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Mergers are important and challenging elements in hospital reforms. The authors study the social aspects of management and the roles of middle managers in the aftermath of a hospital merger. Especially, the purpose of this paper is to investigate how professional staff and middle managers perceive their relationships with top managers several years after the merger.

A survey was conducted among the professional staff in two merging hospitals’ units six years after a merger. Based on the main findings from this survey, a follow-up interview study was done with a group of middle managers.

The management practices were diagnostic with few interactive or communicative activities. The respondents expressed that mistrust developed between the staff and the top management, and a lack of involvement and interaction lead to decoupled and parallel organizations. Social controls, based on shared norms, had not been developed to create mutual commitment and engagement.

Policy makers should be aware of the need in profound change processes not only to change the tangible elements, but to take care of changing the less tangible elements such as norms and values. Professionals in hospitals are in powerful positions, and changes in such organizations are dependent on trust-building, bottom-up initiatives and evolutionary pathways.

The paper addresses the need to understand the dynamics of the social aspect in managing hospitals as knowledge-intensive organizations when comprehensive restructuring processes are taking place over several years.

The hospital sector in Norway has been continuously reorganized since 2002 and the reforms have created organizations that are functionally/vertically controlled, whereas the production lines are coordinated on a process or a lateral basis. The purpose of this paper is to focus on both the perceived functional vertical control and horizontal controls within and between the local hospitals and the regional administrative levels.

A national survey study, complemented with interviews of some key informants and document studies.

The study shows that the functional and vertical lines of management control are perceived to be operating according to the traditional views of management control. The study indicates that the horizontal tasks are not very well implemented, and we did not find interactive and lateral uses of management control systems for managerial purposes.

New control problems arise when services are to be coordinated between autonomous units.

The paper focuses on the control problems found within the horizontal, flat relationship between production units in hospitals; new organizational structures have emerged where lateral relations are important, but traditional control practices follow functional, vertical lines.

The purpose of this paper is to explore how change processes are dependent on historical events, geographical conditions, strong stakeholders and social norms developed over long‐time periods. The paper poses the question: what is the role of path dependencies in mergers between hospitals when motives of the mergers are ambiguous and the context of the change initiatives is characterized by conflicting goals?

The primary objective of this study is to describe the experience of three hospitals that were merged into a hospital enterprise, with the focus on a change in activity from 2003 to 2006. This fieldwork allowed a longitudinal study. The empirical data were generated from observations, interviews, document studies and newspaper clippings.

The investigations showed that the merger forced the hospitals to change, but the new organization – the different components of the merged hospital – followed different pathways to handle the externally imposed changes. Parallel processes evolved, and these processes were rooted in the historical and geographical conditions. Further, the paper illuminates the unique strengths of qualitative research methods that allowed a deeper understanding of these change processes.

The paper's findings add to our knowledge on the complex relations between externally imposed organizational change and the nature of internal organizational behaviour when intertwined with strong stakeholders. The paper particularly highlights the possible consequences when there is little interaction between the changes of systems and the practices of the professionals in hospitals when the processes are heavily influenced by path dependencies rooted in historical and geographical traditions.