Taking sides or bridging worlds? Managerial responses to conflicts and tensions between the core operations and the administration in healthcare.

BACKGROUND: Swedish public healthcare is increasingly characterised by a growing administrative layer and complex governance structures. While administrative personnel have grown in numbers, their coordination and integration with core clinical operations appears to remain underdeveloped, leading to tensions, conflicts and perceived power vacuums. Despite the growing complexity, little research has focused on how healthcare managers, including those outside the clinical line, navigate these tensions. This study addresses this gap by exploring how managers understand and respond to conflicts between administrative and clinical domains, and how these dynamics affect their ability to act as public professionals with 'holistic viewpoints' within public healthcare. METHODS: The study employed qualitative methods, including semi-structured interviews with 24 healthcare managers across three Swedish regions. Participants represented both clinical line organisations and administrative units across hierarchical levels. Thematic reflexive analysis was used to identify patterns in how managers perceive and navigate tensions and conflicts, with a focus on power, conflict resolution, and perception of where one's loyalties lie. RESULTS: The results show how managers often distanced themselves from responsibility for resolving conflicts and managing tensions, delegating integrative tasks to roles with limited mandates. First-line clinical managers aligned with their staff, reinforcing divisions between administration and core operations, and were shown to have much power in practice, yet did not recognise this. Administrative managers lacked legitimacy and formal authority, something which complicated collaboration. Education was proposed as a solution to tensions and conflicts, but often in vague terms. Power was perceived as always residing elsewhere, either with top management, politicians or core operative personnel. While some managers experienced a shift in understanding when moving up the hierarchy, this did not consistently translate into integrative practices. Overall, the findings reveal a gap between the recognition of tensions and conflicts and the capacity or willingness to address them constructively in line with how current research frames 'public professionals'. Managers' actions often reinforced rather than bridged divides, reflecting a lack of holistic perspective amongst healthcare managers. CONCLUSIONS: Healthcare managers struggle to act as public professionals in a fragmented system marked by conflicting logics and unclear mandates. Rather than bridging divides, many reinforce them through alignment with their groups or delegation. Addressing these challenges requires rethinking managerial roles and fostering strategic, integrative leadership across organisational boundaries for healthcare organisations.