The Multiple Middle: Managing in Healthcare

__Abstract__ The future of the middle manager is a much debated topic; not only in healthcare but also in other sectors. The middle manager is either viewed as an important change agent or as a relict of the past. Despite these opposing views, the underlying definition of middle management is one and the same: middle management is defined as a place somewhere ‘in the middle’ of the work floor and higher management. This spatial definition of middle management is foregrounding management activities in ‘upward’ (higher management) and ‘downward’ directions (work floor), while backgrounding other management activities. As a consequence, we only have a partial and limited view of what middle management entails. The central aim of this thesis is to open up the middle by researching the multiplicity of the middle in healthcare, thereby gaining new insights in day-to-day work of middle management and important transitions in this work. This thesis foregrounds alternative middles that so far have received little attention in literature: the middle in-between 1) conflicting values of good care; 2) different justifications used towards stakeholders; 3) professional and managerial discourses; and 4) organizational boundaries between care, welfare and housing. The empirical analysis does not only sheds light on the type of work that is conducted in these middles, but also reveals how this work is reconfigured and partially distributed to clients and professionals. Moreover, the analysis provides an answer to the main question: ‘How is the daily work of middle management enacted and reconfigured in the Dutch c

Who is ‘in’ and who is ‘out’? Participation of older persons in health research and the interplay between capital, habitus and field

Inclusion and exclusion processes in community engagement do not take place in a vacuum, but are embedded in social, political and institutional contexts. T

Can leadership make the difference?:A scoping review of leadership and its effects in child and youth care

Child and youth care (CYC) is operating in an unpredictable environment, making leadership in CYC a challenge. Leaders of CYC operate under public and political pressure to reform failed systems, compete for scarce resources, obtain and sustain a highly skilled workforce, and achieve organizational goals and tasks within a complex network. Although many studies underline the importance of leadership in CYC, there is no clear demarcation of the concept of leadership and its associated effects. By conducting a scoping review of the literature, this study aims to improve a conceptual understanding of leadership and provide insight into the influence of leadership on service delivery in CYC. The results show that the majority of the studies within the scope did not use clear definitions of leadership and did not specify the type or level of leadership. Despite this lack of clarity, most studies do discuss the positive effects of leadership behaviors. Leadership behaviors are primarily associated with positive effects on employee commitment and well-being; i.e. creating and communicating a vision, providing trust, safety and respect, inspire, motivate, stimulate and having a cooperative attitude. These leadership behaviors are not exclusively linked to a specific level of leadership and seem effective at all levels. However, the results also show that support from the top of the organization, noticeable in behavior, is a prerequisite for the other layers of management in the organization to be effective. The lack of clarity about type or level of leadership to which the conclusions apply, makes it difficult to develop and recommend targeted leadership interventions. Therefore, future studies should provide a clear definition of leadership, including job title, job content and leadership level. Our findings suggest that these leadership behaviors, can help CYC professionals navigate through their unpredictable environment and improve the quality of care.</p

Sphere transgressions in the Dutch digital welfare state:causing harm to citizens when legal rules, ethical norms and quality procedures are lacking

Welfare states across the world increasingly experiment with the use of big data and algorithms in the name of efficiency gains and fair decision-making. However, recent public scandals in various countries show persistent problems with how digital welfare states operate at the cost of vulnerable populations. Problems include systemic forms of discrimination, increasing levels of surveillance, stigmatization, and restricted access to public benefits. Rather than viewing these problems as instances of technical implementation hurdles, we argue that digital welfare states currently operate in an institutional void in which legal, ethical, and quality procedures are lacking or ill equipped to address new challenges posed by digital technologies.Based on a secondary analysis of documents, we show how this institutional void empirically manifests itself in the Dutch welfare state by zooming in on two subcases that sparked public controversy in recent years: the childcare benefits scandal that focused on fraud detection and the Top 400/Top 600 that was set-up with the aim of crime prevention. By analyzing these cases, we show how sphere transgressions – understood as the encroachment of digital logic into the sphere of social welfare – can have detrimental consequences for citizens when there is an institutional void. We end with reflections on how to fill the current institutional void and identify ‘soft signals’ that could be used as pointers to recognize the potential undesirable consequences of new sphere transgressions

Which client is worthy of using discretion?:Analysing storytelling practices of Dutch street-level bureaucrats in inter-departmental settings.

Multiple welfare states are re-emphasising the need for street-level bureaucrats’ (SLBs) discretion to stimulate responsive service provision. However, little is known about how SLBs with diverse backgrounds in inter-departmental settings deliberate what it means to use discretion well when different rules, eligibility criteria, and interpretations apply to a client. We address this gap by investigating the stories that participants of a Dutch policy experiment told each other to justify which clients should be granted a flexible interpretation of entitlement categories amid scarcity. We found that ‘caretakers’ used the ‘victim of circumstances’ and ‘good citizen’ plot-type to convince ‘service providers’ that the use of discretion was the right thing to do, whereas the latter used the ‘not needy enough’ or ‘the irresponsible citizen’ plot-type for contestation. Our analysis shows that storytelling helped SLBs to make sense of and bring cohesion to complex situations. Moreover, the analysis shows how stories can have a strong emotional appeal and create a sense of urgency to act collectively, yet can also create divisions and opposition among SLBs. As such, storytelling influences how SLBs think and feel about the client, themselves, and each other, and influences how discretion is used at the front-line of public policy