Enabling Conditions for Hybrid Leadership in Decentralized Healthcare: A Mixed- Methods Study of Clinical Directors in Sweden

Background Clinicians increasingly occupy hybrid roles that combine clinical and managerial responsibilities, particularly in decentralized healthcare systems. The effectiveness of these roles depends on organizational conditions that enable learning, sense-making, and legitimacy. Drawing on and extending the enabling conditions framework for hybrid professionalism, this study examines how clinical directors perceive organizational initiatives intended to support their hybrid managerial roles in everyday practice. Methods A sequential explanatory mixed-methods design was applied. A web-based survey was distributed to all clinical directors (n = 95) in a publicly funded healthcare organization in Sweden, achieving a response rate of 97% (n = 92). Quantitative data were analyzed using descriptive statistics, non-parametric tests, and polarity, intensity, and uncertainty indices. Open-text responses were analyzed using directed qualitative content analysis. Integration followed a sequential explanatory strategy. Results Organizational initiatives generated enabling conditions through interaction opportunities, sense-making tools, and delegated authority, supporting familiarizing, rationalizing, and legitimizing processes. Perceptions varied systematically across care divisions. Psychiatry reported consistently higher levels of perceived support, while primary care, habilitation, and research-oriented units showed greater variability and uncertainty. Leadership development, divisional leadership forums, helpdesk services, and patient safety functions were most consistently perceived as enabling. Digitalization and competence planning systems were more contested. Several inter-divisional differences were statistically significant (p < 0.05). Conclusions The findings demonstrate that hybrid role enactment depends on how organizational initiatives are embedded and experienced in practice rather than on their formal presence alone. By empirically specifying how organizational initiatives operationalize enabling conditions in decentralized settings, this study extends the enabling conditions framework and provides a refined model for analyzing hybrid professionalism in health services organizations.