Breaching the professional social contract to drive system innovation: Nurse managers and the emergence of a new professional group

The movement of healthcare professionals into hybrid manager positions is no longer seen as unusual within the course of a career. However, despite a continuing focus on the potential for hybrid managers to drive system level innovation, extant research suggests that potential is limited by the tensions inherent in the role, creating emotional turbulence and a lack of organizational influence. In this paper we explore these tensions as resulting from potentially unavoidable breaches of social contract, which all healthcare professionals becoming hybrid managers must navigate. Drawing on the case of nurse managers, we present findings from 120 h of ethnographic observation and 79 interviews conducted over three years. We identify three types of identity work in response to social contract breach: flipping between ignoring and separating expectations; reframing expectations; and decoupling expectations; and present a model exploring the outcomes and relationship between each of these responses over time. In doing so we give insight into the emergence of a new professional group we call ‘agents of innovation’, who hold the potential to drive system level innovation within healthcare.