Contingency and paradoxes in management practices—development plan as a case (2024)

RQ1.

How do local (clinical-level) managers organize, navigate and legitimize theprocess of making a development plan?

RQ2.

How can we further understand the role of managers in dealing withcontingency of decisions when applied to organizational work withdevelopment plans?

A functionally differentiated healthcare system

Functional differentiation is central in Luhmann’s (2012) system theory. Functional differentiation isthe division of modern society into multiple functionally specialized andautonomous subsystems, all managing specific functions for society. In thispaper, we argue that functional differentiation is the primary form ofdifferentiation in the healthcare system. Describing the healthcare service asfunctionally differentiated implies that it is one system comprising severalautonomous and self-referencing subsystems, each maintaining its function forthe healthcare service as a whole. “Subsystems” refers to thevarious professions, organizational units and administrative levels in theoverall healthcare system. Such a perspective places a stronger focus on theautonomy of subsystems than on formal and hierarchic organizational structuresin the healthcare system (Vik and Hjelseth,2022). The central subsystem for this paper is an organization unit,a clinic for mental health and substance abuse in the Norwegian specialisthealth service.

The cornerstone of Luhmann’s(1993) systems theory is its distinction between a system and anenvironment. Furthermore, Luhmann describes a system as being operativelyclosed, implying that any operation is always the result of conditions ofpossibility determined within the system itself. Any action or decision taken bythe system is based on the system’s own logic and understanding. Thisinsight implies that at all development plans are created inside the relevantsubsystems. In its most basic form, the development plan can be understood as away of operationalizing an organization’s function: defining its purpose,addressing the reasons for its existence and articulating what it wants toachieve (Bart and Tabone, 1998).Hence, using Luhmann’s (1993)concept, the organization can use the development plan to define itself inrelation to its environment.

Functional differentiation also points to the structural coupling between thehealthcare service and the various functional systems in society. A functionalsystem is an abstract communication system that an organization attaches itselfto by making decisions. Each functional system refers to its own logic,rationality and communicative structures (Luhmann, 2012). Economic, political and health systems are examplesof functional systems that employ different criteria for observing the world.Table1 shows the variouscodes, mediums, programs and functions that organizations can activate throughfunctional systems.

The basic premise of Luhmann’s(2012) work is that the differentiation process of modern societyentails the crystallization of organizations that are attached primarily to onefunctional system. Political parties and public administration communicatethrough the political code while banks and businesses communicate through theeconomic code. Many modern organizations attach themselves not to one primaryfunctional system but to multiple functional systems. This phenomenon isespecially evident in public sector organizations, where the demands of thedifferent functional logics clash—sometimes violently, sometimes nearlyinvisibly, sometimes harmoniously, but always, inevitably, as differences (Knudsen and Vogt, 2014). This“polyphony” means that organizations of the same type could, inprinciple, attach themselves to different functional systems with crucialeffects on their communicative structures. The functional system to which anorganization chooses to attach itself when making a decision will haveconsequences for how it communicates and for how the organization fundamentallyevolves (Åkerstrøm,2002). In the present case, it makes a difference whether healthcareorganizations attach themselves to the health, economic, or political systemwhen communicating about their development plans. Different functional systemscannot understand one another’s rationalities and evaluation criteria,and this can be a central source of tension in the process of constructing adevelopment plan. In the process of constructing a development plan a healthcareorganization must address the needs of stakeholders representing differentfunctional systems. This requirement is central in light of systems theorybecause an organizational system creates itself by forming an internal structurethat mirrors its environment (Luhmann,1978). An organization’s self-description thus greatly dependson how it constructs its environment. In constructing an image of itssurroundings, the organization concomitantly constructs an image of itself. Inthe present case, a healthcare organization is not only one system within oneenvironment but often operates within several systems and environmentalconstructions. Accordingly, one must observe how such organizations communicatemultiple systemic environmental demarcations in their development plan work.

Merging Luhmann’s organization theory with management theory

This study observes how managers handle the tension between communicatingdemarcations from multiple systems and environments and the tension betweencontrol and autonomy on an organizational level, using development plan work asa case. In systems theory, organizations are seen as social systems that canstabilize forms of action and behavior by deciding aboutstronger or weaker conditions for practices and procedures (Luhmann, 1978). In other words,organizational systems operate through decisions and decision communication.

A key theme in Luhmann’s (1978)organization theory concerns how organizations manage the contingency ofdecisions. The contingency of decisions points to the fact that a decision isneither necessary nor certain but could always have been made differently. Thiscontingency makes connectivity less likely because it calls into question thenotion of connecting to a decision that could inherently have been madedifferently (Knudsen, 2012).Connectivity is essential to decisions because it is only the connection tofurther decisions that can turn a decision into a real decision. A decision towhich no further decisions are connected turns out not to be a decision at all,but just noise.

Knudsen (2012) points out that a mainstrategy for managing the contingency of decisions in organizations isdisplacement. For example, an organization can“deparadoxify” its decisions by interpreting them to externalstakeholders as necessary responses, displacing the contingency onto theenvironment. Another way is to displace the contingency onto decision-makers,such as the managers of the organization. Securing legitimacy within theorganization regarding how decisions related to the development plan aredeparadoxed will be crucial for the connectivity of future decisions.

To observe how organizations handle the paradox of decisions, this paper uses theconcept of inclusive managers and brokers. Inclusive management brings togetherparticipants from different practices in collaborative settings. Such acollaborative setting could be important in the process of creating adevelopment plan since the statement must be anchored in theorganization’s employees to be legitimate and successful (Klemm etal.,1991).

A manager can assume the role of promoting, as well as inhibiting, inclusion. Aninclusive manager tries to design inclusive processes and create a community ofparticipation in which people can share information and perspectives and worktogether. However, it is not enough simply to bring people together; the peoplemust also be willing to listen and be engaged in ways that advance thecollaborative process, in which inclusive managers play a key role. Inclusivemanagers identify various relevant areas and know the problems faced in eachone. They encourage people to see different perspectives in discussions ormeetings, fostering an atmosphere in which problem-solving occurs. However,these meetings do not necessarily enable people to feel connected or to trustone another, so joint activities in this sense can be either constructive ordestructive. Managers must try to create joint activities that provide a sharedexperience and transcend boundaries between participants (Feldman and Khademian, 2007).

Kimble etal.(2010) demonstrate that inclusive processes do not have to be drivenby managers and emphasize the role of “brokers.” The work ofbrokers is similar to that of inclusive managers, as brokers make coordinationpossible by opening up new possibilities for learning and exchange. Brokers helpother actors transfer, translate, or transform the meanings encountered duringjoint activities (Carlile, 2004). Adevelopment plan in a functionally differentiated healthcare system must addressvarious perspectives and the needs of different external and internal actors.Translating and transforming meanings and knowledge between these actors isessential in the process of making and legitimizing the plan.

A broker translates knowledge created in one group into the language of anotherso that the new group can integrate it into its cognitive portfolio. To do this,brokers must be able to manage the relationships between individuals and act astranslators. The broker’s role necessitates a delicate balancing act. Tobe effective, brokers must have authority in all groups to which they belong.They must be able to evaluate the knowledge produced by the different groups andearn the trust and respect of the various parties involved. Over time, thebroker’s activities may lead to the development of a repertoire of sharedresources, such as therules and procedures used by the group (Kimble etal.,2010).

The presented theory will be used to identify and show the complexity ofdevelopment plan work in a functionally differentiated healthcare system andhighlight that the plan process opens up for tensions between different logics.The concepts of inclusive management and brokers will be used to analyze howorganizations handle this complexity and how managers navigate and legitimizedecisions related to the development plan within the organization.

The multilevel context of work with development plans

As part of implementing the National Health and Hospital Plan, all healthauthorities have had to create their own development plans.This means that a standard approach is set by the government and then adapted onvarious government levels down to the clinic level. This section examines howgovernment intentions are translated and operationalized through variousgovernment guidelines within Norwegian specialist healthcare down to the cliniclevel. Figure2illustrates the multilevel plan process and the different documents that wereproduced to secure connectivity throughout the different levels of thehealthcare authorities. The overall guidelines on how to manage developmentplans were constructed by the Ministry of Health and Care Services anddistributed to the five regional health authorities. The regional healthauthorities then translated the national guidelines according to their mandate,serving as a premise for the work on local development plans. Based on theirmandates, the local health authorities created their own guidelines. Afterfinalization at the clinical level, the development plans are sent to the upperorganizational level; these plans are then used as a foundation for the localand regional development plans. These plans then make the foundation for thenational development plan. This process is not covered in this article.

Luhmann’s (1993) theoreticalconcepts of connectivity and contingency are used to analyze decisioncommunication regarding development plans in what we call a multileveltranslation process. The Ministry of Health Care Service clearly states thepolitical goals behind the development plan. The political goal of theguidelines is to achieve collectively binding decisions through the developmentplan formulated by the various authorities, clinics and hospitals. Theguidelines present a recommended thematic structure for the development plans,whose main components are to be historical background, current situation,contextual change, desired situation and strategic choices. The guidelines alsoemphasize transparency and stakeholder involvement. All documentation connectedto the development plan process is therefore published, and at all levels thereshould be broad involvement of users, patient organizations, professionals,unions, municipalities and private actors. The emphasis on involvement andtransparency can be understood as a way of legitimizing the politicalsystem’s function of achieving collective, binding decisions regardinghealthcare strategy. Hence, the national guidelines for development plans shouldhelp in navigating the practical work. The guidelines for the plans are thentranslated to the regional health authorities.

The regional health authorities stated that local development plans must follownational and regional instructions issued through various parliamentary reportsand reforms. This includes guidance from the National Health and Hospital Plan(St.meld.11, 2015-2016) and theCoordination Reform (St.meld.nr.47,2008-2009). The regional instructions concentrate on how local healthservices can be adapted to improve regional economic conditions, efficiency,capacity and competence. They also emphasize ways to improve internalcoordination and collaboration with other health regions. The case is a clearexample of how the health authorities, through the regional mandate (3), try toensure connectivity to both the National Health and Hospital Plan and previousreforms. At the same time, there is a shift in focus from a national andpolitical context to a regional and economic context. The goal of thedevelopment plan is no longer merely to create binding decisions regardingstrategy but to create binding decisions regarding strategy based on regionaleconomic conditions. In light of systems theory, the regional mandates entailincorporating the economic code into development plan work.

The local health authorities then created their own guidelines on how toconstruct perform the development plan (4). Connectivity is promoted by statingthat the local development plans must follow the thematic structure recommendedin the national guidelines, but we also see that the local health serviceauthorities emphasize that the local development plan must be based in thedifferent clinic perspectives. The focus is no longer only on general politicalgoals and economic frames; it includes practical implications for patienttreatment, the organization of different services, coordination, staffcompetence and technology. This brings an enormous amount of complexity into theplan process at the clinical level that can foster contingency.

Introducing the development plan

A central actor throughout the work with the development plan at the level of theclinic is the clinic manager. In the case study, the first time the clinicmanager presented the idea of making a development plan was at a leaders’meeting at which various managers and union representatives were present. Theclinic manager began by informing the participants that the clinic needed toaddress strategy and development. He then presented his view of the developmentplan, which he called “a political requirement,” the aim of whichwas to obtain an overview of how the various health organizations organize theirwork at the national, regional and local levels. The clinic manager alsohighlighted the thematic structure in the national guidelines (1). Hespecifically highlighted the clinic and the local health authority’seconomic conditions and proclaimed that “a keyquestion when working on the development plan is how we can get as much healthfor the patient as possible given the economic constraints that we work under.There have to be strategic prioritizations” (Observation 1).

The clinic manager’s presentation illustrated how the various guidelinesensured connectivity. The main translations at the different levels of thehealth authorities, shown in the previous section, were all covered in thepresentation. By calling the development plan a politicalrequirement, the clinic manager activated the political system,placing the contingency of further decisions within the context of a concretedecision premise, namely, the political guidelines. The clinic manager’semphasis on economic conditions also implied that the economic code should beactivated when working on the development plan.

During and after the presentation, there was a range of reactions from both theunion representatives and various managers. There were negative reactionsrelated to the political establishment of guidelines through a top-down processlacking professional involvement. For example, one section manager asked whypoliticians, instead of their own healthcare professionals, were allowed toformulate guidelines for the clinic’s development plan. Another sectionmanager argued that “decisions on the future direction of the cliniccan’t be made only at the top of the system, as the professionals workingwith the patients must be involved in the process.” These reactions wereconnected to the strong use of the political code when presenting thedevelopment plan. The way the clinic managers set the contingency of decisionswithin the context of the politically defined guidelines also resembled atop-down process. By emphasizing the role of healthcare professionals within theorganization, the reactions sought to place decisions regarding the plan insidethe organization itself, in this way activating and reinforcing the functionalsystem of health in the ongoing process.

Based on observations of the presentation of the development plan (Observation1), there was clearly a gap between the organization’s top management(e.g. clinic and unit managers) on the one hand and the section managers andunion representatives on the other. Top management was more comfortable withpolitical rhetoric and working to achieve political and economic goals set atthe national and regional levels—or, using Luhmann’s (1993) concepts, attaching theircommunication to the political and economic function system. Section managersand union representatives, on the other hand, linked themselves more to thefunctional system of health. Discussion in the meeting addressed the fact thatthe organization had not yet decided how to manage the contingency of decisionsconnected to the development plan, nor had they chosen the functional systemthrough which the decisions should be made.

“Making our plan”

This section presents the “hands-on work” of the development plan,constructing the content of the plan and attempting to engage healthcareprofessionals. In this section, systems theory is complemented with thetheoretical concepts of “broker” and inclusive management toanalyze the manager’s role in facilitating participation and involvementwhen formulating a development plan.

Four weeks after the development plan work was first presented, another meetingwas held, led by the clinic manager and a clinical adviser, who were responsiblefor writing and coordinating the clinic’s development plan. The clinicaladviser started the meeting by stating that it was important that thedevelopment plan was based on a mutual understanding of how it could be used inthe clinic. The work process must be driven from within the clinic, and thelocal context must be in focus. He also emphasized that the work must end upwith something more than merely a political document (Observation 2). Here, theclinical adviser was alluding to inclusive management (Feldman and Khademian, 2007) and attempting to translatethe development work from a political requirement into an internal,collaborative practice. To reach this goal, he had to translate and coordinatethe political and economic aspects of the various guidelines into a languagewith which thevarious organizational actors could relate. In theinterviews, conducted after the meeting, the clinical adviser followed up on hisrole and reflected on the process of making the developmentplan:

For me, it was very important that our plan reflectour organization and the professional work done throughout ourorganization. I was concerned that this was not happening. Several timesI tried to make the point that it had to be ourprocess. Our process of actually figuring out what our patients’needs would be in the future and how we should meet them. I felt in themeeting, and several times afterwards, that this point wasn’tgetting through. (Clinical adviser)

The clinical advisers’ reflections touch on how the strategy of displacingthe contingency of development plan decisions in the organization’senvironment had failed. To secure further connectivity the contingency ofdevelopment plan decisions must be placed inside the organization and connectedto the professional practice and not only political and economic goals.

At the meeting, the clinic manager stressed the importance of having adevelopment plan, pointing out that the clinic lacked a clear purpose anddirection and often made reactive and rash decisions instead of anticipatingsituations before they arose. The clinic manager argued that the developmentplan could be a tool for turning around this dynamic. In addition, the clinicmanager wanted the development plan work to be a collaborative practice andemphasized the importance of involving the whole organization. He stated that itwas a personal choice to become involved but that the managers should try tofacilitate discussion about where the focus should be regarding local challengesand areas of improvement. He also pointed out that the management group (clinicmanager and unit managers) could not produce a good plan by themselves(Observation 2).

Both the clinical adviser and the clinic manager emphasized the importance oftranslating the development plan work from the political to the local context.They also pointed out that all managers were responsible for encouraginginvolvement in and enthusiasm for the plan process throughout the organization.This meant that all managers (unit and section managers) in the organizationwere encouraged to assume the role of “brokers” (Carlile, 2004). This role was alsohighlighted through the method by which the clinic organized the work process ofwriting the development plan. To involve the whole organization, it was decidedthat the work process should follow the “line principle.” The goalwas to use the existing organization and arenas within the organization toproduce the development plan. This meant that all unit managers were to usetheir hierarchical lines of authority to produce a description of their currentsituation, possible challenges and future goals and to ensure broad involvement.In this work process, the unit managers had to involve their section managers,who would then involve their healthcare professionals through various staff andunion meetings.

The management’s goal of involving the healthcare professionals inconstructing the development plan was not quite achieved. The line principle didnot have a positive impact on involvement, and the managers did not succeed intheir job as brokers. Based on the interviews and observations, it seems thatthe line principle contributed to the feeling that the plan work was a top-downprocess. In the interviews, the section managers responsible for involving thehealthcare professionals said that it was difficult to get any feedback andenthusiasm from them:

There has been little talk of the missionplan in our section. The goal of the work process was that it should bebottom-up. Yes, it was, and there has been a lot about that goal and Ithink many are tired of the whole thing. Especially those at the bottom.I found it hard to get any feedback or engagement. (Section manager2)

For the development plan, everybodywas supposed to be involved, and our clinic has over 1,000 employees…. There are guidelines from the Ministry of Health and CareServices about what we are to deliver and from Central Health Norwaythrough the mandates. These quickly met with skepticism andindifference. For the employees and many of the managers, the work feelslike a duty, and then people lose their commitment and enthusiasm. Thishas been top-down, not bottom-up at all. We are invited in, but toolate, when everything has already been defined. (Section manager3)

The ambivalence evident at the meeting was due to the fact that the developmentplan was part of the larger political health policy project while being anessential part of the clinic’s strategic development. In response tocriticism that too much planning and too many processes were occurring at thesame time, the clinic manager argued that a new process must not displace oldprocesses. There is a political demand upon which the clinic must deliver, andit should be integrated into the clinic’s strategy work. The clinicmanager noted that the work could also be used to obtain a full picture of themain challenges and collective goals to address (Observation 2).

Here the challenge of translating the political requirements into local strategywork is obvious. The clinic manager attempted to stress the importance of thedevelopment plan, but he also called it a political demand that they might aswell try to use positively. The clinical adviser also noted the contradictionbetween a top-down demand and a bottom-up strategy process, feeling that thishad made it difficult to foster involvement and commitment from theprofessionals:

Another element of this is that the plan ispart of a bigger political order. Everybody knows that our plan will bealmost invisible in the local and regional plans. Maybe we will be ableto find traces of it, but its essence will disappear. This makes it moredifficult to get commitment from the professionals. But itdoesn’t change the fact that we need this kind of plan forourselves. So for me, the process in the clinic ofworking on such a development plan may be more important than thedocument that we will send to the local health authorities. (Clinicaladviser)

Evaluation of the plan process

The last phase was to finalize the development plan. As in previous phases, toobtain broad input and legitimize the content, the finalization of thedevelopment plan was discussed at a managers’ meeting. At this meeting,all the managers and union members representing the various professions werepresent. The objective was to present and discuss the feedback on thedevelopment plan work process and to discuss which areas should be prioritizedin the final version of the statement.

The meeting started with a presentation by the clinic manager. He stated that thedevelopment plan had been introduced as part of a governing process forprofessional and organizational development in clinics all over the country.This meant that decisions regarding professional and organizational change mustbe reflected in the development plan before they could proceed. The developmentplan should, therefore, be the basis for future decisions. This reflects thedesire of governing bodies and healthcare authorities to use development plansto ensure connectivity in decisions concerning organizational and professionaldevelopment. For the clinic manager, it was therefore important that certain keyareas in the organization be prioritized. The clinic manager argued that thework that had been done so far did not constitute a good basis for assessingwhat professional and organizational changes were needed for the future. Hestated that to make this assessment, the professionals must be more involved inthe ongoing development work (Clinic Manager 2, Observation 3).

One section manager questioned the clinic manager’s thoughts oninvolvement when it came to decisions on prioritizing:

Thenational government has given us an order. We cannot prioritize 19areas. It is a managerial responsibility to decide what is to beprioritized. We cannot have a democratic process on this …. Thereare so many different motives and wishes in the clinic that it must beup to the leaders to decide what our focus should be. At the same time,there are quite clear [political] guidelines about what we really shouldprioritize. (Section manager 2)

This discussion was concerned with how the clinic should manage the decisioncontingencies connected to the development plan. The section manager made thepoint that without displacing the paradox or handling the contingency (Knudsen, 2012), there would be nodecisions: the various subsystems were not motivated to understand one anotherand were therefore incapable of reaching an agreement on what should beprioritized in the organization. In the interviews after the meeting, thesection managers criticized the work process, calling it “skin-deepdemocracy”:

I think the process is beingcontaminated by “skin-deep democracy” when it should havebeen [a matter of] good strategic management. The belief in democracyand involvement is “in the time,” but not alladministrative decisions should be made bottom-up. Administrativechanges and organizational goals should be decided at the top. It can beunpleasant, but you cannot make good strategic decisions if you expecteverybody to be involved. (Section manager 2)

The clinic manager responded:

I have to follow the assignment givento me. If I don’t, I have to find another job, but it is alsoimportant to get the process right. I can’t and won’tdecide everything alone. That’s why I think it’s importantto involve the whole clinic. When the time comes, everyone should havehad the opportunity to get involved, and then I will make a decision.(Clinic manager 2)

At the meeting, the clinic manager opened up a discussion of how the organizationshould follow up on the development work. He asked whether there was any realdesire to get involved and what was needed to get the healthcare professionalsinvolved. These questions started a discussion of how the clinic should proceedto ensure the engagement of the healthcare professionals in the future process(Observation 3).

Several union representatives expressed their views on how to involve thehealthcare professionals. One union representative stated that they found itdifficult to get involved in the process because they could not relate to thegeneral matter of clinic strategy. Another union representative added that therewas no shortage of commitment from the professionals in regards to working withpatients but that it could be difficult to get them involved in generalorganizational matters (Observation 3). This feedback shows that the managersdid not succeed in their brokering role (Kimble etal., 2010). In the previousmeeting, it had been stated that it was the managers’ responsibility totranslate the “general” aspects addressed by the variousguidelines into more concrete elements concerning the professionals’local context and practices.

A unit manager then pointed out that the clinic has many arenas in which tofacilitate broad and open processes and asked how these could be better used toachieve broader involvement in finalizing the development plan. Another unionrepresentative agreed, believing that it would be easier to involve thehealthcare professionals in strategy and development questions if they hadarenas in which they could discuss them, rather than simply being told by themanagement to get involved in something (see Observation 3). It was also pointedout that healthcare professionals cannot be seen as a hom*ogeneous group. Forexample, one section manager stated that it was important to involve theprofessionals but did not believe that meetings between the various specialistswould lead to any unity or mutual understanding because there was too muchprofessional disagreement in the organization. One unit manager responded thatit would be unfortunate to gather the different specialist groups separately, asthis would only reinforce the differences between them (see Observation 3).

The point being discussed here concerns the functional differentiation in theclinic and how this challenges the goal of producing a “mutual”mission and development plan. A mission statement should define anorganization’s unique and enduring purpose (Bart and Tabone, 1998). The problem for the clinic wasthat the various subsystems represented by the organization’s sectionsand professional disciplines operated according to different purposes andunderstandings based on their functions in the clinic. This theoretical pointwas exemplified in the interviews when two of the unit managers reflected on theheterogeneous group of professionals working in the clinic:

Toachieve good collaboration in the clinic, we have to break down theprofessional boundaries between drug addiction, psychiatry, andrehabilitation and the geographical boundaries between north and south.(Unit manager)

The problem is that ourfocus is on ourselves and not on the clinic as a whole. Everyone looksat the clinic based on their own sections and unions. The goal must beto achieve a shared understanding … or that we should at leastrelate to the clinic as a whole. The goal must be to bring about acommon culture with the patient in the center (Unit manager2).

Both comments show that the mental health and drug addiction functions consist ofdifferent subsystems, both organizationally and professionally. These differentsubsystems operate according to different understandings and cultures, making itdifficult to achieve uniform understanding and consensus when it comes todescribing the organization’s challenges and long-termgoals—elements that are essential for developing a strategic plan (Baetz and Bart, 1996).

•

Erlend Vik is an associate professor in organization and management atMolde University College. His academic profile is based on healthsociology and public administration. Vik’s main research isrelated to integrated care, coordination of health services and healthmanagement. Theoretically Vik is inspired by Luhmanns theory on socialsystems.

•

Lisa Hansson is a Professor of Urban and Regional Planning at MoldeUniversity College. Hansson work with questions related to reformchanges and governance trends, mainly within sustainable transportsystems. She also works on projects related to multilevel governance andcoordination in health services.

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