation of success in exerting influence over managerial decision-making in rehabilitation, but not in the other two services provided – work-related illness prevention and promotion of employee well-being – and their superiors had asked the experts why they were unsuccessful in all their services. Perhaps the differences in how the respondents value the service are due to different legal regulations. The rehabilitation service is supported by legal responsibilities imposed on managers and by the defining procedures the managers must follow. The state's regulatory role has obviously arranged for the rehabilitation experts to achieve influence over the line managers' decision-making. That is not the case in the areas of work-related illness prevention and employee well-being, leaving the OHS experts providing these services with lower-status positions than what the line managers enjoy.

Our research deals with the work of OHS experts employed in a 90-person section of the county council's 50,000-employee organization. The OHS organization is composed of company physicians, nurses, physiotherapists/ergonomists, behavioral/organizational consultants, health pedagogues and engineers. Client organizations have engaged OHS experts mainly within statutory (AFS, 1994: 1) rehabilitative areas, approximately 80% in individual cases. The main task of company physicians and nurses is to engage in this service.

The latest Swedish work environment legislation (AFS, 2015: 4) has increased the focus on prevention and health promotion, making these services the responsibility of employers and managers. These services constitute the primary tasks of physiotherapists/ergonomists, behavioral/organizational consultants, health pedagogues and engineers although rarely with more than one service in the same organization. OHS experts must be involved in the operational plans and practices of client organizations although agreements often lack clear cooperation goals or conditions and methods for creating health-promoting workplaces. Contracts are established annually, based on estimated service required that year, particularly in rehabilitation, health promotion and contracts negotiated case by case. Client organizations have their own HR managers, each of whom works with a line manager in the client organization, in cooperation with the OHS experts.

The client organization's HR managers usually function as the point of contact to the OHS experts, as HR managers interact with union parties and line managers. HR managers assist line managers in recruitment and systematic work environment issues, and often support line managers in their OHS activities, seeking the role of strategic advisors to managers at all levels.

The setting of this study is a hospital – similar to the archetypical acute care institution (Glouberman and Mintzberg, 2001a, b) in which central coordinating mechanisms are usually embedded in the hierarchy, in managing the coordination between managers and experts as “the standardization of outputs” and “the standardization of work.” However, as Glouberman and Mintzberg described, in situations where outputs and work cannot be standardized, it requires other types of coordination between managers and experts based on mutual judgment. This situation exists in hospitals when experts, such as occupational health experts, are positioned in a peripheral staff unit (support function outside of the unit's operations) to support line managers inside the organization in solving the unit's complex, everyday issues. The line managers are organized in a two-tier system: on the operational level are the unit managers, often nurses, and on the upper level are the department managers, often physicians. Overall, physicians dominate the decision-making concerning major issues, which, for example, could emanate from the OHS experts' suggestions. Glouberman and Mintzberg describe this type of coordination as “flexible communication among peers, so that the unexpected can be dealt with adaptively and collaboratively” (p. 75). They emphasize the role of mutual adjustments, in which managers and experts respond to each other's ideas – in solving complex administrative problems, for example. This means that the hospital setting provides a fertile ground for studying how line managers with high a professional status interact with experts having a lower professional status.

Research methodology

The three main services and attempts to gain influence

Discussion

This article has addressed “How lower-status experts manage to influence line managers' decision-making?”

We argue that experts' interactions with frontline managers in rehabilitation work are an expression of strategic alignment achieved through compatible goal sharing and striving for mutual benefit, as previously observed (Dutton and Ashford, 1993; Mohr and Spekman, 1994). Our study also confirms these conclusions. These findings exhibit what Caldwell (2003) included in his definition of the strategic partner role, in which the expert becomes influential in the managers' strategic decision-making and agenda. OHS experts have established the necessary relationship with frontline managers in rehabilitation work and have framed their practices as elements of the managers' organizational management, which Pritchard (2010) considers necessary prerequisites to a successful cooperation.

Prior studies have often concluded that experts' differences separate them from other organizational actors and have suggested a search for similarities in which the packaging, timing, toolmaking (Dutton et al., 2001; Howard-Grenville, 2007; Hall et al., 2015), or language-as-management tools in communication (Styhre, 2002) explain the experts' success in exerting influence outside of their specialized areas.

Previous research on lower-status experts have urged these experts to gain respected positioning as equals to core professionals (Sandholz et al., 2019, p. 1,350), either by providing solutions to problems crucial for the operations of core actors (Black et al., 2004) or by exerting a skillful dialogical interaction with core actors (Sapir et al., 2016). This study confirms the importance of lower-status experts being recognized as influential and as equal to the core actor.

The contribution of this study is that it illustrates a way for lower-status experts to achieve respected positioning: to manifest a high degree of similarity – and especially a high degree of difference. Difference is reflected in professionalism – demonstrating technical skills based on legitimate knowledge and the accepted attributes of their specific professions, just like the core actors do in their work. To be regarded as important, one must go from being an expert to being an influential professional in line managers' decision-making – just like the core actors do. It seems necessary to undergo a transition of the knowledge base and a transition in communicability in order to overcome jurisdictional entrenchment (Sandholz et al., 2019) and be regarded as strategic by core actors.

Conclusion

The aim of this study was to investigate and to provide a theoretical explanation on how line managers and lower-status experts work together in public health-care organizations, which was achieved by exploring how lower-status experts influence line managers' decision-making, and task prioritizing, in order to guide staff experts' cooperation and performance improvements. This study contributes to an understanding of how experts exert influence over managers' operational decision-making by simultaneously upholding differences and similarities with line managers. Previous research concerning the interaction between experts and managers usually emphasizes the necessity of similarities. But experts in the unsuccessful examples in this study appear to have exhibited too little difference. It appears that the necessary similarities are not achieved by avoiding differences. This is reflected by using positioning acts as a theoretical framework – which has not been used previously in research on workplace safety or in an investigation into experts' actions toward increasing their influence on line managers' decision-making. With this evidence from a public-sector organization, we add to previous studies within the general research field of experts' influence on managers (Dutton et al., 2001; Howard-Grenville, 2007; Hall et al., 2015).

We argue that using this framework and the evidence regarding interactions between experts and managers may aid in understanding how lower-status experts exert influence over the decision-making of managers. Peripheral, lower-status, experts must create legitimacy for their expertise by bridging their self-positioning and available theoretical models (See e.g. Watson, 2008; Freidson, 1970, 2001). With a lack of connection between self-positioning and the available theoretical model, experts cannot construct social positioning acts as grounds for making their knowledge relevant to managers and influencing decision-making. Black et al. (2004, pp. 600–601), Kellogg (2019, pp. 950–951) and DiBenigno (2019) all recommend an adaptation to preconditions; in accordance with Sandholz et al.'s (2019) research, our study emphasizes the need for managers to acknowledge experts' unique contributions through their knowledge base and regard them as equals. Moreover, it emphasizes the need for managers to understand their dependence on expert recommendations in achieving their organization's core goals.

Practical implications: Our study also shows that experts who link their practice and recommendations to scientific knowledge can gain an influence over managers' decision-making, if they can prove that the scientific base of their competence and skills has a status and legitimacy equal to that of the managers' knowledge and skills. Lower-status experts need to match the professional status of line managers also in appearance, by using professional attributes to reach a respected approach for experts' identity positioning.

Future research: It would be appealing to study a case that allowed us to describe in greater detail how identity is performed in the actual work of the unit analyzed – a study that requires observational data, preferably collected longitudinally. A way to study the experts' strategies in greater detail would be to investigate whether the experts employ different strategies depending on what category the line managers belong to and differences between how different kinds of line managers, for example, if they are doctors or nurses, perceive the strategies of experts providing the same category of occupational health service. However, the varying responses from the different managers indicate that it would be difficult for them to differentiate between the strategies with experts delivering the same service. We have made some preliminary observations of similarities and differences across professional groups among experts involved in the three different services. However, this may also be studied more thoroughly in future studies. It would also be intriguing to investigate the question we studied here in an expanded context: the effect on the decision-making line managers who are subject to influence by the internal experts, external experts and semi-external experts like the OHS experts interviewed in this study. We assume that the results are, to a large extent, even if not strictly, transferable to other hospitals and the relationship between line managers and various types of experts in hospitals, also outside of Sweden, given that the client organizations we studied are like the archetypical acute care institutions described by Glouberman and Mintzberg (2001a, b), and also given that OHS experts have a peripheral position similar to several kinds of other support functions held by different types of semi-professional experts that have emerged through the new public management (Ackroyd et al., 2007). This assumption is based on the argument presented by Alvesson and Robertsson (2016) that “in-depth studies potentially offer new theoretical insights, the relevance of which is largely reliant on other researchers to reflect upon the subject matter and/or conduct further studies which add to our repertoire of understandings” (p. 14). However, we would like to see this study extended to hospitals in other countries and to other industries. Even if our results prove to be valid for health care organizations outside of Sweden, in which the managers are physicians, they may not necessarily be generalizable to organizations with managers having a lower academic background – especially managers grounded in natural, empirical science with high demands for evidence-based statements. A similar study in a traditional bureaucracy inhabited by managers working as administrators and caseworkers would also be of interest.

Besides studies in other contexts, it would be of interest to enlarge or replace the theoretical framework used here to consider the importance of the degree to which the experts' concepts and tools have formalized knowledge to enhance management techniques (Hatchuel and Weil, 1995).