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Experiences of healthcare middle managers in developing capacity and capability to manage complexity: a systematic review protocol

Hartviksen, Trude Anita1; Aspfors, Jessica2; Uhrenfeldt, Lisbeth1,3

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JBI Database of Systematic Reviews and Implementation Reports: December 2017 - Volume 15 - Issue 12 - p 2856-2860
doi: 10.11124/JBISRIR-2016-003286
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Healthcare middle managers

Healthcare middle managers (HMMs) are the first line managers and leaders closest to everyday clinical practice. This review will include HMMs in public healthcare services. Healthcare middle managers have an important role in translating top-level policies, strategies and resources into practical improvements. Turnover and shortage of personnel, engagement, motivation and the results of the workplace are all closely associated with healthcare management.1-4

Management in this review is defined as the process of achieving predetermined objectives through human, financial and technical resources.1 Leadership on the other hand is understood as the process of engaging with others to achieve group objectives.1 Healthcare middle managers are required to combine both management and leadership skills in their roles. This review will focus on HMMs’ experiences of developing capacity and capability related to both topics.

The job as HMM is demanding. Multiple sources describe how knowledge in economics, technology, sociocultural systems and politics is needed in this role.1,5-8 Moreover, HMMs are expected to have capacity and capability in communication, negotiation, analysis, developmental strategizing, problem solving, leadership, risk management and networking.1,3-7,9,10 Capacity in this review is understood as HMMs’ knowledge and methods, and the ability to translate knowledge into practical clinical improvements. Capability on the other hand includes driving force, strategy, power, willpower and motivation.11

Healthcare management has traditionally been characterized by strategic planning, and concrete tasks, in a leadership structure based on hierarchical and linear models, with command and control principles, top-down supervision and little room for creativity.3,10-13 Lately, these models have been criticized due to their lack of ability to account for highly complex healthcare organizations.3,10-15 Recent research suggests flexibility among leadership styles as the most essential skill in healthcare leadership, as different leadership styles evoke various responses in different situations.18 Flexibility is thus an essential leadership skill central to HMMs’ capacity and capability.

Traditionally, healthcare middle management has been performed in addition to, and often overshadowed by, more visible clinical tasks related to patient needs.1,6,7 Healthcare middle managers have been expected to be self-taught in leadership,18 and to develop capacity by individual leadership training. This does not correspond with the complexity of the job.16 Complexity in this review describes healthcare as complex adaptive systems comprising groups of individual agents with the freedom to act in unpredictable ways. These actions are interconnected so that one agent's actions change the context for the other agents.18 Healthcare middle managers’ backgrounds have often been clinical, with limited health management qualifications, experience or support.1,14 Their capacity and capability in leadership have been limited, thus needing development.1,6,14,22 As this has been neglected in existent literature, investigating how HMMs gain the capacity and capability to succeed in their role is a phenomenon of interest to this research project.


There is increasing complexity in healthcare services. This increasing complexity involves emerging new principles.3,10,20,21 At the clinical or micro level, the introduction of integrated healthcare illustrates this. Integrated healthcare is based on a stronger first level of care, with multidisciplinary teams, user involvement, and a municipal healthcare in close interaction with specialized care.20-22 In hospitals, care is evolving from the traditional fragmented specialist model to that organized around processes, clinical pathways, integrating evidence-based medicine and a focus on treating persons – not diseases or organs. The increasing complexity requires up-to-date knowledge, new approaches to leadership, and new methods to improve patient care.3,10,20-27 This changes the context for healthcare middle management.

The growing complexity takes place in a society that is also rapidly changing.10,21 The 20th century has been described as the information age, with increasing technology, and with strategic planning as a central feature of healthcare management. Today, society changes so fast that planning and anticipating the next change is challenging.10 This shifting context adds to the complexity in HMM.

This picture of a rapidly changing complex context gives us an understanding of why capacity and capability development is essential to achieve sustainability for HMMs. It is also argued that HMMs’ sustainability influences the sustainability of healthcare organizations as a whole.7 This systematic review will therefore explore HMMs’ development of capacity and capability to handle leadership in this complex context.

Developing capacity and capability

Traditionally, HMMs’ development of capacity and capability has included learning specific competencies in how to undertake specific tasks, such as creating internships or reporting on economic achievement. How to achieve and apply these specific competencies within a complex and changing organization has not received adequate attention.6 Suggested strategies have been system thinking, personal mastery, mental models, building a shared vision, and team learning. These strategies have been understood as cognitive, social and technical processes which include interpretation, internalization, integration and institutionalization.26 However, healthcare middle managers’ capacity and capability development in the present complex healthcare context is a field in need of more knowledge.16,23,27

Previous research has described numerous different approaches to capacity building, such as site-based training and mentoring programs,29 different management systems, for instance the Lean concept,30 periodical meetings,9,31,32 online portals,2 training33,34 and coaching.7 It has been suggested that one way to develop capacity is through cultivating oneself.10,24 However, individual learning is necessary but not sufficient. Working in groups facilitates trust and creative thinking while simultaneously challenging commonly held approaches.7,24 The World Health Organization (WHO) encourages resource networks and knowledge centers, and bottom-up and collaborative approaches.28 Collaborative approaches are action-oriented, and can include face-to-face workshops, site visits and video conferencing.6,12

Developing healthcare middle management capacity takes time as it involves changing integrated cultures, attitudes and habits.1 Leaders learn at varying speeds, and they need a learning environment that is psychologically safe to stimulate active involvement.9,26 It is also crucial that HMMs have the authority and responsibility to disseminate their knowledge.6 In this systematic review HMMs’ development of capacity and capability will be explored.

The importance of a systematic review

The development of leadership and management capabilities have been recognized as fundamental to healthcare organizations. However, there are limited peer-reviewed studies on management, including quality improvement efforts, both in size, scope and rigor.1 A systematic review, focusing on how HMMs develop capacity and capability, will be an important contribution to further the knowledge on this significant subject of knowledge transfer in international healthcare systems. A systematic review will help policy makers and healthcare managers prioritize measures for HMMs development of capability and capacity, and inform HMMs’ knowledge of leadership. The purpose is ultimately to improve the quality of the services available for users of healthcare. A preliminary search in the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, DARE, PROSPERO, PubMed and CINAHL did not identify any current or ongoing systematic reviews on this or similar topics.

Inclusion criteria

Types of participants

This review will consider studies that include HMMs, regardless of how long they have been in the management position and their healthcare field. Healthcare middle managers are understood as leaders closest to healthcare practice, with responsibility for both clinical practice and healthcare personnel. Studies on HMMs without personnel responsibility will be excluded.

Phenomena of interest

This review will consider studies that describe, investigate or explore how HMMs experience developing capacity and capability to manage in a leadership role characterized by high complexity.


This review will consider studies where the context is managing complexity in public healthcare services.

Types of studies

This review will consider studies that focus on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. A second search using all included keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all included reports and articles will be searched for additional studies. Studies published in English, German, Swedish, Norwegian and Danish will be considered for inclusion in this review. Initially, studies published from 2005 to the present will be considered for inclusion in this review. The limitation is chosen due to the rapidly changing complexity in healthcare services in the last decades, including an increased focus on user involvement, and interdisciplinary and interdepartmental cooperation.10-23

The databases to be searched will include: CINAHL, PubMed and Scopus

The search for unpublished studies will include: Google Scholar, MedNar and ProQuest Dissertations and Theses Global.

Initial keywords to be used will be: healthcare; middle manager; first-line manager; leadership; leaders; developing; learning; capacity; capability; complexity. MeSH terms or headings will be used when possible.

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).35 Any disagreements that arise between the reviewers will be resolved through discussion, or with the third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI SUMARI.35 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted if information is missing or unclear.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI.35 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.


The authors would like to thank Hilde Stromme at the Norwegian Electronic Health Library for assistance in choosing relevant databases.


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capability; capacity building; developing; healthcare management; leadership