Challenges of primary health care leadership during the COVID-19 pandemic in Sweden: a qualitative study of managers' experiences.

PURPOSE: At the outbreak of the COVID-19 pandemic, health care was at the centre of the crisis. New demands made existing organizational practices and services obsolete. Primary health care had a great deal of responsibility for COVID-19-related care. The pandemic demanded effective leadership to manage the new difficulties. This paper aims to explore experiences and perceptions of managers in primary health care in relation to their efforts to manage the COVID-19 crisis in their everyday work. DESIGN/METHODOLOGY/APPROACH: The authors used a qualitative approach based on 14 semi-structured interviews with managers in primary health care from four regions in Sweden. The interviews were conducted during September to December 2020. Data were analysed using conventional qualitative content analysis. FINDINGS: Data analysis yielded three categories: lonely in decision-making; stretched to the limit; and proud to have coped. The participants felt lonely in their decision-making, and they were stretched to the limit of their own and the organization's capacity. The psychosocial working conditions in primary care worsened considerably during the pandemic because demands on leaders increased while their ability to control the work situation decreased. However, they also expressed pride that they and their employees had managed the situation by being flexible and having a common focus. ORIGINALITY/VALUE: Looking ahead and using lessons learnt, and apart from making wise decisions under pressure, an important implication for primary health-care leaders is to not underestimate the power of acknowledging the virtues of humanity and justice during a crisis. Continuing professional education for leaders focusing on crisis leadership could help prepare leaders for future crises.

Seven lessons from the coronavirus pandemic for primary health care: A qualitative study of registered and assistant nurses in Sweden.

AIM: The aim of this study was to explore lessons from the pandemic by registered and assistant nurses in Swedish primary health care (PHC) of potential relevance for the future operation of PHC. METHODS: Twenty-one semi-structured interviews were conducted with registered and assistant nurses. We used a purposeful sampling strategy to achieve a diverse sample with regard to size and location of PHC centres. Data were analysed using qualitative content analysis. RESULTS: Analysis yielded two categories: lessons from the pandemic pertaining to PHC personnel and patient behaviours (adaptability of the personnel; importance of hygiene and maintaining physical distance; and importance of being attentive to illness symptoms) and lessons from the pandemic related to primary healthcare work routines (effectiveness of digital job meetings; advantages of digital patient consultations; importance of keeping infectious patients separate from other patients; and the need to allow only pre-booked patient appointments). CONCLUSIONS: The seven sub-categories represent seven lessons from the pandemic. The lessons generated both instrumental knowledge, which the nurses could apply in work-related decisions, and conceptual knowledge which yielded improved understanding of problems and potential solutions for PHC.

Working conditions in primary healthcare during the COVID-19 pandemic: an interview study with physicians in Sweden.

OBJECTIVE: The aim of this study was to explore how the COVID-19 pandemic changed the working conditions of physicians in Swedish primary healthcare. DESIGN: This is a descriptive, qualitative study with individual semistructured interviews. Data were analysed using inductive content analysis. SETTING: Swedish primary healthcare units in both rural and urban areas. PARTICIPANTS: A total of 11 primary care physicians fulfilled participation. RESULTS: Two main categories emerged: 'work organisation and routines' and 'psychosocial work environment', containing three and five subcategories, respectively. The pandemic enforced changes in work organisation and routines. Increased flexibility, including more patient-oriented delivery of care, and novel means of interorganisational and intraorganisational interactions were perceived as positive by physicians. The pandemic also caused several changes in physicians' psychosocial work environment. Increased workload, information overload, as well as ethical considerations and feelings of uncertainty made the work environment stressful for physicians. CONCLUSIONS: The COVID-19 pandemic affected the working conditions of physicians in Swedish primary healthcare in numerous ways. The pandemic enforced changes in work organisation and routines for physicians in primary healthcare. Further research is needed to investigate how the pandemic will affect primary healthcare in the longer term. Learning from the pandemic is important because this will not be the last crisis that primary care and its healthcare professionals will face.

Working conditions in primary care: a qualitative interview study with physicians in Sweden informed by the Effort-Reward-Imbalance model.

BACKGROUND: Many problems with primary care physicians' psychosocial working conditions have been documented. Many studies on working condition have used the Effort-Reward-Imbalance (ERI) model, which posits that poor health and well-being may result from imbalances between the level of effort employees perceive that they put into their work and the rewards they receive. The model has not been used in qualitative research or applied to investigate primary care physicians' working conditions. The aim of this study was to apply the ERI model to explore the perceived efforts and rewards by primary care physicians in Sweden and approaches they take to cope with potential imbalances between these efforts and rewards. METHODS: The study has a qualitative design, using semi-structured interviews. A purposeful sampling strategy was used to achieve a heterogeneous sample of primary care physicians who represented a broad spectrum of experiences and perceptions. We recruited 21 physicians; 15 were employed in public health care and 6 by private health care companies. RESULTS: The analysis of the interviews yielded 11 sub-categories: 6 were mapped to the efforts category, 3 were attributed to the rewards category and 2 were approaches to coping with effort/reward imbalances. Many of the statements concerned efforts in the form of high workload, restricted autonomy and administrative work burden. They also perceived resource restrictions, unpredictability of work and high expectations in their role as physicians as efforts. Three types of rewards emerged; the physicians found their job to be stimulating and meaningful, and the work climate to be supportive. The physicians coped with imbalances by means of job enrichment and using decisional latitude. CONCLUSIONS: Primary care physicians perceive numerous types of efforts in their job, which is consistent with research concerning work stress and associated consequences, such as poor subjective health and well-being. There are also rewards according to primary care physicians, but the findings suggest a lack of reciprocity in terms of efforts and rewards although firm conclusions cannot be drawn since the study did not investigate the magnitude of the various efforts and rewards or the effectiveness of the approaches the physicians use to cope with imbalances. The ERI model was found to be useful to explore physicians' primary care work and working conditions but its applicability likely depends on the type of work or professions being studied.

Digital consultations in Swedish primary health care: a qualitative study of physicians' job control, demand and support.

BACKGROUND: Digital consultation with primary care physicians via mobile telephone apps has been spreading rapidly in Sweden since 2014. Digital consultation allows remote working because physicians can work from home, outside their traditional primary care environment. Despite the spread of digital consultation in primary care, there is a lack of knowledge concerning how the new service affects physicians' psychosocial work environment. Previous research has focused primarily on the patients' point of view and the cost-effectiveness of digital consultation. Hence, there is a paucity of studies from the perspective of physicians, focusing on their psychosocial work environment. The aim of this study was to investigate primary care physicians' perceived work demands, control over working processes, and social support when providing digital consultation to primary care patients. METHODS: The study has a qualitative design, using semi-structured interviews conducted in Sweden in 2019. We used a purposeful sampling strategy to achieve a heterogeneous sample of physicians who represented a broad spectrum of experiences and perceptions. The interviews were conducted by video meeting, telephone, or a personal meeting, depending on what suited the participant best. The interview questions were informed by the Job Demand-Control-Support (JDCS) model, which was also used as the framework to analyze the data by categorizing the physicians' perceptions and experiences into the three categories of the model (Demand, Control, Support), in the deductive analysis of the data. RESULTS: Analysis of the data yielded 9 subcategories, which were mapped onto the 3 categories of the JDCS model. Overall, the participants saw numerous benefits with digital consultations, not only with regard to their own job situation but also for patients and the health care system in general even though they identified some shortcomings and risks with digital care. CONCLUSIONS: This study has demonstrated that physicians perceive working with digital consultation as flexible with a high grade of autonomy and reasonable to low demands. According to the participants, digital consultation is not something you can work with full time if medical skills and abilities are to be maintained and developed.

A randomized cross-over trial of the postprandial effects of three different diets in patients with type 2 diabetes.

BACKGROUND: In the clinic setting both fasting levels of glucose and the area under the curve (AUC) of glucose, by determination of HbA1c levels, are used for risk assessments, in type 2 diabetes (NIDDM). However little is known about postprandial levels, and hence AUC, regarding other traditional risk factors such as insulin and blood-lipids and how this is affected by different diets. OBJECTIVE: To study postprandial effects of three diets, during a single day, in NIDDM. METHODS: A low-fat diet (45-56 energy-% from carbohydrates), and a low-carbohydrate diet (16-24 energy-% from carbohydrates) was compared with a Mediterranean-style diet (black coffee for breakfast and the same total-caloric intake as the other two diets for lunch with red wine, 32-35 energy-% from carbohydrates) in a randomized cross-over design. Total-caloric intake/test-day at the clinic from food was 1025-1080 kCal in men and 905-984 kCal in women. The test meals were consumed at a diabetes ward under supervision. RESULTS: Twenty-one participants were recruited and 19 completed the studies. The low-carbohydrate diet induced lower insulin and glucose excursions compared with the low-fat diet (p<0.0005 for both AUC). The insulin-response following the single Mediterranean-style lunch-meal was more pronounced than during the low-fat diet lunch (insulin increase-ratio of the low-fat diet: 4.35 ± 2.2, of Mediterranean-style diet: 8.12 ± 5.2, p = 0.001) while postprandial glucose levels were similar. The increase-ratio of insulin correlated with the elevation of the incretin glucose-dependent insulinotropic-polypeptide following the Mediterranean-style diet lunch (Spearman, r = 0.64, p = 0.003). CONCLUSIONS: The large Mediterranean-style lunch-meal induced similar postprandial glucose-elevations as the low-fat meal despite almost double amount of calories due to a pronounced insulin-increase. This suggests that accumulation of caloric intake from breakfast and lunch to a single large Mediterranean style lunch-meal in NIDDM might be advantageous from a metabolic perspective. TRIAL REGISTRATION: ClinicalTrials.gov NCT01522157 NCT01522157.