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Towards Dialogue: Bridging Cultural Differences Between Professionals and Managers

Wednesday, August 1st, 2001
Barbara Simpson, The University of Auckland
Bob Large, Auckland District Health Board
Matthew O’Brien, The University of Auckland


The conflicts over values between professional and managerial occupational groups remain a significant obstacle to high performance for many contemporary organisations. Dialogue between these groups offers a means for resolving these tensions, but can be notoriously difficult to establish. This paper explores the potential of Personal Construct Psychology as a way of creating dialogue. The argument is illustrated using the results of a workshop involving 19 senior managers and 33 clinical directors from a large public hospital. The participants found that by elaborating their differences using Personal Construct Psychology, they were then better able to explore their commonalities, thus, providing a foundation for ongoing dialogue.


The many differences between professionals and managers, and the disruptive implications of these differences for organisational life, have been well documented in the organisational studies literature (eg, Raelin 1991). However, the problems of building bridges and creating dialogue between these two occupational groups persist. The problem boils down to the tension between professionals’ desire for autonomy versus managers’ need for control. But a more in-depth analysis points to the different types of knowledge and different learning processes that characterise these two groups.

Professionals typically devote years to the theoretical study of technical particularities and the skills-based development of their individual areas of specialisation. Managers, by contrast, learn their multifaceted role through active, on-the-job engagement with practical organisational issues. Their respective learning processes lead to the development of intra-group understandings and assumptions that become so taken for granted they cease to be questioned by members of the group. Indeed, group members are often not even consciously aware of their own deeply embedded assumptions, until they are confronted with an alternative set of understandings. These deep, tacit assumptions determine how a group perceives, thinks about and reacts to issues and events. Even the language, or jargon, used by group members is shaped by these assumptions and, in turn, provides the vehicle for perpetuating them.

Essentially, the differences between professionals and managers are cultural, arising as they do from the different practices common to each occupational group (see, eg, Brown & Duguid 1991; Lave & Wenger 1991). Schein (1996) illustrates these cultural differences with three specific organisational sub-cultures, which he labels respectively, "operators", who actually run an organisation’s production systems, "engineers", who design and monitor an organisation’s core technologies and "executives", who are concerned with the financial accountability and long term viability of an organisation. All three groups are essential to the overall functioning of an organisation, but their fundamentally different world views create significant potential for organisational dysfunction. The difficulty faced by contemporary organisations is that they are increasingly dependent upon bridging these differences in order to operate effectively in a world that demands high performance.

Bridging between two or more cultures requires more than mere negotiation and compromise. It is also likely to involve the renewal, or transformation, of underlying assumptions within each group as a prelude to building common ground from which to communicate. The literature on organisational learning can be helpful in understanding the requirements for cultural renewal. For instance, Isaacs (1993) has suggested dialogue as a useful tool. He reports several examples where dialogue has been employed to good effect, including a health care community divided by competitive antagonisms. In this case, the parties were able to develop a new set of shared understandings and a new language by means of which they were then able to identify new solutions.

In this article, we take up the suggestion of dialogue as a useful way forward. We begin by exploring the meaning of "dialogue" and the issues involved in its application. Then we introduce Personal Construct Theory (Kelly 1955), which we argue provides a practical means of implementing dialogue. And, finally, we illustrate the utility of Personal Construct Theory using the results of a workshop involving medical clinicians and hospital managers.

Dialogue and Organisational Learning

Bridge building between the professional and managerial cultures is essentially an issue of organisational renewal involving transformation from the professional dominance of past organisational forms to new modes of responsive and flexible organisation (see, eg, Brock, Powell, & Hinings 1999). Crossan, Lane, & White (1999) have developed a model of strategic renewal that identifies four inter-dependent processes of organisational learning:
- intuiting
- interpreting
- integrating
- institutionalising.

Together, these processes span all relevant levels of analysis from the intra-personal, intuitive and often pre-conscious cognitions of individuals, through the inter-personal development of shared interpretations and the integration of these understandings into collective action, to the extra-personal or institutional embedding of systems, structures, procedures and strategies.

This comprehensive model provides a rich integration of the various bodies of literature that inform organisational learning, from entrepreneurship to sensemaking (that is the process by which individuals and organisations make sense of their environments) to institutional theory. In particular, at the inter-personal level, Crossan et al identify dialogue as an important means of facilitating collective mind (Weick & Roberts 1993). The critical feature of dialogue is that it engages not only with the superficial message that is being communicated, but also with the deeper interconnected meanings that underpin the message. Salient as this is to bridge building between cultures, the notion of dialogue nevertheless remains somewhat contested, with scholars from disciplines as diverse as philosophy, linguistics, psychology, anthropology and, of course, organisation studies, each introducing their own particular spin.

To summarise the philosophical arguments on this subject (eg, Sidorkin, 1999; Buber, 1965), "genuine dialogue" requires the creation of a reciprocal relationship that depends for its legitimacy on full and uninhibited disclosure of all opinions and assumptions. A necessary consequence of this requirement is that dialogical speech must always be spontaneous and can never be pre-planned. Faithful commitment to open and honest communication creates the environment where deeper meanings may be safely explored.

The physicist, David Bohm (1996) sees dialogue as a tool for solving many of the problems facing society today. He helpfully distinguishes dialogue from other forms of communication such as discussion or debate. Whereas these latter relate to the establishment and defence of fixed positions in an argument, the purpose of dialogue is to engage in collective inquiry. Discussion and debate are competitive, win-lose models of communication; dialogue is cooperative and win-win by nature.

For this process to be productive, it is essential that participants are willing to suspend their own views and assumptions. This involves the practice of non-judgment and careful observation of the reactions of both self and others. However, it is important to note that "suspension" does not mean the suppression of some perspectives. Bohm (1996, p27) insists that:

. . . everybody is quite free. It is not like a mob where the collective meaning takes over . . . it is something between the individual and the collective. It can move between them. It’s a harmony of the individual and the collective, in which the whole constantly moves towards coherence. So there is both a collective mind and an individual mind, and like a stream, the flow moves between them.

It is inevitable that as dialogue proceeds, participants will reach a point (or many points) of intractability. Bohm describes this as "the impulse of necessity", where participants come to recognise absolute necessities that are apparently non-negotiable within their own belief systems. The function of dialogue is simply to reveal these apparent necessities as the assumptions that they are. Dialogue does not aim to change anybody’s opinion, but merely to illuminate differences. When "absolute necessities" collide, there is an opportunity for dialogue participants to transcend the limitations of their assumptions.

Personal Construct Psychology

Clearly dialogue has great potential as a means of revealing and exploring the deeper, more tacit assumptions that underlie the collective mind. But the process is by no means without its difficulties. Foremost amongst these is the fact that dialogue necessarily involves the emotional engagement of the participants. Experiences of frustration, anger, pain, joy and love are the common currency of the dialogue process. But it is precisely because of this intensity of emotion that dialogue may founder. What is really needed in this process is a relatively non-threatening approach to embarking upon the exploration of shared, often hidden, assumptions.

It is in this context that we propose the use of Personal Construct Psychology, which was originally developed by George Kelly (1955). Kelly recognised that every individual has a unique construct system that has been built up, modified and refined progressively on the basis of life experience. He asserts that we use our construct systems as a means of both predicting and controlling our world. Our constructs are like a template that we use to classify and think about events and experiences. When the template does not fit very well, in other words when its explanatory power is inadequate for our purposes, then we sensibly make adjustments to our construct systems. In other words, Kelly is saying that the ways in which we make meaning are constructed out of our own successive experiences. This constructivist assumption bears a striking resemblance to Bohm’s view that the purpose of dialogue is to collectively construct something new out of disparate thoughts.

Kelly provides a considerable elaboration of his theory of personal constructs, expanding his basic postulate by means of 11 corollaries. It is beyond the scope of this article to delve into this complex theory in great depth, but there are several elements that bear particularly upon our discussion of dialogue. First, Kelly assumes that all constructs are dichotomous in form. That is, every construct is defined in terms of two opposing poles. It is only by understanding this opposition that we can ever grasp the meaning of either pole. Thus for example "feminine" has little or no meaning until it is contrasted with "masculine"; likewise, "day" and "night", "hot" and "cold", "good" and "bad" and so on. Extending this further, there may be multiple contrasts to any particular pole. For instance "light" might be contrasted with "dark", or "heavy". In each case, the opposing pole clarifies the meaning to be ascribed to "light".

Next, Kelly states that any individual’s construct system is comprised of different sub-systems that may be inferentially incompatible. That is to say, the construct sub-system that I use in one set of circumstances may differ from that used in another context. I may, then, appear to behave inconsistently in different situations or at different times. This accounts for the well-known parental dictum "don’t do as I do, do as I say". As part of my construct system is refined through experience, other parts may remain unmodified, because they were not engaged during that particular experience. Over time this may lead to significant internal inconsistencies within my construct system. This element of Kelly’s theory is very relevant to our discussion of dialogue. It suggests that where an impasse is reached, where absolute necessities are in conflict, then a wider exploration of participants’ construct systems may highlight internal inconsistencies that they may then choose to adjust.

Kelly’s philosophical position of constructive alternativism clearly explains how it is that two people who have the same experience may construe it quite differently. But equally, if two people construe an experience similarly, then they can be said to share a common process of construction. This element of Personal Construct Psychology accounts for the development of collective mind and shared meaning. An extension of this argument is that, in order to communicate effectively with another, it is necessary to construe the construction, or thought, process used by that person. In other words, it is necessary not only to anticipate the content of that person’s thoughts (ie, their response) but also what their inner meaning-making process is. To quote Kelly (1963, p95):

the person who is to play a constructive role in a social process with another person need not so much construe things as the other person does as he must effectively construe the other person’s outlook.

This is the essence of reciprocal relationships as discussed by both Buber (1965) and Bohm (1996).

An Illustrative Example - Eliciting Constructs from Hospital Managers and Clinicians

The intersection of Kelly’s theory of personal constructs with the literature on dialogue suggests a potential way forward in the challenging task of bridging cultural differences. By eliciting bipolar constructs that reflect the shared meanings within a cultural group, underlying assumptions may be exposed in a manner that facilitates further exploration. As within-group assumptions are made more explicit, there is then a greater potential for between-group dialogue.

We tried out this approach at a workshop involving 52 senior managers and clinicians from a large public hospital. The clinicians were mostly clinical directors whose jobs involved professional and clinical responsibility and working in conjunction with a business manager to run a discrete clinical service. This role brought them into a working relationship with managers to a far greater extent than the average clinician. The managers present were the general and service managers of the organisation, some of whom had long experience in the health service or backgrounds in clinical health care professions, and others who had come from outside the health sector. Both managers and clinicians were well aware of the tensions between the two occupational groups, but did not know how to begin the task of overcoming the resulting dysfunctions in the organisation. We began the workshop by splitting the participants into two categories: those who described themselves as predominantly managers (19) and those who described themselves as predominantly clinicians (33). Because of the numbers involved, each of these occupational groups was then subdivided into several smaller discussion groups of about 8-10 participants each.

The first task we set for the discussion groups was to identify some of the symbols and rituals that characterise the members’ occupation. The clinicians struggled to find contemporary symbols since the stereotypical stethoscopes and white coats are less in evidence in today’s hospitals. However, they did identify the initiation rites of examinations and internships, ward rounds, tools of trade, structured timetables, jargon and tribal hierarchy as characteristics of their occupation. They also noted several doctors who had attained heroic status in the hospital’s mythology through their memorable and often retold deeds.

The differences between clinicians and managers were clearly highlighted when the managers listed the characteristics of their occupational group. These included financial performance, meetings, reports, committees, planning retreats, Filofax, dress code and deadlines. One of the managers’ discussion groups graphically outlined the characteristics that they identified, as shown in Figure 1. These deeply entrenched characteristics were, of course, already well known to members of both occupational groups. However, the significant differences that they reveal serve to highlight the obstacles that must be overcome in building bridges between these two groups.

Figure 1: Symbols Identified by a Group of Managers

Next the discussion groups were asked to consider an "ideal" member of their occupational group, that is someone who is 100% dedicated to either a clinical or managerial role. The values held by that person were then listed. In terms of Kelly’s theory of personal constructs, these values are the emergent poles of a series of constructs that are shared by members of the group. Once all these values had been listed, the groups were asked to list an opposing, or implicit, pole for each item.

Tables 1 and 2 show the constructs that were identified by clinicians and managers respectively.

Table 1 Values of the "Ideal" Clinician As Construed By Clinicians
Emergent Pole Implicit Pole
Compassion Callousness
Patient committed / high quality care Disinterested
Patient focussed Cost focussed
Patient focussed Patient neglect
Profession focussed Mercenary
Expertise / up to date Unskilled / lazy / incompetent
Collegial Individualist
Thirst for knowledge / desire to teach Complacency / lack of interest
Humour Dull as ditch water
Critical (including self) Unquestioning
Walks on water Sinks / passes water in an emergency
Knowledge and skill Performs repeatedly outside competence
In for the long haul CV enhancer
Accountable / takes responsibility Ducks or shifts responsibility
Always learning Static
Efficient resource use Wasteful of resources
Common sense Theory driven
Consistent / reliable Devious
Decisive Vacillating
Greater good Empire builder
Social focus / advocacy Self interest / self serving
Ethical "Anything it takes"
Ethical and caring Unscrupulous
Ethical Unprincipled
Good integrity Untrustworthy
Excellent communicator Arrogant / fixed / poor listener
Good communication with patients Paternalistic
Good communication with colleagues Autocratic
Good listening skills Dogmatic

Table 2 Values of the "Ideal" Manager As Construed By Managers
Emergent Pole Implicit Pole
Organisational excellence Chaos, individualism
Performance Failure
Results Process, excuses
Objective Subjective
Quality Crappy
Financial viability People not $
Transparency Secretive
Leadership Collectivism
Vision "here and now"
Inspirational Soporific
Innovation Traditional
Continuous improvement Status quo
Consultation Autocracy, consensus
Pragmatic Rigid
Loyalty to organisation Individualism, careerism
Concern for others Selfish
Law abiding Unlawful
Integrity Dishonesty
Ethical Unethical
Integrity Unreliable

Just as each of these occupational groups was able to identify tangible symbols of their organisational roles, so also the language that they use in their shared constructs may be seen as a symbolic representation of their underlying cultural assumptions. The differences in their language are clearly illustrated in Tables 1 and 2, especially when the interpretive implications of the implicit poles are taken into account. The general tone used by the clinicians might be described as passionate and judgmental, whereas the managers’ language is more objectively rational, perhaps even dispassionate. There is also a clear difference in the focus of each group: clinicians place their attention on patients, professional colleagues and the greater social good, whereas managers appear to be concerned almost exclusively with the organisation and its performance. Another marked difference is that whereas the clinicians repeatedly refer to the importance of good communication skills, the managers make no reference to communication other than the rather formal "consultation" process.

These differences were generally easily recognised and well understood by the participants in the workshop. However, what was perhaps more surprising to them was the areas of commonality between the two groups. For instance, both groups generated constructs that relate to ethics and integrity. Both also demonstrated concern about the efficiency with which resources are used, albeit from different perspectives. And both acknowledged accountability as a common theme, although this is largely implicit in the managers’ constructs. Despite differences in the actual lines of accountability, both groups appear to be familiar with the underlying discipline. The recognition of these and other areas of commonality was a valuable outcome from this workshop. Indeed, several participants commented that the exercise had given them a new level of respect for their colleagues from the other occupational group. One participant said "We have more similarities than differences if we listen carefully".

The next stage of the workshop aimed to further investigate the differences and similarities that had been exposed in the process of generating constructs. To this end, we exploited another characteristic of Kelly’s theory, namely the hierarchical inter-relationships between constructs. Once a construct is identified it is possible to move either up or down the hierarchy, towards or away from core identity constructs, by using a laddering process. For this exercise, participants worked in pairs with, as far as possible, one member of each pair coming from each occupational group. They endeavoured to elaborate their construct systems by repeatedly asking questions about "why" and "how". So, for instance, a question such as "Why is that important to you?" or "Why do you do that?", takes the dialogue to a deeper level where there is greater probability of finding values that are shared by both groups. Conversely, a question such as "How does that manifest in your culture?" or "How do you do that?", defines the behaviours that are unique to the culture in question and are, therefore, a potential source of non-negotiable tension between groups. To conclude this exercise, the paired groups were asked to grapple with one final question, which was "How might the non-negotiable differences between clinicians and managers be overcome, given the deeper shared values that have been identified?"

The "why" questioning by workshop participants uncovered a broader range of commonalities than was apparent from the straightforward comparison of Tables 1 and 2. Participants typically identified shared values of loyalty, communication, ethical behaviour, competence and regard for others. By contrast, the "how" questioning produced many divergent examples of difference between the two cultures. For instance, clinicians complained that managers refuse to share commercially sensitive information with them, while managers maintained that clinicians have no need for access to this organisational level intelligence. These positions demonstrate a mutual lack of trust that may only be overcome by working together to build on the fundamental commonalities identified by these two occupational groups. As an example, at the beginning of the workshop a senior manager had asked: "What is the best way to align clinicians to organisational goals and objectives?" The workshop served to highlight the one-sidedness of this question, and to refocus participants on the construction of new, mutually supportive, shared language. So, rephrasing the question in more dialogue sensitive language might result in, "What is the best way for clinicians and managers to co-construct common organisational goals and objectives?"


Dialogue is an ongoing process that ultimately results in the new construction of collective mind. This involves individuals in an exploration of their own, often tacit, beliefs and assumptions through dialogic engagement with others. However, as we noted earlier, this is not an easy process as it demands a willingness to be challenged at the level of core identity. In this article we have demonstrated the potential of Personal Construct Psychology as a relatively non-threatening means of embarking upon a dialogue. The participants in our workshop engaged in a fun process that generated some significant insights for them. Not only did they find it illuminating to express their own assumptions as dichotomous constructs but they also gained new understandings of the "other" culture through the constructs generated by its members. Furthermore, once constructs had been generated, they provided a vehicle for the deeper exploration of commonalities and differences between occupational groups. Although the time constraints of the workshop prevented the formulation of new strategies for bridge-building between these two cultures, participants did benefit from learning new techniques to assist the development of dialogue.

Since this workshop was held, the hospital has moved on to appoint seven senior doctors to positions of clinical leadership. These clinical leaders now participate in the top-level strategising of the hospital and work in partnership with the operational managers of their specific clinical areas of responsibility. The presence of clinical leaders at this level of the organisation has broadened the managers’ understanding of problems to include clinical relevance more directly. At the same time the clinical leaders have had their construct systems stretched to encompass a more strategic view of the health sector with an elaborated understanding of the relationships between the hospital and other stakeholders.

Whilst clinician-manager communication and trust has improved at this top level, it cannot be said to have percolated down to the middle echelons of the hospital structure. The clinical leaders have at times been regarded from below with suspicion, and from the most polarised viewpoints have become more strongly identified with management by their colleagues. The next pressing task facing the hospital, then, is to broaden the dialogue to include senior clinicians and middle management.


We are grateful to the clinicians and managers who so freely and openly shared their constructs with us.


  1. Bohm D. Thought as a system. London: Routledge; 1992.
  2. Bohm D. On dialogue. London: Routledge; 1996.
  3. Brock D, Powell M, Hinings R, editors. Restructuring the professional organization: Accounting, health care and law. London: Routledge; 1999.
  4. Brown JS, Duguid P. Organizational learning and communities-of-practice: Toward a unified view of working, learning and innovation. Organization Science 1991;2(1):40-57.
  5. Buber M. Knowledge of man. London: Unwin; 1965.
  6. Crossan MM, Lane HW, White RE. An organizational learning framework: From intuition to institution. Academy of Management 1999; 24(3):522-537.
  7. Isaacs W. Taking flight: Dialogue, collective thinking, and organizational learning. Organizational Dynamics 1993;22(2):24-39.
  8. Kelly G. Psychology of personal constructs. New York: WW Norton & Company Inc; 1955.
  9. Kelly G. A theory of personality: the psychology of personal constructs. New York: WW Norton & Company Inc; 1963.
  10. Lave J, & Wenger E. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press; 1991.
  11. Raelin J. Clash of cultures: Managers and professionals. Boston: Harvard Business School Press; 1991.
  12. Schein EH. Culture: The missing concept in organization studies. Administrative Science Quarterly June 1996; 41:229-240.
  13. Sidorkin AM. Beyond discourse: Education, the self, and dialogue. New York: State University of New York Press; 1999.
  14. Walker B. A psychology for adventurers: An introduction to personal construct psychology from a social perspective. In D Kalekin-Fishman & B Walker (Eds). Construction of group realities. Malabar, Florida: Krieger Publishing Company; 1996. p997-26.
  15. Weick K, & Roberts K. Collective mind and organizational reliability: The case of flight operations in an aircraft carrier deck. Administrative Science Quarterly 1993; 38:357-381.