On the one hand, tensions are symptoms of change processes, especially if not all partial changes proceed in the same direction and/or at the same speed. On the other hand, tensions also have the potential to trigger further actions and reactions in an organization that have the effect of reinforcing or containing change. In addition to analyzing the causes and manifestations of relevant tensions, dealing with them is also of central importance for a better understanding of the nature and course of change processes. The application of suitable management strategies is crucial in order to influence how well and reflectively a company deals with emerging tensions in change processes and how, if necessary, their activation potential can be used in a targeted manner with a view to desired changes (Smith/Lewis 2011) (see Fig. 1 ).

background

According to Wendy Smith and Marianne Lewis, the starting point for considering and managing organizational tensions is the theoretical examination of organizational paradoxes. The researchers have significantly advanced and shaped this through their work since the beginning of the 21st century (including Lewis 2000; Smith/Lewis 2011, 2022; Lüscher/Lewis 2008; Smith et al. 2017).
The consideration of contrasts within organizations goes back a long way and reached an important milestone with the development of contingency theory in the 1960s. Building on the knowledge that within an organization there are different opinions about goals and procedures as well as the resulting implications for the organizational orientation, the thesis was derived that balancing conflicting requirements increases the effectiveness of an organization (e.g. Lawrence/Lorsch 1967) .
Smith and Lewis start here and significantly expanded the debate regarding conflicting requirements by focusing on strongly contradictory requirements: A holistic, theoretical model of organizational paradoxes. The contradictory requirements of a paradox represent a particularly strong and constant contrast. This is characterized by the fact that diametrically contradictory requirements must be met in order for an organization to continue to exist. This is not the case with a less pronounced contradiction, such as a dilemma, as this can also be resolved by fulfilling a requirement or by separating relevant requirements in terms of fact and time. From these considerations, Smith and Lewis conceptualize a recursive, cyclical model of how decision-makers try to overcome tensions perceived as relevant and thereby provide impetus for the further change process: Necessary decisions by management always give rise to new tensions, but are themselves shaped by them , wanting to deal with the consequences of perceived relevant tensions (Smith/Lewis 2011).
This perspective is relevant: With the increasing dynamics of the relevant environment, increasingly competitive competition and changing legal and social requirements, organizations are exposed to increasing complexity. These and other factors lead to conflicting requirements when acting within and between organizations. This triggers tensions: newly developed approaches meet established practices, internal guidelines meet external needs and the actors' striving for autonomy meets standardization. The different requirements represent opposing poles that lead to points of friction and ultimately to tensions. These tensions are both a) a symptom of potentially avoidable difficulties and b) a possible driver of actions and reactions that advance the organization in its competitiveness and success. According to Smith and Lewis, if it is possible to better understand the causes and possible solutions to tensions, this represents an important step towards resolving conflicts and increasing the effectiveness of the organization through the organizational reflexivity gained in this way.
Smith & Lewis (2011) have identified and described four main categories of organizational tensions (here based on Gersch 2022 with examples from Haring et al. 2022):
• Organizational tensions occur when typically multiple organizational systems that need to be combined require competing designs and processes (e.g. differentiation vs. standardization (Gregory et al. 2015)),
• Performing tensions arise, among other things, when several actors pursue divergent goals in an objectively necessary collaboration (e.g. quality improvement vs. implementation costs (Shaller 2004)),
• Learning tensions involve the use and often destruction of past practices to create new ones (e.g. relief for externals vs. satisfaction for internals (Rowe/Hogarth 2005)),
• Belonging tensions arise from competing identities with which individuals identify. These occur, among other things, when attempting to shift, reallocate or change tasks across established professional boundaries (e.g. interdisciplinary work vs. professional autonomy (Lehn et al. 2018)).
In addition, there are also intermediate categories that can be used to classify tensions that do not clearly fall into one category, but lie between two different categories. Figure 2 below provides an overview of the categories of organizational tensions.

Dealing with organizational tensions

Effectively dealing with tensions and the dynamics associated with them takes both poles of contradiction into account and provides answers for dealing with diverging requirements. In this way, constructive effects can be achieved (virtuous cycles) and lead to synergies that promote the exchange and development of an organization. On the other hand, ignoring organizational tensions or opposing poles can lead to destructive effects (vicious cycles). It would be insufficient to allow unreflective reaction dynamics or to focus on avoiding and/or overcoming any tensions as quickly as possible. In order to deal with tensions reflexively and productively, it is therefore necessary to select suitable measures in order to respond appropriately to the different types and strengths of tensions (Lüscher/Lewis 2008; Lewis 2000; Huq et al. 2017).
The following three management strategies have proven themselves as basic types to promote virtuous cycles and avoid vicious cycles depending on the situation (Lewis 2000; Smith/Lewis 2011, 2022; Gregory et al. 2015; Putnam et al. 2016):

Approach 1: Either-or (Either-or)
The approach attempts to separate conflicting requirements and resolve the conflict in such a way that one element is preferred over the other or tensions are separated spatially and/or temporally. However, this approach can also lead to vicious cycles if the opposing poles are repeatedly and systematically given different consideration. The management strategy generally has the potential to resolve weak conflicts, but stronger tensions and paradoxes usually require a more complex approach.

Approach 2: Both-and
The both-and approach aims to achieve a balance between the opposing poles and integrate them, taking into account the interdependence of the contradictory elements. This management strategy runs the risk of not exploiting the positive potential of tensions.

Approach 3: More-than
The approach aims to develop a new perspective out of the conflict or to create a new element that surpasses the existing divergences. This procedure is characterized by a high level of complexity. However, if implemented effectively, this management strategy can harness the positive potential of tensions to create new responses, while synergistic potential in the existing one may remain untapped.

Use and utilization for health services research

The reality of care is also shaped by different stakeholders from various sectors with diverging professional and experience backgrounds. During change processes within organizations as well as in the context of projects, networks or consortia, these meet, interact and cooperate. The actors involved may have different views on goals and procedures as well as the implications for the organizational and ethical orientation of care. This is also reflected in the different values and perceptions that characterize the heterogeneous work cultures and stakeholder groups in the healthcare sector. Just as different characteristics of community, control, healing and care shape the treatment process itself, the confrontation between work cultures and groups has general implications for the development of healthcare (Haring et al. 2022; Glouberman/Mintzberg 2001).
At the same time, this multitude of contradictory and poorly coordinated elements also increases the complexity. This leads to potentially avoidable conflicts and the resulting destructive tensions in healthcare organizations. An example of a tension that is relevant for different care constellations is the conflict described by Shaller (2004) between integration, which requires cooperation between the actors involved in care, and independence or independence these strive. Such inconsistency can have massive effects on the success of a change process and thus also the competitiveness of an organization in the healthcare sector (Haring et al. 2022).
Due to this relevance, a) a better understanding of the complex structures and relationships is required in order to b) analyze the existing contradictions and paradoxes in care that become visible as a result of the tensions and thus c) not only better manage the occurrence of conflicts and their causes , but also to be able to use the dynamics created by tensions in a targeted manner.
Such an approach represents potential, particularly in view of the worsening financial situation of health insurance companies, which should be leveraged in order to have a positive influence on everyday care. Change processes that are already facing challenges such as a lack of incentive structures and the complexity of the system require a creative approach in order not to fall victim to efficiency and cost-cutting measures. The continuous consideration and management of organizational tensions should therefore be taken into account in change processes from digital transformation (e.g. introduction of the ePA) to the advancement of integrated care models (e.g. implementation of pilotage concepts). <<

“Change processes in healthcare are caught between the different requirements and expectations of the actors. A strengthening of interdisciplinary cooperation meets the striving for professional autonomy of the actors (Lehn et al. 2018) or activities to increase quality conflict with the costs required for this (Shaller 2004), to name just two examples. How these opposing, sometimes contradictory requirements can be managed and the potential created by the tensions can be harnessed has been the subject of organization and management research for many years (including Smith/Lewis 2011). Health services research can also benefit from these perspectives in order to gain relevant insights for the further development of the healthcare system and provide strategic impulses.”

Malte Haring 1, Prof. Dr. Martin Gersch 2
1: Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School
2: Department of Information Systems, School of Business & Economics, Free University of Berlin