Doctoral Thesis in Technology and Health
Organizational flexibility and health among line managers and employees in health care
SARA LARSSON FALLMAN
Stockholm, Sweden 2020 www.kth.se
ISBN: 978-91-7873-720-8 TRITA-CBH-FOU-2020:57
kth royal institute of technology
Sara LarSSon FaLLmanOrganizational flexibility and health among line managers and employees in health careKTH 2020
Organizational flexibility and health among line managers and employees in health care
SARA LARSSON FALLMAN
Doctoral Thesis in Technology and Health KTH Royal Institute of Technology Stockholm, Sweden 2020
Academic Dissertation which, with due permission of the KTH Royal Institute of Technology, is submitted for public defence for the Degree of Doctor of Philosophy on Friday the 11th December 2020, at 1:00 p.m. in T2, KTH, Hälsovägen 11, Huddinge.
© Sara Larsson Fallman ISBN: 978-91-7873-720-8 TRITA-CBH-FOU-2020:57
Printed by: Universitetsservice US-AB, Sweden 2020
Dedication
My mother did not only have the desire for me to go to university, she expected it. Maybe that sounds harsh but with the discovery
she too once had a strong desire to study at a higher level but lacked the opportunity, her demands on me have become evident.
My mother would have been the proudest of all mothers.
Unfortunately, she is not able to experience this moment due to the toll dementia and forgetfulness have taken on her brilliant
mind.
I dedicate this thesis to her.
Floda November 2020
The road not taken
Two roads diverged in a yellow wood, And sorry I could not travel both And be one traveler, long I stood And looked down as far as I could To where it bent in the undergrowth;
Then took the other, just as fair, And having perhaps the better claim, Because it was grassy and wanted wear;
Though as for that the passing there Had worn them really about the same,
And both that morning equally lay In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way, I doubted if I should ever come back.
I shall be telling this with a sigh Somewhere ages and ages hence:
Two roads diverged in a wood, and I – I took the one less traveled by, And that has made all the difference.
By Robert Frost
Abstract
Introduction: Line mangers’ and employees, registered nurses and assistant nurses’, in health care often have a demanding work situation. Sick leave illness and lack of competent staff is a problem. There is a lack of studies on working conditions, such as flexibility and restricted control, from an organizational perspective, (i.e. working conditions formed on a higher level aiming to influence the whole organization) with health care organizations in explicit focus.
Aim: The overall aim was to expand knowledge about how working conditions with specific focus on flexibility and restricted control over work, impact on health and work performance among first and second line managers and employees within health care. In Study I the aim was to generate knowledge about the importance of adjustment latitude at work and at home for return to work or regaining work ability for female HSO workers on long-term sick leave.
In Study II, the aim was to investigate how restricted decision-making autonomy and conflicting demands impact operational managers’ work performance and health. In Study III, the aim was to examine the associations between managerial work performance and self-rated health or burnout among first line nurse managers. In Study IV, the aim was to identify first line managers’ approaches for maintaining low levels of sick leave among health care employees
Method: Both qualitative and quantitative methods have been used. Studies I–III employed a quantitative longitudinal design of questionnaire data. In Study I, data from a 6-year study was used. Study II is based on data collected at two points in time, approximately one year apart. The analyses in Study III were performed using data from three points in time, approximately one year apart. Study IV, used a qualitative approach in analyses of interviews with first line managers responsible for units with low sick leave among the employees.
Results: The results show the importance of having working conditions that allowed for a flexible work situation and a favorable adjustment latitude among employees. The result showed employee who had more opportunities to make adjustment latitudes at work had higher degree of work ability and a higher degree of return to work than those who had fever possibilities for adjustments. First line managers responsible for units with low sick leave among the employees were flexible, and had a holistic approach to meet the employees’ needs for flexible working conditions. Inversely, restricted control in form of top-down control and low control over the own work was associated with lower health, higher degree of burnout and lower ability to perform work.
Conclusions: Organizational flexibility from superiors and top management is important for health because it shapes working conditions that support and facilitate individual line managers and employees’ capability to perform their work. In specific, higher opportunities for adjustments of pace and place of work are important for employees’ health. Line managers’ work performance may be supported by higher organizational flexibility in decision-making while restricted control over work conditions were associated with lower health. A holistic approach in relation to the employees’ needs seems to have positive impact on lower sick leave.
Keywords: psychosocial working conditions, nurses, flexibility, control, sick leave, leadership, work-related health, longitudinal data
Sammanfattning
Inledning: Linjechefer och anställda, sjuksköterskor och undersköterskor, inom hälso- och sjukvården har ofta en krävande arbetssituation, många gånger med små möjligheter att påverka denna. Sjukfrånvaro, ohälsa och brist på kompetent personal är ett problem. Det saknas studier som ur ett organisatoriskt perspektiv studerar arbetsförhållanden med specifikt fokus på hård styrning respektive flexibilitet, inom hälso- och sjukvårdsorganisationer.
Syfte: Det övergripande syftet var att öka kunskapen om hur arbetsförhållanden påverkan hälsan och möjlighet att utföra sitt arbete bland linjechefer och anställda inom hälso- och sjukvården. Ett specifikt fokus låg på flexibilitet och begränsad kontroll över arbetet. I studie I var syftet att öka kunskapen om betydelsen av att kunna göra anpassningar i arbetet, både på arbetet och i hemmet, för en ökad arbetsförmåga och återgång till arbetet efter långtidssjukskrivning. Studie II syftade till att undersöka hur begränsad autonomi och motstridiga krav påverkade linjechefernas hälsa och förmåga att utföra sitt arbete. I studie III var syftet att undersöka hur låg kontroll över arbete påverkade hälsa och burnout bland första linjens sjuksköterskechefer. I studie IV var syftet att identifiera om chefer på enheter med låga sjukskrivningstal hade några gemensamma ledarskapsegenskaper.
Metod: Både kvalitativa och kvantitativa metoder använts. I studierna I–III användes en kvantitativ longitudinell design med enkätdata. Studie I baserades på data från en 6-års studie. Studie II baserades på data insamlat vid två tidpunkter, med ungefär ett års mellanrum. Analyserna I studie III bygger på data insamlat vid tre tidpunkter, med ungefär ett års mellanrum. I studie IV användes en kvalitativ metod. Intervjuer med chefer ansvariga för enheter med låga sjukskrivningsnivåer bland medarbetarna genomfördes.
Resultat: Resultaten visade vikten av att ha arbetsförhållanden som möjliggjorde för en flexibilitet i den anställdes arbetssituation samt gynnsamma möjligheter till anpassningar i arbetet för medarbetarna.
Medarbetare som hade fler möjligheter att göra anpassningar i sin arbetssituation på arbetet hade högre arbetsförmåga och högre grad av återgång till arbetslivet än de med färre möjligheter att göra anpassningar.
Chefer som var ansvariga för enheter med låg sjukskrivning bland de anställda hade ett holistiskt förhållningssätt gentemot medarbetarnas behov av flexibla arbetsförhållanden. Omvänt visades att hård styrning var förknippat med sämre hälsa och möjlighet att utföra sitt arbete och låg kontroll över eget arbete var förknippat med sämre hälsa och högre grad av burnout.
Slutsatser: Organisatorisk flexibilitet från chefer och högsta ledning är viktigt för hälsan eftersom den skapar arbetsförhållanden som stödjer och främjar linjecheferna och medarbetarnas förmåga att utföra sitt arbete.
Specifikt är fler möjligheter att göra anpassningar av tempo och plats är viktiga för de anställdas hälsa. Linjechefers möjlighet att utföra sitt arbete kan stödjas av högre organisatorisk flexibilitet vid beslutsfattande medan begränsad kontroll över arbetsförhållande var förknippat med lägre hälsa. Ett holistiskt förhållningssätt i relation till medarbetarnas behov kan ha betydelse för mindre sjukskrivning.
Nyckelord: psykosociala arbetsförhållanden, kontroll, sjuksköterskor, undersköterskor, flexibilitet, sjukskrivning, ledarskap, arbetsrelaterad hälsa, longitudinell data
List of studies
This thesis is based on the following studies, which from this point forward are referred to in the text by their Roman numerals.
I. Dellve, L., Fallman, S. L., & Ahlstrom, L. (2016). Return to work from long‑term sick leave: a six-year prospective study of the importance of adjustment latitudes at work and home. International Archives of Occupational and Environmental Health, 89(1), 171–179.
II. Fallman, S. L., Jutengren, G., & Dellve, L. (2019). The impact of restricted decision-making autonomy on health care managers’ health and work performance. Journal of Nursing Management, 27(4), 706–714.
III. Fallman, S. L., Dellve, L., & Ahlstrom, L. First line nurse managers’
managerial work performance and burnout over time – a prospective study.
Submitted.
IV. Fallman, S. L., Dellve, L., & Kullén Engström, A. Managerial approaches for maintaining low levels of sick leave: A qualitative study. Submitted.
All previously published paper have been reprinted with the permission of the publisher
Abbreviations
GMSI Gothenburg manager stress inventory HCO Health care organization
HSO Human service organization J-DC Job demands-control model J-DR Job demands-resources model NPM New public management RTW Return to work
SEM Structural equation modeling
SOHSM Systematic occupational and health safety management SRH Self-rated health
SWEBO The Swedish scale for work engagement and burnout WAI Work ability index
WAS Work ability score
WHO World health organization
Contents
Introduction ... 1
Background ... 4
Working in Public Health Care Organizations ... 4
Public health care organization in Sweden ... 4
Organizational working conditions among line managers and employees ... 5
Health and illness among line managers and employees in health care ... 7
Organizational flexibility ... 10
Theories on restricted control and flexibility ... 10
Restricted control or flexible working conditions ... 11
System theory ... 15
Aim ... 17
Overall aim ... 17
Specific aims ... 17
Method ... 18
Design ... 18
Sample, sampling and health care settings... 19
Data collection ... 22
Questionnaires ... 22
Register-based data ... 22
Interviews ... 23
Measures ... 23
Health and work performance ... 23
Organizational conditions forming restricted control or flexibility ... 25
Analyses ... 27
Quantitative analyses ... 27
Qualitative analyses ... 28
Ethics ... 29
Results ... 30
Impact of flexibility and adjustment latitude among employees ... 30
Restricted decision latitude, work performance, and health ... 31
Managerial work performance of organizing the work ... 32
Managerial work performance of evaluation the work ... 32
Managerial approaches of flexibility for employee wellbeing ... 33
Discussion ... 35
Line managers’ restricted control and employee flexibility ... 35
Organizational flexibility and individual capability, from a system theory perspective ... 38
Methodological discussion ... 40
Conclusion ... 44
General conclusion ... 45
Specific conclusions ... 45
Implications ... 46
Future research ... 47 Acknowledgement ... 48 References ... 50
1
Introduction
Health care has a pivotal role in society and almost all people have been, or will in the future be, in need of services from health care providers. To meet this demand, it is in the best interests of society that health care be well functioning, cost-effective, and of high quality. Providing health care employees with a healthy and satisfactory social and organizational work environment is one key factor to achieve such organizational aims. However, line managers, nurses, and assistant nurses often describe their actual work situation as characterized by unrealistic demands and relatively little opportunity to influence circumstances at work (Karanikola et al., 2014). This may result in a situation where employees leave their position, or worse, get sick from work. To avoid this situation and to maintain high quality health care, it is necessary to provide decent working conditions. The focus of this thesis is organizational working conditions for line managers and employees in health care. Line managers are the link between top management and employees. First line managers are directly involved with the employees work situation, whereas second line managers manage first line managers. The aim is to expand knowledge of organizational flexibility, and examine the impact of lack of control at work, vs. flexibility, on the health of line managers and employees in health care.
In Sweden, the employer is responsible, by law, for providing the prerequisites for his or her employees to perform their work without getting sick or injured (AFS 2015:4). Even though there has been a general decline in sick leave numbers during the last few years, the health care sector still has the highest sick leave absence on the Swedish labor market (SKR, 2020b). In addition to current high rates of sick leave, labor market analysts forecast upcoming staff shortages in health care. In fact, a shortage of registered nurses in the Swedish health care sector has already been reported and within the next 10 years, the same pattern is expected for assistant nurses (SOU 2019:20). Regarding managers in health care, recruitment difficulties have been reported in addition to high turnover and high intentions to leave (Skagert et al., 2012;
Warshawsky & Havens, 2014). The research literature provides ample evidence that stability and continuity among employees in health care is associated with patients’ health-related outcome (e.g. Aiken et al., 2014). Line managers’ leadership behavior impacts employees’ wellbeing at work, which is indicated by such factors as job satisfaction, work performance (Cummings et al., 2018; Saleh et al., 2018), and low frequency of sick leave (Schreuder et al., 2011).
2
During the last decades, there has been an increasing demand for productivity and quality of care. At the same time, there is also a demand for cutting costs in public health care. The increased demands for productivity can be related to the introduction of concepts and approaches derived from the free market. In public enterprise, these ideas are applied in the form of new public management (NPM) (Christensen & Lægreid, 2007; Hood, 1995). This management model is a governance approach to public sector management that was introduced in the early 1980s as a way to make the public sector more competitive using business models derived from the private sector (Hood, 1995).
As a result of applying these market-like structures in health care organizations, both line managers (Kelliher & Parry, 2015) and employees (Dellve et al., 2016; Nappo, 2019) report higher work load. Further, a stricter top-down management style throughout the organization can, for line managers, mean a lack of control and restricted decision-making autonomy over their operational responsibilities. These types of restrictions on autonomy have previously been shown to have negative consequences for employees’
health (Karasek & Theorell, 1990). Another consequence of increased demands for cost-effectiveness and productivity in health care organizations is that line managers commonly perceive competing demands in their endeavor to meet the goals of the organization (Tengelin et al., 2011; Udod & Care, 2013).
Frequent exposure to such work environment contributes to negative health related outcomes (Kath et al., 2012). Recently, there has been an increasing interest in sustainable working conditions. Research shows that employee- friendly and flexible working conditions have been successful in preventing illness and prolonged periods of sick leave and consequently, that the employees remained in work later in life (Nilsson, 2016).
In order to get a full picture of line managers and employees’ situation in terms of health and illness, it is important to scrutinize the entire organizational system. Information of how the different parts and levels of the organizational system interact can provide important additional knowledge. To achieve sustainability, all parts of the organization must be involved. In system theory, all parts are linked together and there is a constant interaction between the different levels. The Bio ecological system theory describes how the society interacts with individuals, and the other way around, as well as their dependency on each other (Bronfenbrenner, 1996). It uses a holistic approach and is suitable for examining health problems as they appear in daily work (Stokols, 2000).
3
In sum, line managers and employees in health care, including registered nurses and assistant nurses have a demanding work situation, which can sometimes lead to illness. In addition, there is a lack of qualified employees, and this situation is expected to exacerbate due to changing demographics, high turnover, and retirements. In combination, these circumstances add to the challenge of providing health care with well-qualified employees.
Studies on working conditions from an organizational perspective, (i.e., working conditions developed at a higher level aiming to influence the whole organization) have been conducted (Aronsson et al., 2019; Cedstrand et al., 2020; Dellve & Eriksson, 2017; Eriksson, 2011; Skagert, 2010; Svartengren et al., 2013). However, the impact of such working conditions specifically in health care is less studied (Arnetz & Blomkvist, 2007; Di Tecco et al., 2020;
Nielsen et al., 2020). This thesis undertakes these issues by using a longitudinal research methodology and using a systemic theoretical approach.
4
Background
Working in Public Health Care Organizations Public health care organization in Sweden
Swedish health care has a historical background, and ideological basis, that is distinct from health care in some other parts of the world. Part of the ideological basis is that the health care system in Sweden builds upon the idea of solidarity between its citizens. The system is financed by taxes and has a central role in the construction of the society. According to Swedish law, all people living/situated in Sweden have a right have access to public care (SFS 2017:30). The law of access to care also includes basic health care for people who are in Sweden illegally or who are asylum seekers (SFS 2013:407).
Moreover, all health care services must be administered with respect for the equal value of all people; those who have the greatest need should be given priority (SFS 2017:30).
Health care is a politically controlled function and politicians at the national level have the overall mandate to decide on health care priorities; however, municipalities and county councils are ultimately responsible for the provision of health care (Berlin & Kastberg, 2011). The health care sector is a highly specialized sector with well-educated and highly skilled staff, consisting of many different professions interacting in a multidisciplinary way. Involving larger numbers of stakeholders, public health care organizations differ from private, profit-driven companies.
In the late 1970s, some key concepts from the free market were broadly introduced into health care, such as decentralization, measurable standards, and efficiency (Hood, 1995). These concepts are interconnected and are part of the management model called new public management (NPM). It is an umbrella term for a number of market concepts applied to public enterprises with the intention to increase efficiency (Christensen & Lægreid, 2007; Hood, 1995). In Sweden, this development implied a de-regulation of health care, which meant that private actors, both profit-making companies and cooperatives, would be able to gain access to the health care market. The logic behind this deregulation was to increase quality of care and to achieve cost reductions by letting health care providers compete for patients who could turn to a health care provider of their own choice without any restrictions (Berlin &
Kastberg, 2011). As a parallel process, an explicit demand for economic efficiency, both in the public debate and from the political management, has become gradually more pronounced.
5
Many public healthcare organizations have struggled with these changes and demands. Research indicates that the restructuring of health care towards NPM models of management has increased job demands on line managers (Kelliher & Parry, 2015). In Swedish health care, NPM has commonly implied a strict top-down management style and it has been criticized for increasing activities related to administrative work (Arman et al., 2009). With the aim of cutting costs and shortening waiting times, as well as providing high quality health care, there has also been an interest in finding new models to organize health care. Some models has been developed in line with values and principles derived from “Lean Production”. Lean Production was developed in industry to increase work improvements and efficiency, and have been applied in health care organizations. Objectives when implementing Lean Production is often to reduce waste and maximize customer values (reduce activities that do not add value to the customer/patient), strengthen the work with continuous improvements, and improve flow in production (e.g. care processes) (Womack
& Jones, 1996; Brandao de Souza, 2009). Implementation of different models of care processes, e.g. Lean Production, has been one way of reorganizing health care to achieve the most effective organization (Eriksson et al., 2016).
These organizational developments have influenced both line managers’ and employees’ working conditions, for the worse or for the better (Dellve et al., 2015; Landsbergis et al., 1999; Westgaard & Winkel, 2011). There are studies reporting that these developments and the implementation of process-based governance leave less room for autonomous decision making and thus reduce flexibility in working conditions (Conti et al., 2006).
Organizational working conditions among line managers and employees
Regardless of the financial and ideological values underlying the health care system, managers and employees are key to providing safe and secure patient care. First and second line managers together with registered nurses and assistant nurses are the focus of this thesis, and the definitions of them are presented below.
First and second line managers are the link between top management and employees, and have an important role in the organization (Guest & Woodrow, 2012). First and second line describes the level of management within the organization. First line managers are directly involved in the employees’ work situation and have an impact on patient outcome, whereas second line managers are in a position where they manage other managers. Common for both levels is that they have subordinates reporting to them and that they in turn report to higher level of management. Both management levels are in the articles of this thesis labeled as to first line nurse managers, first line managers, or operational managers and are subsequently in this text referred to as line managers or just managers.
6
Line managers’ leadership has a significant impact on employees’ health (see e.g., Cummings et al., 2018), which, in turn, has an effect on patient outcome, including mortality, safety, and satisfaction (Aiken et al., 2014; Coster et al., 2018; Dempsey & Assi, 2018; Neuraz et al., 2015). The work environment at the different levels in the organizations can be seen as a chain of circumstances where the health and wellbeing of line managers have bearing on patient safety.
Studies report that the line managers in health care finds their work meaningful (Ericsson & Augustinsson, 2015; kallman et al., 2019; Johansson et al., 2010; Swedish Social Insurance Agency, 2018) and are committed to their work of making their unit function well for the patient and having a healthy staff. The role of line managers is complex, multifaceted, and in constant change (Karlberg Traav et al., 2018; Pegram et al., 2015). Their work tasks have changed in the last decades, and today, line managers are responsible for the ongoing daily work as well as the improvement work at the unit. Line managers in general have a demanding work situation with high workload, and many different tasks, often with unclear and competing demands (Baker et al., 2012; Kristiansen et al., 2016; Udod & Care, 2011; Wong
& Laschinger, 2015). Furthermore, they often have a large team of employees to supervise (i.e., a wide span of control), which increases the complexity of their work (Wallin et al., 2014; Wong et al., 2015). For line managers to be able to cope with their extended and complex role they need training in organization and management (Dellve & Wikström, 2009; Thompson &
Fairchild, 2013; Wikström & Dellve, 2009). However, line managers in health care are often poorly prepared for the challenges involved in management responsibilities (Hader, 2011; Udod & Care, 2013; Vitale, 2018).
Registered nurses and assistant nurses are the two largest groups of employees in Swedish health care organizations (SKR, 2020a). The two shares some common work tasks, although their work also differs in many respects.
Registered nurses are responsible for the care daily work with the patient and care on the ward, such as administering medication, monitoring patient progress, and educating patients on post-discharge care and prevention. The registered nurses are in the leading position in the care of the patient and are responsible for delegating tasks to the assistant nurses (SOSFS 1997:14;
Swenurse, 2017), which implies more autonomy in their work situation. In addition, as the name implies, registered nurses have to be registered and needs a license, while assistant nurses do not. These professions have in common that over 80 percent of these employees in public health care are women (SKR, 2019). Registered nurses and assistant nurses report a work situation similar to what line managers’ report in so far as they enjoy their work (Johansson et al., 2013) but that they also experience working conditions that are characterized by high pressure, high work pace, and high demands (Aiken
7
et al., 2013; Duffield et al., 2011a). These working conditions are often the cause for not having enough time to complete all the assigned tasks, which can lead to moral distress (de Veer et al., 2013; Dellve & Wikström, 2009). In Study I in this thesis, the sample consisted of female service workers who were employed in municipalities. Their work preconditions were similar to that of employees participating in Study IV. The majority of these women were employed in care work, for example elderly care, or worked with disabled persons. In the text, they are referred to as employees.
An experienced and long-term stable working group consisting of more or less the same employees caring for the patient and, therefore, providing continuity in care is of importance in health care (Aiken et al., 2014). Unfortunately, this is often not the case today as the care is frequently hampered by lack of staff.
The lack of a stable working group can be due to sick leave, high staff turnover rates and difficulties to recruit, causing an unstable situation.
Health and illness among line managers and employees in health care
One goal in striving to maintain safe and secure care for the patients is to have healthy employees and line managers in health care are important. However, studies show that employees in health care often experience work-related stress and burnout (Adriaenssens et al., 2015; Chernoff et al., 2018; Nowrouzi et al., 2015). One contributing factor is likely the nature of their organizational work environment, which is typically characterized by high demands and stress. Studies of health care line managers’ health and its determinants are sparse. One out of six line managers reported high feelings of emotional exhaustion (Van Bogaert et al., 2014). In addition, turnover or intention to leave their position are high among managers are (Skagert et al., 2012;
Warshawsky & Havens, 2014). Health, illness, work ability, burnout, sick leave, and work performance are complex phenomena, which are central in this thesis. These concepts and how they are operationalized in this thesis will be explained below.
Health is an important issue for most people and the definition of health differs depending on the perspective. In 1946, the World Health Organization (WHO) formulated a definition of health, describing it as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”
and further viewing it as a resource for everyday life (WHO, 2020). From a value-oriented holistic approach, the concepts of health and illness are assumed to involve the whole person and emphasize the individual’s resources and capabilities to achieve vital goals (Nordenfelt, 2006). From a capability perspective, the focus of health and well-being is what individuals are able to do or to be. The essence of the capability perspective is that two individuals can
8
have the same function and the same capacity, but may still perceive their personal level of capability differently (Robeyns, 2005). Based on the above reasoning, in this thesis, health is seen as a subjective and individual concept that should be considered holistically and in accordance with the capability approach. More specifically, in this thesis the concept of health has been formulated as follows: Satisfying health exists for individuals who are physically and mentally able to live their lives in a way that they wish to, and who can perform the activities they desire without being hampered by physical or mental issues. Self-rated health (SRH) is a subjective measure of health that has been one of the most used measures in health research since 1950 (Garrity et al., 1978). Several studies show that self-rated health predicts mortality (Desalvo et al., 2005; Jylhä, 2009).
Work ability is most common referred to as an individual’s ability to balance between work demands and personal resources, and her or his physical and intellectual ability to perform her or his work (Ilmarinen, 2009). A large amount of research has been conducted on the concept of work ability. For example, poor work ability has been associated with long-term sickness absence and work disability, and increased risk of early retirement, as well as decreased functional ability and higher mortality in old age (Jääskeläinen et al., 2016; Schouten et al., 2015; Von Bonsdorff et al., 2011). A widely used instrument to measure work ability is the work ability index (WAI). The WAI is an index created to measure work ability among occupational health workers. It has been criticized for containing several questions that do not directly measure work ability (Bohle et al., 2010). Instead of using the more complex WAI it has therefore been suggested to use a single-item question of work ability. Both the WAI and the single-item question have shown strong associations with sick leave and health (Ahlstrom et al., 2010).
Burnout is a stress-related syndrome experienced by individuals as a response to chronic job stressors. Burnout was first studied in the 1970s. A uniform definition has not been agreed on, but the definition of burnout by Maslach et al. (1996) as “a crisis in the relationship with work, but not necessarily with the people they [the individual] work[s] with” (p. 20) is often applied. Burnout manifests through emotional exhaustion, cynicism, and inattentiveness (Schaufeli & Salanova, 2007) and is the result of a persistent imbalance between demands and mental resources (Bakker & Demerouti, 2007). There are different opinions on what triggers these manifestations of burnout. Some researchers hold that it starts with emotional exhaustion that eventually results in depersonalization and a cynical attitude towards work (Maslach, 2001; Taris et al., 2005), whereas others claim that exhaustion and depersonalization develop in a parallel process with the actual burnout syndrome (see, e.g., (Demerouti et al., 2001). Burnout is associated with many negative work-related outcomes, such as sick leave, work overload, intention
9
to leave/turnover intention, and job strain (Warshawsky & Havens, 2014;
Wong & Laschinger, 2015), which in the end can contribute to increased sick leave.
Sick leave can have comprising consequences for the individual, both socially (Lännerström et al., 2013) and financially (Andrén & Palmer, 2008). In addition, sickness absence also entails large costs for the society (Regeringskansliet, 2015). Sick leave frequencies in Sweden are characterized by quite a large fluctuation and has in the latest decades have been some peaks and troughs with the latest peak in 2017 (Swedish Social Insurance Agency, 2018). From 2010, there was a rise in sick leave numbers, but this leveled out in the spring of 2017, whereafter numbers decreased slightly (SKR, 2020b).
The reasons for the fluctuations in sick leave frequency are not entirely clear.
In part, they can be explained by changes in the authorities’ handling of the sick leave process. In times when cases are handled faster, or when more people are denied access to sick leave insurance, changes in sickness benefits, etc. this is shown in the sick leave reports as decreases in frequency. In Sweden, the highest sick leave rates are found among employees in municipalities and county councils (Swedish Social Insurance Agency, 2019).
Over the years, the level of sick leave in the county councils has generally been somewhat lower than within the municipalities (SKR, 2020b). In recent years, there have been some changes in sick leave diagnoses. In the past, the most common sick leave diagnoses were diseases involving the musculoskeletal system and connective tissue. However, during the last five years, mental illness and mental syndromes, as well as behavioral disorders, have become the most frequent diagnoses, in general, for both men and women (Swedish Social Insurance Agency, 2019). Sick leave due to mental health disorders often tends to be prolonged. Sick leave increases with age and in the public sector, about 40 percent of employees are over 50 years old, whereas the same figure for the private sector is about 25 percent (Andersson et al., 2020).
The content of managerial work, and how the line managers should perform their work, is an area that has been well examined for a number of decades (see e.g., Tengblad, 2012). However, what impacts the managers’ own perception of how they can perform their work is less studied. In this thesis, the definition of managerial work performance is seen as the line managers’ own perception of how their possibilities to perform their managerial work.
10 Organizational flexibility
Organizational flexibility includes the shaping and forming of working conditions and can be defined in different ways. One way to define it is in terms of the organization’s ability to adapt to changes (Dreyer & Grønhaug, 2004).
Another ways to define the concept is in terms of where, when and how the work is performed (Ramendran et al., 2013). In this thesis, the definition of a beneficial organizational flexibility is formulated as follows: Line managers and employees are allowed flexibility and adjustment latitude in creating a work situation that gives them the best conditions for performing their work.
Studies on working conditions from an organizational perspective, i.e. working conditions developed at a higher level aiming to influence the whole organization (Stoetzer et al., 2014; Svartengren et al., 2013), and specifically in relation to improvement work (e.g., Dellve et al., 2015) and specific health improvements (e.g., Eriksson, 2011; Lundmark et al., 2017) have been conducted. Nevertheless, there are still few empirical and longitudinal studies of the impact of working conditions from an organizational flexibility perspective on health care workers’ health.
In trying to prevent illness at work and help workers achieve a balance between work and private life an increased interest has been directed towards the concept of flexible working conditions in organizations. The concept of flexibility is often poorly defined (van Gool et al., 2017) and can be interpreted in a multitude of ways, which will be presented in the next section. In addition, theories on restricted control over own work vs. flexible working conditions will be presented; thereafter, the line managers and employees’ working conditions for restricted control and flexibility will be contextualized.
Theories on restricted control and flexibility
When working conditions are studied and the balance between work demands and control over work is in focus, the following theoretical models are most frequently used: the Job Demands-Control (JD-C) model (Karasek, 1979); and the Job Demands-Resources (JD-R) model (Bakker & Demerouti, 2007;
Demerouti et al., 2001).
The theoretical logic behind the JD-C model is that individual control over the own work situation can buffer the negative impact that various demands at work might have on the individual’s stress level. The employee’s level of stress can be estimated using two orthogonal dimensions, namely, decision latitude (control) and height of strain (demands). The variable of decision latitude represents the employee’s freedom to influence, organize, and perform at, her or his work and is measured as a continuum from low to high levels of individual control. Height of strain represents external sources that induce
11
psychological stress and the concept covers characteristics in the work situation such as the work rate, pressure, effort and difficulty. Like decision latitude, height of strain should be considered a continuous concept ranging from low to high levels of strain.
In the JD-C model, four different work situations with different degrees of control and demands are identified: (1) Passive jobs – low possibility to control the work, in combination with low demands; (2) low strain jobs – high possibility to control own work, with low job demands; (3) high strain jobs – low possibility to have control over work, in combination with high demands;
and (4) active jobs – high possibility to control own work, in combination with high demands (Karasek & Theorell, 1990). Therefore, when a worker has high strain, this does not automatically imply a bad work situation with a lot of stress; rather, it is low job decision latitude, in combination with high demands, that determines whether a situation is stressful or not. This model was supplemented with the dimension of support as a way to explain that unhealthy demands can to some extent be counterbalanced by support from managers (Johnson & Hall, 1988).
A criticism of the JD-C model has been put forward concerning its narrow set of predictor variables. As the limited number of predictor variables covered by the JD-C model is unlikely to have relevance for most existing job positions, an extension of the JD-C model was developed, which, in addition to demands and control, also took into consideration the recourses available to the employee. In this extension, the JD-R model, the employee resources are used as a variable that balance the demands on the employee (Bakker & Demerouti, 2007). The dimensions are divided into job demands and job resources, and job resources in turn are split up into workplace resources and personal resources. Demands are defined as physical, psychological, or organizational aspects of work that are perceived by the individual as stressors only when she or he does not have enough resources to handle the demands (Bakker &
Demerouti, 2007). Inadequate resources are predictors of future stress and burnout (Demerouti et al., 2001) and correlate negatively with work engagement (Crawford et al., 2010). Studies have shown that resources such as autonomy or social support reduce the employee turnover and intention to leave (Bakker et al., 2003).
Restricted control or flexible working conditions
A number of concepts central to the theoretical discussion of line managers and employees’ working conditions for strict control vs. flexibility are in focus.
The concepts used in the study are presented below. First, the concepts underlying strict control are presented and after that, different aspects of flexibility are presented and conceptualized.
12 Restricted control
Decision making is a process in which the individual makes choices based on her or his knowledge and values (Koubel, 2013). Settling a decision is the act of choosing between different options and can be based on explicit or tacit knowledge (Brockmann & Anthony, 2002). Some decisions are made in daily life and are based on repeated experience, while other decisions are professional. Professional decision making is open to scrutiny and can be evaluated by ethical and legal standards (Koubel, 2013). Decision-making autonomy can be limited by, for example, restrictions from (top) management.
Line managers normally describe restricted decision-making autonomy in negative terms, by referring to experiences such as those characterized by poor support, limited decision latitude, and ethical stress (Skagert et al., 2008).
Conflicting demands can emerge due to contradictory demands on what a line manager’s work should include (Kristiansen et al., 2016), and the conflicting demands regarding time and expectations contribute to a fragmented work situation (Tengelin et al., 2011). Line managers in health care often experience conflicting demands between different management tasks, which can influence their health and their ability to perform their work.
Flexible working conditions
The term working conditions refers to employees’ conditions of employment, conditions that are the core of paid work. The term covers a wide range of items such as working time, and physical and psychosocial conditions (Eurofound, 2020b). The interest in flexible working conditions has increased. The literature show that there are both positive and negative aspects to flexible working conditions and when studying the concept two main views becomes visible. The first of these does not have a particular employee-friendly focus.
This view concerns companies’ and the employers’ aspirations to constantly adapt to the current situation through for example, increased or decreased demands, in order to achieve more profit and cost effectiveness. According to this view, employees are expected to change their schedules and working hours at short notice. The alternative is to work for an agency as companies often rely on agencies to be able to cope with unexpected peaks and lows in production (Furåker et al., 2007). Most agency workers have insecure employment.
The second view is more employee-friendly. Along with difficulties to retain qualified staff, and with changes in demographics, today there are more women in the labor market, more single parents, and dual earners couple, leading to a change in focus regarding who is meant to benefit from the flexible working conditions (Atkinson & Sandiford, 2016). Changes such as flexibility were introduced so as to make it possible for employees to create a balance between their work and their private life. Adding to the positive list, a Cochrane literature review showed that flexible working conditions aiming to increase
13
employee control, i.e., allowing employees to schedule their own work time, had a positive impact on employee health (Joyce et al., 2010). Other studies have shown that flexible working conditions mean that the employee experiences more control over work (Kossek et al., 2006). Further, flexible working conditions are associated with reduced turnover intention and decreased absenteeism (Thompson et al., 2015). Other positive outcomes of flexible working conditions are lower stress and strain, better physical health (Butler et al., 2009), higher job satisfaction and organizational commitment (Kelliher & Anderson, 2008), and improved employee engagement (Rosen et al., 2013; Thompson et al., 2015). One way of granting flexibility is self- scheduling. A review concluded that self-scheduling is a major factor that influences job satisfaction and gives the registered nurse freedom and the control to manage the demands of work (Koning, 2014). However, the nature of nursing makes it more difficult to implement flexible working conditions to full extent (Harris et al., 2010), especially if the nursing takes place in a unit employing shift workers (Mercer et al., 2014).
Flexibility in the form of possibilities to take unscheduled short breaks, for a few minutes initiated by the employee, seems to have the potential to affect employees’ resource levels during the day (Sianoja et al., 2016). Other studies report that employees feel more engaged in the daily work when taking short breaks (Kühnel et al., 2017), while lack of breaks have been connected musculoskeletal pain (Janga & Akinfenwa, 2012). Few studies have been conducted on health care workers’ possibility to take short breaks, but research has shown that there is a difficulty for registered nurses, among others, to take enough rest breaks (Monaghan et al., 2018; Rogers et al., 2004).
Another dimension of flexibility is adjustment latitude. Johansson and Lundberg (2004) use the term “adjustment latitude,” as meaning opportunities to adjust work because of illness. The dimension is including the opportunities people have to reduce or in other ways change their work effort when ill. Such opportunities can include choosing among work tasks or working at a slower pace. Previous studies have shown the importance of high adjustment latitude at work, for preventing sick leave in both men and women (Hultin et al., 2010), and for work ability (Johansson et al., 2012), return to work (RTW) when on sick leave (Dellve et al., 2006; Whittaker et al., 2012), and staying at work (de Vries et al., 2011). Negative consequences of flexible working conditions have been highlighted, including that the work becomes more boundless (Allvin, 2011). However, when given the autonomy of flexible working conditions, employees often work harder and increase their working hours (Lott & Chung, 2016). This phenomenon is called the
“autonomy paradox” (Mazmanian et al., 2013).
14
When arranging flexible working conditions, line managers have an important role. It is often up to the line managers to set and facilitate employees’ flexible working conditions. Managers’ personal attitudes and experience of flexible working conditions have been demonstrated to influence their commitment to structuring the new work arrangement. Line managers have a crucial role in the implementation of flexible working policies and they have a large influence in the process of making flexible work arrangements possible (Cooper & Baird, 2015). Line managers also often are in a position to decide which employee should be allowed flexible arrangements.
The challenge to get the right balance between working life and private life, often referred to as work-life balance, is a topic that has received increasing attention (Chunta, 2020; Mullen, 2015; Wood et al., 2020). The definition of the concept varies between studies. Some of the early definitions suggested that the employee should literally have an equal amount of time and engagement for her or his working life and private life to achieve a balance, stating that employees who had more time for their private life had an unbalanced situation (Brough et al., 2020). In this thesis, balance between working life and private life is rather seen in a holistic perspective, where it is the individual’s own perception of a balanced life situation that is seen as optimal. As balance is subjective it is difficult to sum up in detail what the right or optimal balance is. This way of viewing the situation is in accordance with Greenhaus and Allens (2011) who emphasize that the balance should be defined from the employee’s perspective.
In this thesis, flexibility is referred to as the organizational preconditions provided by employers for their employees, to enable the employees to maintain a sustainable balance between working life and private life. This definition is inspired by the definition in Hill et al. (2008): “Workplace flexibility: the ability of workers to make choices influencing when, where and for how long they engage in work-related tasks” (p. 153). However, health care employees are in most cases not able to influence the place where to perform their work (Mercer et al., 2014); therefore, the definition we use in this thesis is more suitable for the health care sector. Although many studies have been performed on the concept of flexibility, there is not a single theory explicitly focusing on the concept in a broader sense including several organizational/system levels. According to Hill et al. (2008), the most often used theoretical framework is that of ecological system theory. The ecological system takes a holistic approach and can be used to examine health problems as they appear in the daily work and social life (Stokols, 2000).
15 System theory
Health care organizations are highly specialized and have been described as a complex system of interdependent functions, departments, professions, and organizational levels (Plsek & Greenhalgh, 2001). In a complex system, there are interactions between several different components. The fundamental idea of system theory is its holistic approach, whose goal is to attend to the broad picture of the whole system rather than on single components (Bertalanffy, 1968; Kira & van Eijnatten, 2011). Furthermore, in order to reach sustainability in work systems each part of the organization should be sustainable (Docherty, 2008). To understand the challenges of a health care organization, it is important to understand the complex pattern that creates the system. In system theories the individual are commonly overlooked, which led Bronfenbrenner and Ceci (1994) to develop the bio ecological system theory. The bio ecological system theory aims to describe how society interacts with individuals and vice versa, how the individual integrates with the environment and with the society, and how these parts of the system are interdependent. The bio ecological model focuses on a constant and mutual adaption between a society in change and the individual in development (Bronfenbrenner & Ceci, 1994).
By creating sustainable working systems in health care organizations, the line managers and leadership have shown the important role they play in creating good working conditions. However, a system theory approach where all levels are included may have even stronger explanatory power. Dellve and Eriksson (2017) have developed an integrated system theory approach for sustainable working conditions. Sustainable working conditions or sustainable work has been defined as conditions that support the development of employees’
personal resources for crafting their job situation and their work and thus their ability to remain at work (Kira & Van Eijnatten, 2010; Eurofound, 2020a).
Consequently, conditions that restrain their possibilities to use their personal resources could limit their ability to shape conditions for work and performance.
According to them system theory in combination with managerial knowledge is an indispensable foundation for creating a sustainable work environment.
System theory opens for a holistic approach and for an understanding of the various levels in the organization so that efforts can be made to synchronize the different organizational levels by building bridges between them.
16
The different organizational levels described by Dellve and Eriksson (2017) in their system theory approach build on Bronfenbrenner’s (1999) and Bone (2015) models and correspond with the models’ five levels: (1) individual; (2) micro; (3) meso; (4) macro; and (5) chrono. In these, the individual is at the center and everything concerning the employee’s direct work, environment, workplace, and work group is at this level (Dellve & Eriksson, 2017). The micro level includes a pattern of activities and relations (Bronfenbrenner, 1996;
Bronfenbrenner & Ceci, 1994) and concerns everything that is experienced by the employee, most often on a daily basis (Bone, 2015). The meso level contains structures related to norms and cultures constitute the formal work organization. In the strategies of this level to develop work structures lies the macro level, which is the political level: here overall structures and reforms are formulated and implemented. The chrono level is the time line in the model – it describes styles and developments in time that impact the society and work environments (Dellve & Eriksson, 2017), for example, the inclusion of private companies in the health care sector.
Using a system theory perspective in combination with their practical managerial knowledge would likely give the line managers substantial reasons to allow organizational flexibility for their employees. Therefore, in attempting to comprehend how separate results in this dissertation project contribute to the general understanding of organizations, this thesis takes a system theory perspective.
17
Aim
Overall aim
The overall aim was to expand knowledge about how working conditions with specific focus on flexibility and restricted control over work, impact health and work performance among first and second line managers and employees within health care.
Specific aims
The specific aims of each study were as follows:
Study I: to generate knowledge about the importance of adjustment latitude at work and at home for return to work or regaining work ability for female HSO workers on long-term sick leave.
Study II: to investigate how restricted decision-making autonomy and conflicting demands impact operational managers’ work performance and health.
Study III: to examine the associations between managerial work performance and self-rated health or burnout among first-line nurse managers.
Study IV: to identify first line managers’ approaches for maintaining low levels of sick leave among health care employees.
