Human Resources Management (HRM) is a system that guarantees the effective use of knowledge, competences, abilities, and other characteristics possessed by individuals aiming for the achievement of an organisation’s goals. For this reason, the topic of HRM has been very widely debated in literature since the post-industrial period, when it was highlighted that productivity is increasingly based on the knowledge, skills, and abilities of the trained human intellect . These aspects are particularly evident in public organisations since the assets that incur the most costs are an organisation’s employees and because the production and quality of services depend directly on employee contribution . Nevertheless, with the exception of the aspect of employee/industrial relations, the public sector compared to the private sector  has been neglected by HRM research. Research has however found that there are at least four main reasons for focusing on HRM in the public sector . These include: 1) the lack of attention given to the public sector context in the HRM literature; 2) the importance of public sector services and the role of human resource in delivering these services; 3) the level of public investment in civil services and the need for agencies to maximise this investment; 4) the scale of workforce-related challenges confronting public sector agencies.
Historically, HRM practices in the public sector followed a traditional model of personnel administration, in which a bureaucratic employment policy accompanied Weberian practices and principles of rule-governed rational action. However, results widely perceived as unsatisfactory and the awareness of a new management approach based on the responsibility and efficiency of personnel called this system into question . The introduction of New Public Management (NPM) shifted the emphasis in the public sector from administration towards management in order to achieve efficiency, effectiveness and quality of care. These new business practices include new ways of managing public sector employees, and HRM was thus included in the public sector reform agenda . Today the traditional notions of career service, stable and lifelong employment and service-wide employment conditions have been challenged by principles of NPM.
An important cadre of the public sector workforce that has been especially affected by NPM are the many professions represented in public sector organisations. Evetts and Burchner-Jeziorska define a “professional” as an individual who possesses knowledge and skills designated by a professional body, usually in conjunction with universities and/or professional bodies as well as the government, and controlling entry to a profession . These characteristics allow professionals greater autonomy in making decisions in the workplace and an exclusive identity that establishes boundaries between themselves and others. It is this power which has enabled them to challenge and even violate managerial directives in ways in which other employees cannot . Several authors claim that the HRM practices inspired by NPM have in fact failed in public organisations where there is a large proportion of professionals [3, 5, 9]. For such organisations, it is necessary to implement innovative HRM systems that enhance the characteristics of professionals, i.e. their competences and autonomy. Nevertheless, although in literature the HRM practices that enhance competences are considered innovative [10, 11], there are few studies in this direction [2, 12]. In this scenario, the first stage for developing successful HRM is knowing which competences are perceived as crucial by professionals in order to improve performance. This aspect is preliminary for all stages of the human resource cycle: which competences should be recruited, developed, evaluated and rewarded? Our research aims to answer this question with specific reference to the public healthcare sector, where the issue of competences is a particularly critical aspect for HRM practices [2, 13]. However, the issue of skills of healthcare professionals is complicated, because they are required to have both clinical and managerial competences . The need for healthcare organisations to search for increasingly efficient and efficacious management has led to a shift from a model of professional bureaucracy, characterised by professionals outside the administrative hierarchy, to a model where managerial competences are required from clinicians . In this new model of organisation, clinicians are required to have transversal competences. Alongside technical professional skills, they should possess management skills for managing and enhancing resources. Thus, when healthcare organisations design their HRM practices, they now need to take into consideration the new role of the clinician in the healthcare process as well as the development of new competences required to perform the role played in the organisation. From this perspective, the present study focuses on managerial competences required by professionals to fill the role of manager-clinician.
Our study was conducted in Italy. The Italian National Health System (NHS) was established in 1978, inspired by the United Kingdom NHS. It is predominantly public and characterised by professionals who possess both clinical and managerial skills. These characteristics are common to most healthcare systems in industrialised countries, as shown in the next section of this paper, and for this reason our findings can be generalised . We contribute to the literature on HRM practices in healthcare sector. The results are useful to all those organisations that want to invest in human resources to increase the quality of their performance.
Managerial competences: geographical framework
The shift to a model relying on managerial competences of clinicians has occurred in most industrialised countries. In the United Kingdom, for example, the Thatcher reforms ushered in change within the traditional model of public services . The 1983 Griffiths Report in fact recommended that hospital physicians should take responsibility for management together with clinical autonomy. In Denmark, the first attempt to strengthen internal hospital management in 1984 occurred with a White Paper on the productivity of hospitals, which contains recommendations on the “modifications to management” model . In France, the idea of strengthening hospital management appeared as early as 1983, although there was no decisive move toward the method until 2002. In 2007, the Hospital Plan reorganised units into centres each with their own budget, utilising a model similar to the British one . In Italy the 1992 reform stated that healthcare organisations were legally independent entities and increasing attention was paid to costing, management, and efficiency. The new role of Chief of Unit came into being; this individual is responsible for running and organising the structure, managing human resources, managing clinical outcomes, planning and scheduling projects, and overseeing financial, technical, and administrative targets. In the United States, the shift included various reforms, which affected both teaching and the methods of assessing student healthcare skills. The Joint Commission requires specific certification for suppliers of healthcare for the accreditation of an institution. These changes were significant in terms of professional autonomy, given that the conflicting forces of the market and legislation are capable of undermining the medical profession. Taking responsibility for management is a highly complex matter in any case, although it has long been seen simply as an administrative activity specific to the medical profession . Promoting and enhancing managerial competences is therefore a significant challenge, and today these skills are often poorly developed among healthcare professionals . There are also studies finding that clinicians believe they have not received adequate training for these managerial roles . The blame for this lies partly with curricula of medical schools, which have largely failed to offer sufficient training.
Managerial competences: literature framework
The terms “leadership” and “management”, are used with reference to clinical personnel to describe managers who combine a clinical professional background with managerial competences and responsibilities. As fields of study, medicine and management follow different types of logic, and a manager with a clinical professional profile needs to be able to shift from one field to another. Dual responsibility in clinical practice and management entails modifying the chain of command and generates changes with regard to both organisational configuration and professional responsibility . This type of management model reached Italy from the United States during the 1990s, and aimed to assign every Chief of Unit budget, financial, and HRM responsibilities, and to promote a new type of divisional model. The model spread worldwide, involving providers in many other countries, such as Canada and the United Kingdom, where the term “manager-clinician” became widespread . The term also spread to Australia, New Zealand, Scandinavian countries, Italy, France, Germany and the Netherlands [15, 23]. The position of the manager-clinician, and the interpretation of his or her role within the organisation is not free from issues. He or she, after all, does not possess the preparation or background for the role, and potential problems may reflect the absence of management training, capacity, time, and personality. These aspects generate further issues involving professional identity, lack of role awareness within the organisation, and can entail poor communication with other group members . These elements partially reflect the professional development of the manager-clinician, which often lies outside a continuous program based on a model of competences.
The literature on the competences of the manager-clinician is limited and partial, and provides no mutually agreed-upon definition of the role . Furthermore, current studies supply generic and partial indications regarding managerial competences without stating the specific competences necessary for a manager-clinician . Nevertheless, although there is no consensus as to what is required, the concept of key competences is discussed in various studies, which find they vary according to the level of management and respective local context . The Healthcare Leadership Alliance describes five competency domains common among all practicing healthcare managers . Other studies identify managerial competences necessary for clinical governance in different countries. One study conducted by five Canadian medical schools identified eight roles of a clinician: medical expert, communicator, collaborator and colleague, health supporter, learner, manager, researcher, and clinician as an individual . Similarly, a United States study of 100 clinicians identified aspects of their role to be: possessing the required capacity for communication, guaranteeing quality, and managing human resources. This study noted, however, that this list is not exhaustive and that other key areas of management may have been overlooked . The American College of Preventive Medicine also published a definition of four main managerial competences for clinicians: supplying health care, managing costs, managing elements of the organisation, and possessing legal knowledge .
In conclusion, there are many studies on managerial competences in the field of health, but there is no shared vision regarding the exact competences required; most importantly, there is an absence of studies exploring the specific competences required of a manager-clinician. This study thus builds on the domains of managerial competences identified by the literature to date, and aims to identify applicable competences that are both determinant for the healthcare sector and necessary to improve organisation performance. It is essential to identify these competences in order to enact policies for their development and to make the HRM system capable of developing and enhancing them.