Challenges in hybrid management in healthcare: a study of the interplay between divisional managers and clinical directors in a decentralized healthcare organization in Sweden

The integration of medical professionals into management—so-called hybrid management—has emerged as a key strategy in public healthcare reforms. Clinical directorates (CDs) are often seen as vehicles for this integration. While prior studies have explored hybrid management roles and decentralization, less is known about how multiple hybrid-managerial levels interact within one organization. This study examines the perceptions of clinical directors in a large, decentralized healthcare provider in Sweden, following the introduction of a divisional hybrid-managerial level intended to enhance efficiency and coordination. A sequential explanatory mixed-methods approach was used, combining two web-based surveys (2018 and 2019) sent to all clinical directors (n = 95). The responses were analyzed quantitatively via nonparametric tests (Mann‒Whitney exact test, Fisher’s exact test) and indices (polarity, intensity, uncertainty). The open-ended responses were analyzed via directed content analysis to deepen the interpretation of the quantitative trends. Response rates were high (84% in 2018; 97% in 2019). The introduction of a divisional hybrid-managerial level yielded mixed results. Some improvements in coordination and leadership support, particularly in mental health care services, have been reported. However, many clinical directors—especially in primary care—perceived increased administrative burden, unclear roles, and confusion over responsibilities. Statistical analysis confirmed significant changes in perceived time for patient care and administrative burden but not in central support. The qualitative data revealed that while some directors appreciated improved strategic dialog, others cited increased complexity and ineffective support systems. Introducing a divisional hybrid-managerial level in a decentralized healthcare setting can improve coordination but risks adding bureaucratic complexity without clear role definitions and adequate support. The study underscores the importance of clarifying authority and responsibilities when layering hybrid roles. Effective hybrid management requires more than professional alignment—it demands robust systems, clear communication, and a culture that reconciles managerial and professional logics. These findings offer insights for health systems pursuing hybrid governance models and contribute to theory on decentralized management in complex service organizations.