5. Discussion

The discussion aims to delve into the research’s salient contributions, while simultaneously grappling with its constraints and potential future trajectories.

5.1. Research contributions

The research emphasizes the mechanisms that facilitate the development of a social structure and social systems in pluralistic organizations and govern individual and collective actions that regulate the process of organizational transformation.
These relationships, initially based on power, communication, and sanctions 35, evolve and modify social systems.
The ongoing health crisis has significantly disrupted the traditional social order and power dynamics within pluralistic organizations38,40. As the situation continues to evolve, middle management has seized power, which was originally delegated by top management who now admit they have limited control over the situation on the ground. This power grab is supported by several factors, including middle management’s organizational and business expertise, as well as their knowledge of the reality on the ground. With this newfound power, middle management is able to define rules and strategies that address the challenges faced by professionals in the field. Inter-professional interactions between middle managers from different disciplines are strong, based on the expertise of each, which contributes to the development of a new organizational structure. This process requires recognizing and combining everyone’s expertise. The interactional mechanisms associated with this structure rely on communication supported by top management, who establish spaces for multi-professional and inter-hierarchical exchange. The collective dynamic is facilitated by the creation of forums for exchange, such as crisis cells, and a shared perception, based on field data, of a situation calling for transformation. The synergy between individual actions and collective dynamics is essential for driving organizational transformations.
Middle management is the linchpin of social systems and the founder of social structure. They are both builders and catalysts of transformation. This capacity is based on inter-professional relationships founded on trust, and on a presence between professionals that provides access to information and to realities on the ground. Social systems are typically constructed through the coordinated efforts of middle managers and field professionals, who span a variety of professional disciplines. These individuals possess a deep understanding of the practical realities on the ground and possess the expertise necessary to devise effective organizational strategies for delivering care and related services. They are responsible for designing and continually refining procedures to ensure optimal functioning. This capacity is made possible by the confidence that top management has in these middle managers, who are regularly updated on the information and instructions communicated by supervisory authorities. The actions of individuals and groups have a recursive impact on the structure, with the return-to-equilibrium phase being temporary and giving way to increased agility. The external environment influences structural adjustment through both top-down and bottom-up communication and access to information, leading to a mechanism of joint regulation between structure and activities. Procedures may emerge from field practices, but the allocation of resources and skills is determined within the structure. This implies an appropriate allocation of resources and skills, with the structure and activity interacting and intertwining to enable a high degree of agility.
However, this agility is supported by planning and control mechanisms based on trust and transparency between parties. Therefore, this research suggests that organizational transformations within pluralistic organizations should be understood as a processual, systemic, and multi-level (figure 4).