N522 Module 2 assignment: organizational structure and design analysis paper, a full sample

Two Bosses and No Answer: Analyzing a Matrix Reporting Structure for Nurses in a 12-Clinic Primary Care Network

Student Name

Master of Science in Nursing Program, Aspen University

N522: Modern Organizations and Health Care

Instructor Name

Month Day, Year

Two Bosses and No Answer: Analyzing a Matrix Reporting Structure for Nurses in a 12-Clinic Primary Care Network

Organizational structure determines who decides, who is accountable, and how information moves. In health care, structure shapes whether a nurse with a question gets an answer in five minutes or five days. This paper analyzes the reporting structure for registered nurses in a composite primary care network, uses Mintzberg's configurations and research on matrix management to diagnose its problems, and proposes a redesign.

The Network and Its Structure

Valley Community Health is a composite network of 12 primary care clinics with 64 registered nurses, 90 medical assistants, and 70 physicians and advanced practice providers. Four years ago, to standardize nursing practice across sites, the network created a central Director of Clinical Nursing. Clinic RNs now report to two people: their clinic's practice manager, usually a nonclinical administrator who controls schedules, time off, and daily assignments, and the director, who sets clinical protocols, competencies, and performance standards. It is a classic matrix: a functional nursing line crossing a geographic clinic line.

The results are mixed. Clinical protocols are more consistent than before, and nurses value having a clinical leader. But nurses report conflicting instructions, such as a practice manager asking an RN to cover the front desk while the director expects the nurse to complete care management calls. Annual evaluations are written by practice managers who cannot judge clinical performance. Turnover among clinic RNs reached 22 percent last year, and exit interviews frequently mention "not knowing who my boss is."

Diagnosis Using Mintzberg's Configurations

Mintzberg (1979) described organizations by the part that dominates them and the way they coordinate work. Primary care clinics resemble a professional bureaucracy, in which highly trained professionals coordinate through standardized skills learned in their training rather than through direct supervision. In such organizations, professionals expect autonomy over clinical work and resist control by administrators who lack their expertise.

The practice manager line applies direct supervision, the coordination mechanism of a simple structure or machine bureaucracy, to professionals whose work is coordinated by standardized skills. When a nonclinical manager reassigns an RN from care management to reception, the manager treats nursing time as a generic resource, while the nurse and the director see it as professional work with clinical consequences. The conflict is not about personalities; it is built into a structure that asks two coordination mechanisms to govern the same hour of a nurse's day.

What Research on Matrix Structures Suggests

Matrix structures were widely adopted by hospitals in the 1970s and 1980s, and many were later abandoned. In a study of U.S. hospitals, Burns and Wholey (1993) found that adoption was influenced by organizational characteristics, such as size and the diversity of services, and by imitation of other hospitals in the same networks, and that abandonment was also shaped by what peer organizations did rather than only by whether the matrix worked internally. The finding suggests that matrix structures are often chosen because they are fashionable rather than because they fit the work.

Matrix structures can succeed when the two lines have clearly divided authority and a shared process for resolving conflicts. They fail when both lines claim the same decisions. At Valley, both managers claim control over how RN time is used, and there is no mechanism for resolving the conflict other than the nurse's own judgment, which leaves the nurse exposed to criticism from whichever boss is disappointed.

An older distinction helps explain why. Burns and Stalker (1961) contrasted mechanistic structures, with clear hierarchies and fixed roles suited to stable conditions, and organic structures, with fluid roles and lateral communication suited to changing conditions. Primary care has become more organic in its demands, with nurses managing chronic disease, coordinating transitions, and responding to walk-in needs, yet the practice manager line still treats the clinic as a mechanistic unit with fixed posts to fill. A structure built for a stable front office sits uneasily on professional work that changes by the hour.

The Costs of the Current Design

The structure has measurable costs. Replacing an RN in primary care costs a substantial share of annual salary once recruitment, orientation, and lost productivity are counted, so a 22 percent turnover rate among 64 nurses means about 14 departures a year and a large recurring expense. Care management calls that are postponed when nurses are pulled to the front desk translate into missed follow-up for patients with diabetes and heart failure, the patients whose avoidable emergency visits the network is trying to reduce. And evaluations by nonclinical managers deprive nurses of meaningful feedback on the work they were hired to do.

A Redesigned Structure

The proposal keeps the benefits of the matrix while dividing authority clearly. Clinical nursing work, including protocols, competencies, care management priorities, and clinical performance evaluation, would belong to the nursing line, with a new role of regional nurse manager overseeing four clinics each and reporting to the director. Operational matters, including clinic hours, space, and nonclinical staffing, would remain with practice managers. RN schedules would be set jointly, with a written rule that RNs are not reassigned to nonclinical duties except in declared emergencies.

A monthly clinic operations meeting including the practice manager and the regional nurse manager would resolve conflicts before they reach the nurse. Success would be measured by RN turnover, completion rates for care management calls, and nurse survey responses about role clarity, reviewed at six and twelve months.

Implementation would begin with the clinics where turnover has been highest, so the network can test the new division of authority before extending it to all 12 sites. Practice managers would need reassurance that they are not losing influence, since they remain accountable for clinic operations and patient access, and a short written charter signed by both lines would make the division of decisions visible to staff.

Conclusion

Valley's matrix brought clinical consistency but placed nurses between two coordination systems that claim the same decisions. Mintzberg's configurations explain why professionals resist direct supervision by nonclinical managers, and research on matrix management suggests that such structures fail when authority is not clearly divided. A redesign that assigns clinical decisions to a nursing line, operational decisions to clinic managers, and conflicts to a joint forum should reduce turnover and protect the care management work that patients depend on.

References

Burns, L. R., & Wholey, D. R. (1993). Adoption and abandonment of matrix management programs: Effects of organizational characteristics and interorganizational networks. Academy of Management Journal, 36(1), 106-138. https://doi.org/10.5465/256514

Burns, T., & Stalker, G. M. (1961). The management of innovation. Tavistock.

Mintzberg, H. (1979). The structuring of organizations: A synthesis of the research. Prentice-Hall.