# New Management Systems and the Ambiguous Nature of Resources: A Qualitative Study about Healthcare Middle Managers

Véronique Haberey-Knuessi, Jean-Luc Heeb

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Véronique Haberey-Knuessi, Jean-Luc Heeb. New Management Systems and the Ambiguous Nature of Resources: A Qualitative Study about Healthcare Middle Managers. International Archives of Nursing and Health Care, 2017, 3 (2), 10.23937/2469-5823/1510071. hal-04051743

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REVIEW ARTICLE

# New Management Systems and the Ambiguous Nature of Resources: A Qualitative Study about Healthcare Middle Managers

Véronique Haberey-Knuessi<fnref n="1" />* and Jean-Luc Heeb<fnref n="2" />

*Corresponding author: Véronique Haberey-Knuessi, Professor, Haute Ecole de Santé Arc, University of Applied Sciences of Western Switzerland, Espace de l'Europe 11, 2000 Neuchâtel, Switzerland, Tel: +41-32-930-1224, Fax: +41-32-930-1213, E-mail: veronique.haberey-knuessi@arc.ch

The focus of this article is an empirical investigation using the Demerouti model to examine the stress factors affecting nursing managers, doctors and nurses in their work, and the resources available to them. A survey conducted by healthcare managers showed that despite being very highly motivated in their work, their engagement with it is sometimes incomplete. The study revealed that the professional reality of these managers has changed significantly in recent years, owing to the introduction of new public policies and the resulting major changes that have occurred in how healthcare institutions function. Thus, while the Demerouti model insists on the importance of achieving a balance between the demands of the job and the resources available, the actual daily lives of middle managers show that demands are very high while resources are sometimes insufficient or insufficiently valued. Here we consider the ambiguous nature of some of these resources which, although described as such, tend under the influence of various factors to become constraints exercising a detrimental effect on professional commitment.

## Stress Management

Stress is a phenomenon that receives a great deal of attention from the media whether in the medical press, mainstream newspapers, scientific journals or the media as a whole. It has been recognised as causing numerous problems and there has therefore been much research aiming to improve our understanding of it, particularly with respect to occupational health. It

was first defined in the 1950s by the psychologist Hans Selye and is characterised by a high psychological and physical burden, which can become a problem when an individual's resources are no longer able to compensate for the burden and re-establish balance. The resources that an individual uses to manage activates compensatory mechanisms to help it respond to these demands. If the stress lasts, however, the body's resources begin to be depleted and can no longer fully meet its needs - a process of exhaustion begins and the stress becomes detrimental to the individual's health.

This understanding of stress leads to two potential types of action to stem the phenomenon. The first strategy involves attempting to do something about the actual cause of the stress, i.e. the context or the specific elements that result in the overload of demands that create the stress: workload, emotional weight, financial problems, and so on. The second strategy, on the other hand, focuses on the individual and his or her capacity to respond to stress in a positive manner, i.e. by mobilising the relevant resources. The research presented here uses Demerouti's Job Demand-Resources Model (JD-R Model) to understand the dynamics of what happens with these resources. We attempt to show how S. Hobfoll's thoughts on resources provide an valuable complement to Demerouti's model with respect to identifying all the various facets of the complex problem of stress. This will be particularly interesting in a management system that is itself a powerful generator of stress.

<footnote n="1">¹Haute Ecole de Santé Arc, University of Applied Sciences of Western Switzerland, Switzerland</footnote>

<footnote n="2">²Haute école de travail social Fribourg, University of Applied Sciences of Western Switzerland, Switzerland</footnote>
## Rationalisation, an Added Pressure

When managers of health or social care organisations are faced with constraints - especially financial ones - they are compelled to establish rationalisation measures. Just like business operates in the industrial and commercial sectors, they have to optimise resources whilst reducing costs to a minimum. In order to control rapidly spiralling costs, healthcare institutions have been burdened with methods of regulation that involve stress-inducing budget restriction policies [1]. As a consequence, various measures and major organisational changes have been implemented which had a strong impact on the hospital and care context. These policies which all come under the new public management umbrella and emerged in the '70s are underpinned by management theories that originated in industry. They are aligned with principles like market orientation, decentralisation, cost reduction or managerialism to increase efficiency and effectiveness of public service organisations. In order to reach this goal 'lean management' is a frequently used strategy to rule organisations [2].

If it is to be able to compete, the organisation must think not only in terms of reducing costs by cutting jobs, but also in terms of improving performance and quality without increasing costs. Such strategies require good knowledge of existing resources so that they can be used to the best possible advantage. However, not only material issues such as better use of equipment or pooling of various support functions are relevant. They include also - and most significantly - human factors like matching the skills available to the objectives set, ensuring that the tasks required are suited to an employee's qualifications or employees engage with their work. In the '90s, a number of management trends were often connected with the 'lean management' philosophy originating from Japanese Toyotism. The aim of these trends was to develop more efficient systems of organisation. The concept of 'lean management' first appeared against a background of economic crisis. Its propensity for infiltrating every sector and every professional sphere, including the healthcare sector and its various institutions, has prompted us to try and improve our understanding of the phenomenon [3]. The word 'lean' is used to describe a management theory that aims to divest a process of anything superfluous to its needs, resulting in a system that produces just enough, just in time. To achieve this, every stage of the production process is closely examined with the aim of eliminating waste of any kind, particularly as regards time and procedures as this is seen as an obstacle to performance. According to Hohmann [4], 'lean' refers to a "system that aims to generate maximum added value as cheaply and quickly as possible by using just enough resources to give clients what they see as valuable". Managers have a specific role in this process, especially as regards implementing a long term strategic vision

and orienting every action and decision in its direction. Managing this ongoing interface between short, medium and long-term objectives and the tasks carried out by employees on a day-to-day basis, this is the role of middle managers, in healthcare establishments. This role has changed significantly.

## Middle Managers, the Mainstay of New Public Management

Before new public management was implemented, these nursing managers carried out primarily organisational tasks and were more or less hidden in the wake of the doctors. Nowadays, however, they have had to come out of the shadows and fulfil a key role in the establishment. While this new way of organising things has given managers new goals and offers interesting challenges, it is not without its problems.

In this style of management, managers are expected to be hands-on. They must be familiar with all the particularities of the terrain so that they can guide and support their teams effectively. With client satisfaction as its central focus in the context of hospitals, 'lean management' needs to have a long term strategy to ensure its actions last. It must also be able to anticipate new challenges to come. Governance facilitates the implementation of mechanisms that allow an organisation to address the objectives set within different time-frames. As the people responsible for implementing institutional strategies, middle managers have to try and reconcile the demands of the latter with the imperatives directly connected with the actual functioning of the various services. They try to achieve a consensus, whilst eliciting and encouraging change when it is inevitable. The aim of 'lean management' is to seek out any problems encountered during operational phases in real time so as to respond and undertake corrective measures as quickly as possible. To this end, middle managers are expected to find out about any problems or difficulties that may arise, while the employees are also encouraged to help find solutions and suggest improvements.

When seen from this theoretical angle, 'lean management' is an idealised version of how large establishments might be managed that is underpinned by a highly participative vision. However, it is clear from the work of various authors that this ideal is still a long way off, particularly in the many establishments which restricted the vision to the aspect of cost cutting [4-6]. When the focus is only on costs, everything is undertaken in order to root out non-essential expenditures, but the positive aspects of the policy - such as education and training, finding time for dialogue, joint knowledge building and experience-sharing - are left by the wayside. This is likely to result in a system which becomes ineffective [7] or even detrimental to health, because it generates significant stress in a variety of areas. Negative effects that have been demonstrated so far relate to physical issues, including accelerated work rates and increasingly repet-
itive tasks impacting on blood pressure or Musculoskel-
etal Disorders (MSDs) [7].

But there is also a psychological impact: According
to Bourgeois and Gonon [8], this new way of organis-
ing work is associated with loss of meaning. Especial-
ly standardisation of activity and acceleration of work
rates have been recognized as sources of stress that
result in absenteeism and loss of qualified staff [9]. An-
other consequence of the intensification of activity is
that workers' discretionary power is reduced [10]. Par-
adoxically, however, the 'lean management' encourag-
es increased autonomy for workers. According to some
authors, while there is less overt control from the 'boss',
it has simply been replaced by alternative means of con-
trol consisting of procedures, administrative regulations
and other similar constraints [11].

In this kind of system, middle managers play a key role,
which is why such positions are becoming increasingly
common. They are coaches or leader-mediators who also
have a supervisory function as they must ensure that the
objectives set by management are met [7]. Such managers
find themselves at the sometimes uncomfortable interface
between their overburdened, discontented teams and the
management's practically unattainable orders and objec-
tives. The ever-increasing multiplicity of demands made
on them in terms of service, quality, organisation and flex-
ibility goes hand-in-hand with an increased number of re-
sponsibilities, which in turn has its own consequences in
relation to stress [12].

The policy of continuous improvement that underpins
new management styles rests on indicators that show
whether or not the processes used achieve the expected
outcomes. However, it also questions whether further im-
provements can be made. The resulting proliferation of
dashboards with their many and various indicators con-
tributes to increased anxiety amongst staff. Such indica-
tors are often inflexible and distanced from the realities of
day-to-day work and their rigidity may seriously hamper
the flow of any professional activity [13]. This means that
managers must try and find a balance between responding
to the indicators and interpreting their relevance to what
the actual work involves in the real world.

Clearly, the demands made on workers have increased
significantly, but they have also increased with respect to
the new professional class of middle managers. Faced with
the obvious difficulties of trying to alleviate a professional
situation that is impacted by significant budgetary issues
and policies that are primarily cost-cutting exercises, it be-
comes of paramount importance to consider the problem
from another angle: resources.

Importance of Resources as a Compensatory
Mechanism

Resources play a key role when considering any ac-
tivity because they help us understand, perform and as-
sess what is to be done. For a long time they were seen

purely as a way of balancing the workload, but they
have since then been recognised as a fundamental ele-
ment in motivational processes. They are also thought
to contribute to our coping strategies by giving them a
creative dynamic [14] and they affect the development
and protection of other values [15].

People have a two-pronged response to stress. On
the one hand there are our involuntary defence mecha-
nisms and on the other our coping strategies which we
consciously bring into play to help us to deal with the
stressful situation [16]. The coping process can involve a
cognitive, emotional or behavioural activity and is a re-
sponse that draws on both our own personal resources
and those of our surrounding environment [17]. Coping
strategies help us to imagine that things could be dif-
ferent or that we could have a different impact on what
happens, thereby making reality easier to understand
and manage [18]. Within this coping dimension, our
personal resources help us to develop an appropriate
response.

The difficulties inherent in the current hospital con-
text have a significant influence on people's health, par-
ticularly when stressful phenomena result in the failure
of neurohormonal compensatory mechanisms and indi-
viduals must therefore suffer the physical and psycho-
logical consequences of such stress. This is another rea-
son why a more far-reaching study of available resourc-
es and how they might be further developed appears to
be of particular relevance.

For this reason we decided to use the Job De-
mands-Resources (JD-R) model put forward by Demer-
outi, et al. [19] as the theoretical framework for the re-
search outlined below. This model highlights the funda-
mental role played by values in an individual's relation-
ship with stress particularly with reference to stress in
the workplace. The heuristic use of this model together
with its broad perspective and flexibility makes it an ap-
propriate choice in both research and practice.

The aim of the JD-R model is to combine two fields
of research: research into stress and research into mo-
tivation. According to this model, constraints impact on
stress and resources impact on motivation. The JD-R
model was validated in 2001 and is intended to be in-
tegrative and multifactorial. It is in line with those of
Karasek [20] and Siegrist [21]. It allows the researcher
to go beyond simply recording pathogenic or facilitat-
ing factors and functioning modes in order to examine
the dynamic role played by resources. According to this
model, a worker's well-being is directly related to the
characteristics of the work-place which are viewed as
demands and resources.

On one side lie the Job Demands, i.e. constraints
the worker encounters in his or her professional life.
Be they physical, social or organisational, their com-
mon denominator is that they all require personal in-
vestment on the part of the worker concerned. Under
certain conditions, they can lead to total exhaustion of
physical and mental resources and cause a variety of
physical and psychological symptoms. On the other side
Demerouti's model focuses on the internal and external
resources available to the worker named *Job Resources*.
This refers to the physical, psychological, social and or-
ganisational resources that reduce the negative impact
of the demands imposed providing a kind of protection
and helping the person concerned to achieve the objec-
tives set [19,22].

According to Demerouti, the simultaneous existence
of high levels of demand combined with insufficient
resources becomes a major source of stress. Various
pieces of research also show that people can react very
differently to stress depending on the personal, social
and organisational resources available when subjected
to similar workloads [23]. The compensatory nature of
the resources helps to protect people from stress and
its harmful effects. Unlike the models referred to earli-
er, Demerouti sees the concept of resources in a much
broader sense and not just as referring to resources
that are specific to the work context. Here the dynam-
ic role played by resources of every kind is emphasised
and they are seen as motivating factors or factors con-
tributing to job satisfaction [24]. According to the JD-R
model, resources have an intrinsically motivating role in
that they encourage a sense of personal fulfilment and
an extrinsic role because they make it easier to perform
the task. Thus, they stimulate engagement. This latter
aspect is said to be of even greater importance when
demands are high, but only in so far as the necessary
resources are available [15]. Moreover, they would ap-
pear to be auto-stimulatory as the existence of resourc-
es promotes the development of new resources in a
kind of virtuous circle [15].

Hobfoll's 'resources spiral' theory [25] postulates
that people try to store up resources accumulating
more and more so as to build up stocks to draw on
when demands are high. Resources are a central ele-
ment in terms of guaranteeing the well-being to which
one aspire. Thus a pleasant working environment is a
source of increased self-esteem and self-confidence as
it offers possibilities of self-fulfillment. It will in turn act
as a brake on the negative effects of excessive demands.
Conversely, stress would seem to appear not just when
there are insufficient resources, but also when one is
faced with the probable loss of resources in the near or
more distant future [26].

According to Schaufeli & Taris [27], resources also
alter an individual's perception of the features of his or
her professional situation and its related constraints,
particularly in terms of the positive effect they can have
on his or her sense of effectiveness. From this point of
view, they appear to play the part of a third variable
that explains the relationship between an individual's

perception of the characteristics of his or her working
environment and the level of satisfaction experienced
there.

However, as Schaufeli, et al. [27] pointed out, De-
merouti's model is more a description than an expla-
nation. Although a causal relationship has been shown
between resources and constraints with their relative
effects in terms of satisfaction or stress, no comprehen-
sive analysis of this relationship with respect to resourc-
es is offered. The observation is purely a dichotomous
description of resources and constraints, whereas in
practice things are not always so clear-cut. Thus Nahr-
gang, et al. [28] showed that a demand that stimulates,
though it can have a positive effect on workers, will
become a source of stress with negative effects if it is
too challenging. This prompts consideration of whether
specific resources, depending on the intensity of their
presence and the stresscircumstances in which they
operate, might possibly turn them into stress factors
themselves. This approach, moreover, corresponds with
a failing consideration we detected when exploring the
JD-R model [15]. This study seeks to address this omis-
sion by examining in more detail certain resources that
are frequently deployed in the context of management
styles like 'lean management'. It aims to understand to
what extent resources can go on being resources rather
than turning into constraints.

Method of Data Collection and Analysis

The empirical data come from a two year research
programme conducted in French-speaking Switzerland
between 2011 and 2013 in five hospitals of varying siz-
es: two local hospitals with fewer than 300 beds, two
regional hospitals with between 300 and 1000 beds
and a university hospital with over 1000 beds. The data
presented in this article were collected from managers
working in these organisations in a variety of different
roles: doctor-managers, nursing managers, cross-func-
tional healthcare managers, technical managers and
administrative managers. Participation was entirely vol-
untary. The high percentage of manager participation
in our investigation bears witness to the level of inter-
est in this issue. An overall response rate of 70.7% was
achieved.

The 942 participants were first asked to complete
a questionnaire, after which a number of focus groups
were conducted by the authors in the various institu-
tions (12 focus groups in all, attended by a total of 108
managers). In terms of ethical considerations, those
who took part were given all the guarantees inherent to
a research programme before they participated in a fo-
cus group such as conditions of participation, possibility
of withdrawal, confidentiality agreement, etc. Two to
three focus groups were held in each institution, com-
posed of managers from 10 to 12 different people each
time. There were slightly more female participants in
the focus groups - 61 women as against 47 men. Nearly
two thirds were nurse managers, one third were doctors and the remainder were cross-functional, technical or administrative managers. All were aged between 25 and 57-years-old. The large majority were able to report quite significant experience of working in their field of management (7 to 27 years).

The focus lasted an average of two hours and a free discussion, guided by a semi-directive framework, allowed free exchanges which gave very rich results.

The specific aim of this research was to understand the impact of new management styles on managers' professional practice and, more particularly, on their job satisfaction and their health taking a descriptive approach [29]. In this respect, the research was intended to comprehensively examine how the people involved perceived their reality.

Because the most significant results were obtained in the focus groups, as they offered the opportunity to examine the various subjects in depth through especially rich exchanges, we chose to present here only these focus groups results. Only a few percentages will be mentioned of the quantitative phase which are particularly illustrating in some subjects.

All the focus group meetings were recorded with the agreement of those taking part, and the recordings transcribed for the purpose of detailed analysis by theme. Each focus group meeting was first examined on its own in order to determine the main themes, after which the themes from the different groups were collated to provide an overall template that enabled final categorisation [30].

## Results

Nearly 60% of the middle managers reported a good level of job satisfaction. However, significant differences in motivation and commitment were revealed in this study. Even when work motivation levels were very high on the commitment scale [31], commitment levels were significantly lower. This suggests the presence of disruptive elements, given that motivation precedes engagement and is in fact the basis for it. There would seem to be an obstacle hampering the smooth transition from motivation to practical engagement.

The investigation revealed three main brakes on manager engagement: increased workload, very heavy responsibilities assumed despite only limited autonomy and high demands in terms of flexibility. This resources will be further commented together with resources as a major asset.

## Increased workload

The size of the workload makes managers feel as if they never quite finish anything, because they are always in fire-fighting mode and therefore never able to go into a matter in depth. Managers identified increased workload as resulting in physical and psychological disorders.

This is sometimes accompanied by a mental load, for example when managers have to ask their teams to comply with a management decision they do not agree with or which creates an overload for employees who are already stretched to the limit. In the words of one such nursing manager: "Every day we see the distress people already suffer at work, we know what the changes will involve but there's nothing we can do".

In addition to the increased workload, ethical issues also weigh on managers' minds. Whether it is about substandard care or a mismatch between the values of the hierarchy and those of the team, this can have a significant impact on how a manager feels - several managers (physicians and nursing managers) said that such aspects of their work prevented them from engaging fully with it. Mental load may be expressed by physical symptoms (headaches, digestive disorders, etc.) but it can also lead to the frequent use of sleeping pills (15% of participants) or the use of analgesics whether very frequently (8%) or occasionally (38%). In-depth investigation we drove among participants during the focus groups shows that physical and mental symptoms have increased since reorganisation and new management styles have been introduced. Contradictory instructions are a major source of stress for these managers.

## Responsibility and autonomy - high expectations

Managers in nursing but also in medicine recognised that this new mode of organisation has given them a new type of responsibility. They are aware of their central role and their superiors acknowledge that they are a vital link in the chain of command when it comes to ensuring that their teams implement the decisions that the institution has made. The longest serving amongst them states that they now have a higher status than they did before the reforms were introduced and enjoy having a mission to complete with a certain degree of new autonomy. Nevertheless, they are not all convinced that the extra autonomy brings added value as they feel that it is accompanied by greater responsibility yet no extra help. This extra responsibility is a particularly weighty load in that it must be assumed within a delicate context comprising numerous uncertainties over which they have very little control. As pointed out by a nursing manager: "Middle managers are not allowed to have a point of view about what happens in terms of policy decisions. They are told what to do middle managers are quite simply muzzled".

The system's poor organisation is another reason why this extra responsibility can be so burdensome. Many managers, especially physicians, deplored the increasing lack of organisation that had accompanied the introduction of the new public management reforms. Where previously only one person was responsible, there is now an imposing array of line managers. A physician manager mentioned: "So when you have to make a decision, no matter how secondary, it has to go right
up through the hierarchy and then come all the way down again - it can take months for something as trivial as a minor purchase". Diluting responsibility in this way means that "no-one feels responsible" (physician), which then leads to institutionalised inertia. The new managerial policies and the grouping together of healthcare facilities have resulted in far more management jobs and the various departments have been given different directorates in a system that has been described as "tentacular" (physician). A radiologist-manager described the almost "schizophrenic" pressures caused by being part of the medical directorate on a personal level while the radiology department itself was attached to a different directorate with a different set of objectives. In another establishment, closure of the diabetes outpatient department had forced the specialist nurses to join a polyclinic and provide healthcare procedures for which they were neither qualified nor motivated.

All these new responsibilities must be exercised within a context of just-in-time healthcare where the very heavy workload forces managers to work extremely busy shifts and long hours without enough rest periods. Indeed a young doctor talk of how hard it was to spend 70 hours a week in an oncology department working with patients whose suffering he was scarcely able to hear because he himself had reached his limit. An older doctor described the dismay engendered by the relatively recent introduction of a new policy whereby new staff are taken on without consulting him. This has resulted in the mass recruitment of very young, inexperienced nurses and a worrying increase in the number of critical incidents - some fatal - occurring in his department. The presence of just a few experienced professionals would ensure that complications in a patient's condition were recognised and appropriate action taken. But financial considerations took precedence.

## From instruction to flexibility and adaptation

Staff reported that they were expected to continually adapt their behaviour in order to meet the new requirements, but this only results in exhausting the people who have to deal with the constant changes. In view of their responsibilities, managers also have to be highly flexible - not just in what they do and say but also regarding communication as managers are expected to be available at all times. Continually on the alert with breaks regularly interrupted by telephone calls, managers are under constant pressure. They feel that they are expected to answer the phone even if it has never been stated officially. The same can be said for emails during holiday periods. Many managers prefer to deal with them as they arrive in order to avoid ploughing through the huge number that have accumulated after just one week's holiday.

The greatest pressure, however, is doubtless connected with meeting objectives. Managers have to deal with specific objectives that are increasingly hard

to achieve yet they can also see the problems likely to occur if they are not met. For example, one doctor explained that he is expected to see a certain number of patients during his clinic. If he does not meet this objective, he will not lose his job but "it will lead to a whole lot of minor consequences from refusing a training request to moving my office to an isolated room at the other end of the hospital or not being consulted when decisions are being made". As resources are limited they are given, he told us, "to people who will make the best use of them". This doctor therefore has no choice but to meet the imposed performance objectives.

Managers appreciate being given responsibility as long as they can exercise it in accordance with their values. However, this condition appears to be increasingly uncertain and a nursing manager described how difficult it is "not to be able to look after the team and having to neglect the most vulnerable". They all recognise that the managerial reforms have given them more professional autonomy when it comes to managing their teams for example, but they deplore the growing lack of managerial autonomy at a time when they are being given more and more management tasks to complete.

To sum up, middle managers are undeniably motivated with respect to their activities and the associated challenges. But the responsibility allocated to them must be accompanied by the resources needed for its implementation, true discretionary powers and an autonomy that is not designed solely with regard to efficiency criteria. In addition, while flexibility can offer an opportunity to explore new horizons and new practices, it damages team spirit and undermines recognition of professional skills by suggesting that anyone can turn their hand to any activity when imposed to excess.

## Resources, a major asset

The great majority of resources are allocated as specific support for third parties. Support from line managers is highly appreciated even if the fact that this upper hierarchy has listened does not mean that the situation will change and problems will be solved. Simply having the opportunity to talk to one's line manager can be soothing. On the contrary, feeling that one's needs and perceptions are not being taken seriously engenders a feeling of malaise and frustration. Many managers said that they were unhappy with the lack of attention and recognition they receive from their superiors. Everyone questioned stressed that help and support from colleagues was of paramount importance and that it was difficult to implement decisions from management bodies without this special upholding, particularly if the decisions were not very well received.

Even the more popular aspects of these new roles such as project management and increased flexibility also tend to distance nurse managers from their teams as they become increasingly absorbed in a variety of
cross-functional projects. This leads to a feeling of iso-
lation that is hard to manage. Especially nursing man-
agers experience this loneliness. As they are no longer
involved in day-to-day nursing activities, they can quick-
ly lose touch with the world of healthcare even though
it was the original motivation for choosing their career.
They describe a dual loss - they no longer have any con-
tact with patients and they no longer feel part of a team
- knowing as they do that their presence is not always
welcome.

Discussion

Results of this qualitative study are about the health-
care managers' view on changes in their organisation-
al setting and possible consequences on resources. As
such, the study stresses the perception of the manag-
ers and not an objective causal link between new public
management and work conditions. Managers reported
changes which they attributed to requests of the hos-
pital management. They located this changes within a
context of reformed management policies. Thus, re-
sults shoud be understand according to Thomas' theo-
rem [32]: since managers consider changes due to new
management policies as real, their consequences on
their working conditions are real. However, considering
that Switzerland's healthcare system is increasingly and
consistently governed by new public management rules
[33], the managers' perception mirrors organisational
changes, especially when they mention changes regard-
ing chiefly workload, responsibilities or flexibility. Addi-
tionaly, managers' consistent perception across the five
different hospitals they worked in suggest that their sub-
jectivity echoes a common objective process of change.
Furthermore, when looking at consequences, findings
among nursing managers revealed that the type of hos-
pital was not relevant to exhaustion [34]. Also, findings
are in line with previous empirical research emphasising
the relationship between managerial changes in hospi-
tals and profesionals' health [35-37].

Limitations of some resources

According to Demerouti's JD-R model, resources are a catalyst promoting motivation and engagement particularly in the context of a demanding job. However, Demerouti and Bakker also talks about certain aspects that in fact become obstacles to these resources such as role conflicts, work overload and task ambiguity [15]. While the tasks allocated can be motivating factors, this only happens if they are balanced out by the appropriate resources.

To some extent, both autonomy and responsibility
are beneficial dimensions. They provide managers with
a certain degree of freedom and enable them to find
meaning in their work, to prove their capacity and to
obtain social recognition. But when a facilitating envi-
ronment that promotes autonomy and responsibility is
missing, they become constraints. Indeed, autonomy

then turns out to be nothing else than a form of con-
trolled freedom (for exemple by objectives that have to
be achieved) and responsibility becomes burdensome
because it is no longer in accordance with the means of
the person.

According to Hobfoll [25], stress and disengagement arise in three situations: lack of sufficient resources, threatened lack of resources in the future and the impossibility of obtaining more resources. The present research shows that managers encounter the first situation less frequently, but encounter the second and third alternatives very much more frequently. The interviews conducted confirmed that fear of deteriorating working conditions significantly hampers engagement because of the anticipated problems. Moreover, owing to their threatening nature, people tended to assign greater importance to losses than to the resources themselves. The impact of losses are “rooted in cognition” [26]. For managers, the loss of autonomy in a context increasingly bound by protocols where monitoring takes place implicitly through multiple procedures and assessments results in a significant fear that their professional practice will suffer. This leads to demotivation by anticipation. Furthermore, the impact of the loss of resources depends on the value accorded to them in relation to one’s culture or environment.

Importance of personal and professional values

In the healthcare world, collective values are of par-
amount importance [26]. Indeed, teamwork and peer
recognition were two of the elements most frequently
mentioned as sources of satisfaction or even as being
the reason for someone's choice of career in the pres-
ent research. It is therefore easy to understand why loss
of the relational dimension with respect to the team,
a knock-on effect of the new organisation systems and
new missions might constitute a major depletion of re-
sources. In this study, all the managers agreed that they
were initially supported by their teams when organisa-
tional problems arose. However, their inability to im-
prove working conditions undermined their legitimacy
in the long term and sometimes resulted in their exclu-
sion from the team.

Just like this relational value, managers also emphasised the importance of values associated with quality of care. Here too, they were reacting before the event as most of them said that at the moment they were still able to provide quality care. But they can see an imminent danger in a management system that puts quantity and efficiency before relational and holistic care that is the basis of their understanding of healthcare. There is no doubt that this is one of the principal causes of distress, exhaustion and resignation. The most flagrant example was given to us by one of the institutions where we conducted our investigation, currently being taken over by a large private-sector group. The managers bitterly described how the group made no attempt to
hide that its aim was to "make money, not take care of people". Also, members of the medical staff should agree to be "formatted" in the group philosophy, i.e. profitable patients only, high-end accommodation, etc. if they wished to go on working there. They were told that if they could not adhere to this philosophy then they should leave.

## Quality of care, conditions of engagement

These various elements explain the difference that we observed between managers' motivation levels and their engagement levels. They are still highly motivated but engage far less with their work because of declining or disappearing resources. Engagement is being replaced by a protective attitude resembling a retreat [15].

We have outlined how frustrating and even damaging it is for managers to feel unable to care about patients or teams according to one's values. They experience this impossibility as a personal failure and often feel guilty. Because this is source of suffering, many of them explained to have made a deliberate choice to restrict their commitment when compared with the past. They prefer to remain aloof even if it is sometimes considered as disengagement.

When considering resources, it becomes clear that they are not always objective or easy to evaluate. In fact they can be of a fundamentally subjective and symbolic nature. We cannot therefore focus solely on the loss of material resources. We must also take into account less visible resources and consider their quality and distinctive features. Similarly, assessing the resources available to an employee at a precise moment in time whilst ignoring their evolutionary character is extremely limiting. Demerouti and Bakker [15] recognise that the results of an investigation can be very different depending on whether the focus is the short or the long term, as the impact of resources takes place over a period of time - a factor that also affects their quality. From this point of view, Hobfoll [26] takes into account the effects of anticipated changes and enables us to fill the gap in the JD-R model which only takes a snapshot of the resources available at the time.

## Resources, a multifaceted concept

Demerouti's JD-R model uses the concept of resources in its broadest sense, but it would be of interest to look at this notion in greater depth so as to fully understand their quality and particular features. What may indeed act as a resource in some situations may in others turn out to be a constraint. Thus, for example, autonomy and responsibility can be seen as a challenge by some persons in some situations and become a source of motivation. In other circumstances they become a burden exerting pressure and even resulting in exhaustion. By understanding the nature of these resources, managers would be able to assess both their scope and their limits.

Thereby, they could possibly establish a better balance with the demands made by their work. Acknowledging the value of resources is an important way for managers to recognise the efforts of their teams. Indeed, it should be kept in mind that lack of recognition is one of the principal causes of disengagement. Our research shows that such a quest is even more vital in so far as the new management styles are much more interested in results and process efficiency than in considering people and their needs. In such circumstances, factors that would normally be seen as resources run the risk of quickly becoming constraints if the fact that they involve human beings is not taken into account.

New public management is regarded as an opportunity to concentrate efforts and avoid wasting energy. It promotes synergies and opens up new possibilities. Managers are happy to take part in addressing such a significant challenge and the associated workload is not seen as a problem as long as they are able to take it on. In this respect, Demerouti's model allows us to see how the inherent values align with the constraints imposed. But the problem is caused by the nature of the resources themselves and how they fit into the timeframe. And this is where it appears to be of particular interest to link Demerouti's model with that of Hobfoll who focuses on these very aspects. When factors like responsibility and flexibility are customarily considered as resources, they can in fact become constraints, particularly if they are underpinned by different values. There is therefore much work to be done at management level to see resources not just in generic terms but also in terms of values.

## Conclusion

It is no doubt unrealistic to imagine that there is such a thing as the perfect management system enabling all the tensions within an organisation to be resolved. Nevertheless, it is possible to seek ways of working together to build a future that has meaning for the individuals involved and fits in with a company's strategy and development at the same time. Strategies are key and 'lean management' is a tool for implementing them [4]. Where there is a common interest, a company can develop its full potential. We cannot overemphasise the importance of the virtuous circle. Where satisfied employees are motivated to engage with their tasks and therefore accomplish high quality work, this has in turn positive consequences for both the institution and the employees concerned in terms of recognition which will itself become a new source of motivation. However, diverging interests and unanswered problems open the door to the kind of double constraints that put people into quasi-schizophrenic conditions which will eventually have a detrimental effect on their health [38]. "Respect for the community means taking into account the fact that a company exists within a social framework that it must take into consideration" [38]. In addition to respect for
the community, the issue here is about the central place
of the individual at the heart of every production process.

While strategic management is based on the concept
of value creation, this cannot be the sole purpose of an
organisation's management policy. Value must be created
'with', 'by' and 'for' people and must include the elements
that are seen to constitute 'value in the eyes of the profes-
sionals'. To take their vision of healthcare into considera-
tion, it would seem appropriate for middle managers to be
involved in managing the institutions where they work. If
hands-on professionals were to take part in managing hos-
pital structures, various pitfalls would doubtless be avoid-
ed. A dialogue could take place with respect to the values
promoted by the different parties and a consensus could
be sought that would be able to take into account the spe-
cific nature of healthcare and how it exists within a time-
frame. More appropriate indicators than those based on
purely performance-based criteria, which are quantified
and evaluated solely in the short term, could be sought.
This would mean that healthcare professionals feel that
their philosophy received more recognition and therefore
the dynamic would guarantee renewed motivation that
could in turn be transformed into genuine engagement
[27].

Demerouti's JD-R model can help management to un-
derstand the role played by resources and how to stimu-
late them, thereby helping to give healthcare professionals
their rightful place. But it also highlights that they have lim-
its and must be considered with reference to a timeframe
that is in line with people's actual needs. Management will
truly be able to influence employee engagement only if it
takes these needs into account [39].

Acknowledgement

The research was funded by the Swiss National Sci-
ence Foundation (grant 13DPD6_134764) and approved
by the ethics committee of Lausanne University.

Conflict of Interest

No.

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