From shared practices to unspoken challenges: a qualitative inquiry into healthcare management in Switzerland

Background Contemporary healthcare systems face a paradox: managerial competencies are crucial for financial sustainability and quality of care, yet remain underdeveloped. While evidence‑based management (EBMgt) highlights the importance of management knowledge, it remains unclear how healthcare managers experience and articulate the tensions and difficulties associated with their role. This study identifies challenges arising both from daily managerial practice and from managers’ perceptions of their role and expectations. Methods We conducted 31 semi‑structured interviews with managers in French‑speaking Switzerland and other linguistic regions, spanning clinical and administrative backgrounds, organisational types, and management levels. Using an abductive analysis combining deductive and inductive coding, we built a thematic map distinguishing lived challenges (experiences of managerial work) from perceived challenges (how managers frame their problems, needs, and expectations) and unspoken challenges (tensions that managers experience or witness but struggle to explicitly formulate as managerial difficulties). Results Lived challenges reveal how professional trajectories into management and the use of management knowledge differ by background. Physicians often “become managers by chance”, with limited formal preparation and reliance on intuition, role models, and general management books, adopting a more constructivist and experience-driven approach to management knowledge. Nurses follow more intentional, training‑based routes and mobilise protocols and peer networks collectively. Across groups, the systematic use of research‑based management evidence remains limited. Perceived challenges cluster into two types. Transversal challenges are shared across settings and professions. They concern transformations in the relationship to work, management of emotional labour, and tensions around shared governance. Context‑related challenges arise when managerial work extends beyond organisational boundaries, including boundary‑spanning, advocacy, and interprofessional collaboration in fragmented coordination structures. Unspoken challenges remain difficult for participants to articulate and include gendered expectations in leadership and the delegation of digital and technical transformations to specialists, which obscures their managerial dimension. Conclusions By articulating lived versus perceived challenges and specifying transversal, context‑related, and unspoken categories, this study offers a practice‑based contribution to EBMgt and knowledge translation. It shows that what counts as a “managerial challenge” is shaped by professional socialisation and a clinical‑centred mandate that privileges team‑focused, relational work while rendering outward‑facing, technical, and strategic tasks invisible. Recognising this typology can inform management education and organisational policies on advancing evidence‑informed, interprofessional, and context‑sensitive managerial competencies.