Unfolding alignment - How top management work to align demand and capacity: an ethnographic study of resilience in a Swedish healthcare region.

BACKGROUND: Resilient healthcare organizations maintain critical functions and high-quality care under varying conditions. While previous research has focused on the activities of frontline healthcare professionals working at the "sharp end" of care, less attention has been paid to managers at the top management level. More knowledge is needed to fully understand how the managers align demand and capacity at the "blunt end" of care. Therefore, this study aimed to explore how top managers work to align demand and capacity in a healthcare region in Sweden. METHODS: Observations of management team meetings, interviews, and conversations were conducted with top managers responsible for healthcare in one of Sweden's 21 regions. Data collection used an ethnographic approach. Data were analyzed using qualitative reflexive thematic analysis. RESULTS: The data showed how alignment work was done through active reflection that built on past experiences and on structures built into the organization at the same time as taking future potential outcomes and consequences into account. In addition to collaborative, preventive, supportive, and contextualizing work, which was conducted in the present, a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders. CONCLUSION: This study explored how top managers work to align demand and capacity in a healthcare region in Sweden. It was shown how four categories of work; collaborative, preventive, supportive and contextualization work, together with a general approach; focusing on opportunities, building on a stable past and taking a reflective stance, constitute alignment in practice. More; the alignment work was done in the here and now, with both the past and future in mind. The ability to take action to benefit the whole is a possibility and a responsibility for top management. In the region studied, this was done by aligning demands with capacity based on past experiences and focusing on the available opportunities to connect knowledge needed within and across organizational borders.

How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study.

PURPOSE: This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement. DESIGN/METHODOLOGY/APPROACH: Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method. FINDINGS: The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus. PRACTICAL IMPLICATIONS: For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed. ORIGINALITY/VALUE: Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.

Primary care physicians' views of standardised care pathways in cancer care: A Swedish qualitative study on implementation experiences.

OBJECTIVE: Primary care physicians (PCPs) recently started using standardised care pathways (PCPs) to refer patients to specialists for diagnostics in Sweden. The aim of the current study is therefore to examine PCPs views of implementing standardised care pathways (SCPs) in cancer care. METHOD: In total, 27 semi-structured interviews (17 individual and 10 group interviews) were conducted within 24 primary care units, including 61 physicians representing the public and private sectors. Interviews were conducted during 2017 and 2018. Data were analysed using a thematic analysis approach. RESULTS: Eight themes, including both perceived opportunities and challenges with the SCPs, were identified in the analysis. Most PCPs valued the SCPs, citing that they expedited the referral system and decreased patient waiting time. However, the guidelines were not completely clear leaving PCPs to wonder what constituted an SCP referral, who should initiate the referral, and how PCPs should communicate and collaborate with specialists. CONCLUSION: SCPs were a welcomed organisational change by PCPs, where PCPs thought that the SCPs could help in providing better patient care to potential cancer patients. However, updated guidelines and clarifications within the SCPs are warranted to have increased services for both the patients and medical personnel.

Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work.

BACKGROUND: Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers' is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. METHODS: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. RESULTS: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. CONCLUSIONS: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit's safety culture.

Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians.

BACKGROUND: The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. METHODS: Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. RESULTS: Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. CONCLUSIONS: Three reasons work together to explain primary care physicians' use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.

Patient experience of communication consistency amongst staff is related to nurse-physician teamwork in hospitals.

Aim: To investigate whether nurse reported teamwork with physicians was associated with patient perceived consistency in staff-to-patient communication. Design: A cross-sectional survey design was used, drawing on data collected from two surveys in England. Methods: Teamwork was assessed using data from the RN4CAST survey of 2,990 nurses in 31 Trusts in England. Data on patient experience derived from the National Health Services Adult Inpatient Questionnaire, including 12,506 patients in the same Trusts. A cross-sectional design with multivariate logistic regression was used. Results: Each 5% increase in the proportion of nurses who agree that there "is a lot of teamwork between nurses and physicians" was associated with 7% lower odds that patients reported inconsistency in communication amongst staff. The results suggest that patients seem to experience the consequences of less teamwork between nurses and physicians through their own perceptions of inconsistency in communication between staff. The findings emphasize good teamwork between doctors and nurses are not only important for the team, but also can have consequences for patients. It provides additional incentive to find mechanisms to breakdown disciplinary barriers and improve the cohesion of clinical teams for the benefit of their patients.

What happened and why? A programme theory-based qualitative evaluation of a healthcare-academia partnership reform in primary care.

BACKGROUND: There is increasing interest in and demands for partnerships between academia and healthcare practices. Few empirical studies have described the influence of such partnerships from a practice perspective. The purpose of this study was to evaluate the impact of a reform launched to increase integration between primary care and academia and to identify potential reasons for why the observed impact occurred in three areas targeted by the reform: research, student education, and continued professional development. METHODS: The study was conducted in Stockholm County, the largest healthcare region in Sweden, at the introduction of a partnership between primary care and academia, including eight coordinating centres and approximately 500 surrounding primary care units. A programme theory-based qualitative approach to evaluation was used, building on document analysis, and in-depth interviews with the centre managers (n = 6) and coordinators (n = 8) conducted 42-66 months after the initiation of the reform. RESULTS: The analysis showed that the reform had some impact on all three areas targeted by the reform: research, student education, and continued professional development. The input that contributed most extensively to the impact was the establishment of facilitating roles. Most changes occurred at the coordinating centres and primarily in the area of student education. The effect on student education was primarily due to having prior experience in this area and perceptions of timely benefits of students to care practice. CONCLUSIONS: Partnerships between primary care and academia hold the potential of practice impact. To increase integration between primary care and academia, the components of the integration must be understandable and relevant for primary care practitioners, and importantly, compliant with delivery of primary care.

Implementing standardized cancer patient pathways (CPPs) - a qualitative study exploring the perspectives of health care professionals.

BACKGROUND: Many countries have implemented standardized cancer patient pathways (CPPs) to reduce waiting times in cancer care and to ensure timely and quick diagnosis as well as treatment. Yet, no studies have explored the implementation process as perceived by the health care professionals working in the CPPs. The aim of this study is to explore the experiences of health care professionals (HPCs) involved in the CPPs. METHODS: A descriptive qualitative design was adopted. Thematic analysis was applied to individual interviews conducted in 2016-2017 with 58 participants working in six different CPPs in Sweden's largest region, covering care for around 2.3 million inhabitants. RESULTS: In general, the health care professionals had a positive attitude towards the implementation of the CPPs. Our findings showed that the CPPs require close collaboration, both between and within different health care professional groups and units, something that was not always probable due to differences in resource capacity. Better dissemination to all relevant professionals, better conceptualization, and equivalent opportunities in terms of resources were identified by the respondents as being important yet lacking in practice. The analysis showed possible negative effects of the CPP, such as crowding-out on other patient groups. CONCLUSION: The CPPs were introduced to address challenges with long waiting times and unequal cancer care. By exploring the experiences of health care professionals involved in the implementation of CPPs, our findings show challenges with multi-level coordination and collaboration, policy dissemination, and resource constraints. The analysis also showed that the implementation of CPPs risk being accompanied by unintended effects such as longer waiting times for other patients and patient groups in need of the same health care resources. The results shed light on and contribute to an understanding of the challenges, opportunities and ways forward.

How does leadership manifest in the patient-therapist interaction among physiotherapists in primary health care? A qualitative study.

Objectives: Health care is undergoing changes and this requires the participation and leadership of all health-care professions. While numerous studies have explored leadership competence among physicians and nurses, the physiotherapy profession has received but limited attention. The aim of this study was to explore how leadership manifests in the patient-therapist interaction among physiotherapists in primary health care and how the physiotherapists themselves relate their perception of leadership to their clinical practice. Methods: A qualitative study with semi-structured interviews was conducted with a purposive sample of 10 physiotherapists working in primary health care. The interviews were analyzed using inductive qualitative content analysis. Results: Five themes were identified related to how leadership manifests in the patient-therapist interaction: (1) establishing resonant relationships; (2) engaging patients to build ownership; (3) drawing on authority; (4) building on professionalism; and (5) relating physiotherapists clinical practice to leadership. Conclusion: This study describes how leadership manifests in the patient-physiotherapist interaction. The findings can be used to empower physiotherapists in their clinical leadership and to give them confidence in taking on formal leadership roles, thus becoming active participants in improving health care. Future studies are needed to explore other aspects of leadership used in physiotherapy clinical practice.

Leading top-down implementation processes: a qualitative study on the role of managers.

BACKGROUND: Leadership has been identified as an influential factor in implementation processes in healthcare organizations. However, the processes through which leaders affect implementation outcomes are largely unknown. The purpose of this study is to analyse how managers interpret and make sense of a large scale top-down implementation initiative and what implications this has for the implementation process. This was studied at the implementation of an academic primary healthcare initiative covering 210 primary healthcare centres in central Sweden. The aim of the initiative was to integrate research and education into regular primary healthcare services. METHODS: The study builds on 16 in-depth individual semi-structured interviews with all managers (n = 8) who had operative responsibility for the implementation. Each manager was interviewed twice during the initial phase of the implementation. Data were analysed using a thematic approach guided by theory on managerial role taking based on the Transforming Experience Framework. RESULTS: How the managers interpreted and made sense of the implementation task built on three factors: how they perceived the different parts of the initiative, how they perceived themselves in relation to these parts, and the resources available for the initiative. Based on how they combined these three factors the managers chose to integrate or separate the different parts of the initiative in their management of the implementation process. CONCLUSIONS: This research emphasizes that managers in healthcare seem to have a substantial impact on how and to what extent different tasks are addressed and prioritized in top-down implementation processes. This has policy implications. To achieve intended implementation outcomes, the authors recognize the necessity of an early and on-going dialogue about how the implementation is perceived by the managers responsible for the implementation.

Factors influencing early stage healthcare-academia partnerships.

Purpose The purpose of this paper is to explore factors influencing early implementation and intermediate outcomes of a healthcare-academia partnership in a primary healthcare setting. Design/methodology/approach The Academic Primary Healthcare Network (APHN) initiative was launched in 2011 in Stockholm County, Sweden and included 201 primary healthcare centres. Semi-structured interviews were conducted in 2013-2014 with all coordinating managers ( n=8) and coordinators ( n=4). A strategic change model framework was used to collect and analyse data. Findings Several factors were identified to aid early implementation: assignment and guidelines that allowed flexibility; supportive management; dedicated staff; facilities that enabled APHN actions to be integrated into healthcare practice; and positive experiences from research and educational activities. Implementation was hindered by: discrepancies between objectives and resources; underspecified guidelines that trigger passivity; limited research and educational activities; a conflicting non-supportive reimbursement system; limited planning; and organisational fragmentation. Intermediate outcomes revealed that various actions, informed by the APHN assignment, were launched in all APHNs. Practical implications The findings can be rendered applicable by preparing stakeholders in healthcare services to optimise early implementation of healthcare-academia partnerships. Originality/value This study increases understanding of interactions between factors that influence early stage partnerships between healthcare services and academia in primary healthcare settings.

Going beyond "two-getherness": Nurse managers' experiences of working together in a leadership model where more than two share the same chair.

OBJECTIVE: To explore nurse manager experiences of working in leadership constellations where more than two managers share leadership, and to compare this multilateral sharing form to what is known about experiences of working in joint leadership in pairs. DESIGN AND SETTING: A qualitative design based on semi-structured interviews with nurse managers in two multilaterally shared leadership constellations at two intensive care units at an emergency hospital in Sweden. Data were analysed using a thematic and comparative approach. FINDINGS: The comparative analysis identified four aspects that differ decisively from the positive picture in the literature on joint pair leadership: the perception of mandate with reduced decision-making power and reduced access to forums, the way of working with a strict division of tasks and a rotating schedule, a need to cope with the increasing number of internal relations and a feeling of doubt concerning trust. CONCLUSION: Shared leadership between nurse managers has gone from being a tight collaboration based on a feeling of "two-getherness", to being an organisational solution multilateral in character. In this transformation, a weakening of leadership qualities has occurred. Further research is necessary on how this new organisational solution impacts the nurse managers, their staff and the care provided in healthcare organisations generally.

Closing the gender leadership gap: a multi-centre cross-country comparison of women in management and leadership in academic health centres in the European Union.

BACKGROUND: Women's participation in medicine and the need for gender equality in healthcare are increasingly recognised, yet little attention is paid to leadership and management positions in large publicly funded academic health centres. This study illustrates such a need, taking the case of four large European centres: Charité - Universitätsmedizin Berlin (Germany), Karolinska Institutet (Sweden), Medizinische Universität Wien (Austria), and Oxford Academic Health Science Centre (United Kingdom). CASE: The percentage of female medical students and doctors in all four countries is now well within the 40-60% gender balance zone. Women are less well represented among specialists and remain significantly under-represented among senior doctors and full professors. All four centres have made progress in closing the gender leadership gap on boards and other top-level decision-making bodies, but a gender leadership gap remains relevant. The level of achieved gender balance varies significantly between the centres and largely mirrors country-specific welfare state models, with more equal gender relations in Sweden than in the other countries. Notably, there are also similar trends across countries and centres: gender inequality is stronger within academic enterprises than within hospital enterprises and stronger in middle management than at the top level. These novel findings reveal fissures in the 'glass ceiling' effects at top-level management, while the barriers for women shift to middle-level management and remain strong in academic positions. The uneven shifts in the leadership gap are highly relevant and have policy implications. CONCLUSION: Setting gender balance objectives exclusively for top-level decision-making bodies may not effectively promote a wider goal of gender equality. Academic health centres should pay greater attention to gender equality as an issue of organisational performance and good leadership at all levels of management, with particular attention to academic enterprises and newly created management structures. Developing comprehensive gender-sensitive health workforce monitoring systems and comparing progress across academic health centres in Europe could help to identify the gender leadership gap and utilise health human resources more effectively.

Does lean muddy the quality improvement waters? A qualitative study of how a hospital management team understands lean in the context of quality improvement.

BACKGROUND: Health care has experimented with many different quality improvement (QI) approaches with greater variation in name than content. This has been dubbed pseudoinnovation. However, it could also be that the subtleties and differences are not clearly understood. To explore this further, the purpose of this study was to explore how hospital managers perceive lean in the context of QI. METHODS: We used a qualitative study design with semi-structured interviews to explore twelve top managers' perceptions of the relationship between lean and quality improvement (QI) at a university-affiliated hospital. RESULTS: Managers described that QI and lean shared the same overall purpose: focus on patient needs and improve efficiency and effectiveness. Employee involvement was emphasized in both strategies, as well as the support offered by managers of staff initiatives. QI was perceived as a strategy that could support structural changes at the organizational level whereas lean was seen as applicable at the operational level. Moreover, lean carried a negative connotation, lacked the credibility of QI, and was perceived as a management fad. CONCLUSIONS: Aspects of QI and lean were misunderstood. In a context where lean remains an abstract term, and staff associate lean with automotive applications and cost reduction, it may be fruitful for managers to invest time and resources to develop a strategy for continual improvement and utilize vocabulary that resonates with health care staff. This could reduce the risk that improvement efforts are rejected out of hand.

Medicine and management: looking inside the box of changing hospital governance.

BACKGROUND: Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing 'hybridization' of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study. METHODS: We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the 'managed' and the 'managing' doctors in an organization. RESULTS: Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial-professional coordination at the micro-level of the organization. CONCLUSION: This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management.

Healthcare managers' construction of the manager role in relation to the medical profession.

Purpose - The purpose of this paper is to explore how healthcare managers construct the manager role in relation to the medical profession in their organisations. Design/methodology/approach - In total, 18 of Sweden's 20 healthcare chief executive officers (CEOs) and 20 clinical department managers (CDMs) were interviewed about their views on management of physicians. Interviews were performed in the context of one aspect of healthcare management; i.e., management of physicians' sickness certification practice. A discourse analysis approach was used for data analysis. Findings - Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse dominated and managers frequently used the attributes "physician" or "non-physician" to categorise themselves or other managers in their managerial roles. Some managers, both CEOs and CDMs, shifted between the management- and profession-based discourses, resulting in a kind of "yes, but […]" approach to management in the organisations. The dominating profession-based discourse served to reproduce the power and status of physicians within the organisation, thereby rendering the manager role weaker than the medical profession for both physician and non-physician managers. Research limitations/implications - Further studies are needed to explore the impact of gender, managerial level, and basic profession on how managers construct the manager role in relation to physicians. Practical implications - The results suggest that there is a need to address the organisational conditions for managers' role taking in healthcare organisations. Originality/value - Despite the general strengthening of the manager position in healthcare through political reforms during the last decades, this study shows that a profession-based discourse clearly dominated in how the managers constructed the manager role in relation to the medical profession on the workplace level in their organisations.

Management and medicine: why we need a new approach to the relationship.

New Public Management has affected the relationship between corporate managerialism and professional modes of governing hospitals. While doctors' increasing involvement in management may have positive effects on health care, hospital governance, health care policies and medical education have largely failed to support this change. There is a need for new policies and approaches to support the changing connections between medicine and management that abandons both the military discourse of 'wars' and 'battlefields' and the new rhetoric of 'clinical leadership'.

Health care management of sickness certification tasks: results from two surveys to physicians.

BACKGROUND: Health care in general and physicians in particular, play an important role in patients' sickness certification processes. However, a lack of management within health care regarding how sickness certification is carried out has been identified in Sweden. A variety of interventions to increase the quality of sickness certification were introduced by the government and County Councils. Some of these measures were specifically aimed at strengthening health care management of sickness certification; e.g. policy making and management support. The aim was to describe to what extent physicians in different medical specialties had access to a joint policy regarding sickness certification in their clinical settings and experienced management support in carrying out sickness certification. METHOD: A descriptive study, based on data from two cross-sectional questionnaires sent to all physicians in the Stockholm County regarding their sickness certification practice. Criteria for inclusion in this study were working in a clinical setting, being a board-certified specialist, <65 years of age, and having sickness certification consultations at least a few times a year. These criteria were met by 2497 physicians in 2004 and 2204 physicians in 2008. Proportions were calculated regarding access to policy and management support, stratified according to medical specialty. RESULTS: The proportions of physicians working in clinical settings with a well-established policy regarding sickness certification were generally low both in 2004 and 2008, but varied greatly between different types of medical specialties (from 6.1% to 46.9%). Also, reports of access to substantial management support regarding sickness certification varied greatly between medical specialties (from 10.5% to 48.8%). More than one third of the physicians reported having no such management support. CONCLUSIONS: Most physicians did not work in a clinical setting with a well-established policy on sickness certification tasks, nor did they experience substantial support from their manager. The results indicate a need of strengthening health care management of sickness certification tasks in order to better support physicians in these tasks.

Managers' perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare.

BACKGROUND: This study focused on the manager role in the manager-physician relationship, considered from the manager perspective. The aim was to understand how top executives in Swedish healthcare regard management of physicians in their organisations, and what this implies for the manager role in relation to the medical profession. Abbott's theory of professional jurisdiction was used to inform thinking about managerial control and legitimacy in relation to physicians. METHODS: Data from semi-structured individual interviews with 18 of the 20 county council chief executive officers (CEOs) in Sweden were subjected to qualitative analysis. RESULTS: The results show that, when asked about their views on management of physicians, the CEOs talked about "how physicians are" rather than describing their own or their subordinate managers' managerial behaviour or strategies. Three types of descriptions of physicians were identified: 1) they have high status and expertise; 2) they lack knowledge of the system; 3) they do what they want in the organisation. The CEOs seldom reported that general management strategies were used to manage physicians. Instead, they described four types of physician-specific management strategies that were used in their organisations: organisational separation of physicians; "nagging and arguing"; compensations; relying on the physician role. These strategies seemed to reflect pragmatic behaviour on behalf of the managers that helped them to maintain control over physicians in daily work. However, in a longer perspective, they seemed to decrease the legitimacy of the manager role and also contribute to weakening of that role in the organisation. CONCLUSIONS: Many CEOs seemed to regard the manager role in their organisations as weak and described difficulties in both taking and defining that role (for themselves or others) in relation to the physician role. Further research is needed to elucidate how managers in healthcare organisations assume the manager role in relation to the medical profession. Studies indicate that lack of clarity concerning manager role authority and responsibility may have negative consequences not only for the working conditions of managers, physicians, and other healthcare professionals, but also for the quality of care.

Problems in sickness certification of patients: a qualitative study on views of 26 physicians in Sweden.

OBJECTIVE: To identify what problems physicians experience in sickness certification of patients. DESIGN: Qualitative analyses of data from six focus-group discussions. SETTING: Four counties in different regions of Sweden. PARTICIPANTS: Twenty-six physicians strategically selected to achieve variation with regard to sex, geographical location, urban/rural area, and type of clinic. RESULTS: The problems involved four areas: society and the social insurance system, the organization of healthcare, the performance of other actors in the system, and the physicians' working situation. In all areas the problems also involved manager issues such as overall leadership, organization of healthcare, and existing incentives and support systems for physicians' handling of patients' sickness certification. Many physicians described feelings of fatigue and a lack of pride in their work with sickness certification tasks, as they believed they contributed to unnecessary sickness absence and to medicalization of patients' non-medical problems. CONCLUSIONS: The problems identified have negative consequences both for patients and for the well-being of physicians. Many of the problems seem related to inadequate leadership and management of sickness certification issues. Therefore, they cannot be handled merely by training of physicians, which has so far been the main intervention in this area. They also have to be addressed on manager levels within healthcare. Further research is needed on how physicians cope with the problems identified and on managers' strategies and responsibilities in relation to these problems. If the complexity of the problems is not recognized, there is a risk that inadequate actions will be taken to solve them.