Employee silence in health care: Charting new avenues for leadership and management.

ISSUE: Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive. CRITICAL THEORETICAL ANALYSIS: Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture. INSIGHT/ADVANCE: The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice. PRACTICE IMPLICATIONS: Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care.

Managerial approaches for maintaining low levels of sick leave: A qualitative study.

AIM: The aim of this study was to identify first-line managers' approaches for maintaining low levels of sick leave among health care employees. INTRODUCTION: One challenge in health care is the high level of sick leave among employees. High work demands and conflicting pressures characterize the work situation of both employees and first-line managers, with potential negative effects on work-related health. METHOD: First-line managers at units with low and/or decreasing sick leave were interviewed. Thematic analysis was used to analyse the data. RESULTS: The managers took a holistic approach in meeting their employees' broader needs, and they were balancing high organisational demands through insubordination. To keep sick leave rate low, they created possibilities for the employees to influence their own working life through a present, visible and trustful leadership. CONCLUSION: Managers responsible for units with low sick leave seemed to utilize a holistic approach with focus on their employees and prioritized needs of their employees before organisational demands from top management. IMPLICATIONS FOR NURSING MANAGEMENT: First-line managers in health care can have impact on sick leave among their employees and create good working conditions, despite pressure from their superiors.

Gender equality and managers' work in elderly and social care: A structural equation modelling approach.

AIM: The study explores whether, and how, gender equality is associated with key aspects related to operative managers' improvement work. We explore the possible associations between gender equality and; prioritization of social regulations in operative decision-making, engagement in operative improvement work, group dynamics challenges and collaboration between managers and subordinates. BACKGROUND: Regarding organizational relations and preconditions for providing good care and developing operative work in the social and elderly care sector, the value of having organizational gender equality is unknown. METHOD: Associations were analysed using structural equation modelling of questionnaire data. The questionnaire was distributed to first-line managers in a large city in Sweden (n = 598, response rate 56%). RESULTS: Positive perceptions of organizations' gender equality were significantly associated with more engagement in operative improvement work, fewer group dynamics challenges and higher priority of social regulations in unit decision-making, also when controlling for confounders. Gender equality had no association with managers' collaboration with subordinates in this study. CONCLUSION(S): This study demonstrates that equal opportunities for male and female workers could benefit operative managers' improvement work. IMPLICATIONS FOR NURSING MANAGEMENT: Organizations that strive to improve conditions for operative work, which strengthen preconditions for service development, should include values of gender equality.

Sex differences in dementia: on the potentially mediating effects of educational attainment and experiences of psychological distress.

BACKGROUND: Old-age dementias are known to disproportionally affect women as well as individuals with low educational attainment. The higher lifetime risk of dementia among women is usually attributed to their longer life expectancy. However, the impact of sex, and subsequent gender inequity, is likely to be more multifaceted than this explanation implies. Not least because of historical inequities in access to education between the sexes and the gender and socio-economic gradients in risk factors such as stress, depression and social isolation. Consequently, the present study sought to test whether differences in educational attainment and experiences of general psychological distress mediate the association between female sex and dementia. METHODS: The study utilizes data obtained through the Gothenburg H70 Birth Cohort Study and the Prospective Populations Study on Women (n = 892). Data were analysed using Confirmatory Factor Analysis (CFA) and Structural Equation Modelling (SEM) with Weighted Least Squares Means and Variance adjusted (WLSMV) estimation. General psychological distress was indicated by a latent variable and constructed from five manifest items (previous depression, stress, self-esteem, chronic loneliness and satisfaction with social situation) that were all measured at baseline. RESULTS: While the results could not corroborate that education directly mediates the effect of sex on dementia, level of distress was predicted by both female sex (0.607, p < .001) and education (- 0.166, p < .01) and, in turn, shown to be significantly associated with dementia (0.167, p < .05), also after controlling for confounders. When time from baseline to diagnosis was increased through sequential exclusion of dementia cases, the effect of distress on dementia was no longer significant. CONCLUSION: The overall findings suggest that social (dis) advantage predicts general psychological distress, which thereby constitutes a potential, and rarely acknowledged, pathway between female sex, education, and dementia. They further underline the importance of attending to both education and distress as 'gendered' phenomena when considering the nature of their associations with dementia. However, the possibility of reverse causality bias must be acknowledged and the need for longitudinal studies with longer follow-up stressed.

"Nurses' use of visual management in hospitals-A longitudinal, quantitative study on its implications on systems performance and working conditions".

AIM: The aim of this study was to examine potential benefits provided by daily visual management tool use and explore its association with systems performance and working conditions among hospital nurses. BACKGROUND: Visual management tools used in everyday work and improvement work in health care theoretically contribute to shared understanding of complex work systems and provide certain user benefits. Cognitive load, miscommunication within and between professional groups, and pressure to engage in care process redesign add to nurses' strained working conditions. DESIGN: Quantitative longitudinal. METHODS: Questionnaires were distributed at T0, (N = 948, 66% response rate), T1 (N = 900, 70% response rate), and T2 (N = 621, 72% response rate) to nurses at five hospitals. Three groups of users (daily users, start users, and non-daily users) were compared by means T1-T2 (significance tested with Wilcoxon signed rank test) and by mixed model repeated measures T0, T1, T2. RESULTS: Daily use associated to better overview of work, collaboration, social capital, and clinical engagement. Job resources were rated higher by daily users. Mental stress increased and development opportunities decreased over time among non-daily users. There were associations between use and perceptions of systems performance, though the differences between groups were small. CONCLUSION: This study specifically explores visual management tool use in the hospital setting, which contributes to research by broadening the understanding of cognitive, social, and emotional benefits provided by visual management tool use. Daily use was associated to positive working conditions, small but positive differences in systems performance, and indicated a buffering effect on nurses' mental stress.

The impact of restricted decision-making autonomy on health care managers' health and work performance.

AIM: The aim of this study was to investigate how restricted decision-making autonomy and conflicting demands impact operational managers' work performance and health. BACKGROUND: Managers at operational level (first- and second-line managers') in health care organisations are commonly exposed to strain in their work situation with high demands and a challenging work context. Although they play an important role, the knowledge about the causal associations between stressful job demands and their consequences is limited. METHODS: A prospective design with questionnaire data collected at two points in time, 1 year apart, from a sample of operational managers (N = 162) at five Swedish hospitals was used to conduct a structural equation model analysis with cross-lagged paths. RESULTS: Restricted decision-making autonomy was negatively associated with both the managers' health and their managerial work performance over time. CONCLUSIONS: Health care managers' work performance and health may be sustained by the top management allowing them a higher degree of autonomy in their decision-making. IMPLICATIONS FOR NURSING MANAGEMENT: This study suggests that nursing leaders should create the circumstances for operational managers' to have higher levels of autonomy in their area of responsibility and the freedom to prioritize their managerial workload.

Women with Neck Pain on Long-Term Sick Leave-Approaches Used in the Return to Work Process: A Qualitative Study.

Purpose There are difficulties in the process of return to work (RTW) from long-term sick leave, both in general and regarding sick leave because of neck pain in particular. Neck pain is difficult to assess, problematic to rehabilitate, and hard to cure; and it is not always easy to decide whether the pain is work-related. The outcome of RTW could be dependent upon individuals' approaches, defensive or offensive behaviors, and choices related to their self-efficacy. The aim of this study was to identify approaches used in the RTW process among women with neck pain on long-term sick leave from human service organizations. Methods This is a qualitative descriptive study based on grounded theory. A Swedish cohort of 207 women with a history of long-term sick leave with neck pain from human service organizations answered open-ended written questions at 0, 6, and 12 months, and 6 years; and 16 women were interviewed. Results Individuals expressed their coping approaches in terms of fluctuating in work status over time: either as a strategy or as a consequence. Periods of sick leave were interwoven with periods of work. The women were either controlling the interaction or struggling in the interaction with stakeholders. Conclusions Return to work outcomes may be improved if the fluctuating work status over time is taken into account in the design of rehabilitation efforts for women with a history of long-term sick leave and with chronical musculoskeletal conditions.

Importance of social capital at the workplace for return to work among women with a history of long-term sick leave: a cohort study.

BACKGROUND: The workplace is an essential source of social capital for many people; it provides mutual support and gives meaning to life. However, few prospective studies have thoroughly investigated the importance of aspects of social capital in the workplace. The aim of this study was to investigate the associations between aspects of social capital (social support, sense of community, and quality of leadership) at the workplace, and work ability, working degree, and vitality among women with a history of long-term sick leave from human service organizations. METHODS: A longitudinal cohort study was performed among women with a history of long-term sick leave. The study started in 2005, and the women were followed up at 6 months, 1 year, and 6 years using self-reported questionnaires (baseline n = 283). Linear mixed models were used for longitudinal analysis of the repeated measurements of prospective degree of work ability, working degree, and vitality. Analyses were performed with different models; the explanatory variables for each model were social support, sense of community, and quality of leadership and time. RESULTS: Social capital in terms of quality of leadership (being good at solving conflicts and giving high priority to job satisfaction), sense of community (co-operation between colleagues) and social support (help and support from immediate superiors and colleagues) increased the women's work ability score (WAS) as well as working degree over time. Additionally, social capital in terms of quality of leadership increased the women's vitality score over time. CONCLUSIONS: A sustainable return-to-work process among individuals with a history of long-term sick leave, going in and out of work participation, could be supported with social support, good quality of leadership, and a sense of community at the workplace. The responsibility for the rehabilitation process can not be reduced to an individual problem, but ought to include all stakeholders involved in the process, such as managers, colleagues, health care services, and the social security agency.

Return to work from long-term sick leave: a six-year prospective study of the importance of adjustment latitudes at work and home.

PURPOSE: The aim was to investigate the long-term importance of adjustment latitude for increased work ability and return to work among female human service workers on long-term sick leave. METHODS: A cohort of female human service workers on long-term sick leave (>60 days) was given a questionnaire four times (0, 6, 12, 60 months). Linear mixed models were used for longitudinal analysis of the repeated measurements of work ability and return to work. RESULTS: Having a higher level of adjustment latitude was associated with both increased work ability and return to work. Adjustments related to work pace were strongly associated with increased work ability, as were adjustments to the work place. Having individual opportunities for taking short breaks and a general acceptance of taking short breaks were associated with increased work ability. At home, a higher level of responsibility for household work was related to increased work ability and return to work. Individuals with possibilities for adjustment latitude, especially pace and place at work, and an acceptance of taking breaks had greater increased work ability over time and a greater work ability compared with individuals who did not have such opportunities. CONCLUSIONS: This study highlights the importance of opportunities for adjustment latitude at work to increase work ability and return to work among female human service workers who have been on long-term sick leave. The results support push and pull theories for individual decision-making on return to work.

Social support outside work and return to work among women on long-term sick leave working within human service organizations.

AIM: To investigate the relationships between return to work and social support outside work among women on long-term sick leave from human service organizations. BACKGROUND: Work is an important part of life and is, in general, considered to be supportive of health and wellbeing. Few studies have thoroughly investigated the importance of aspects of social support outside work for return to work. METHODS: A cohort of women on long-term sick leave was followed with questionnaires from 2005 to 2012. RESULTS: The availability of social attachment increased the women's work ability, return to work, and vitality significantly more over time. There were positive relationships between return to work and seeking support in terms of emotional support and comfort and expressing unpleasant feelings. CONCLUSIONS: Important resources to increase return to work can be found in factors outside work, such as close social relationships and support seeking. Thus, it is important to take the woman's whole life situation into account and not focus solely on aspects related to the workplace.

Health care managers' views on and approaches to implementing models for improving care processes.

AIM: To develop a deeper understanding of health-care managers' views on and approaches to the implementation of models for improving care processes. BACKGROUND: In health care, there are difficulties in implementing models for improving care processes that have been decided on by upper management. Leadership approaches to this implementation can affect the outcome. METHOD: In-depth interviews with first- and second-line managers in Swedish hospitals were conducted and analysed using grounded theory. RESULTS: 'Coaching for participation' emerged as a central theme for managers in handling top-down initiated process development. The vertical approach in this coaching addresses how managers attempt to sustain unit integrity through adapting and translating orders from top management. The horizontal approach in the coaching refers to managers' strategies for motivating and engaging their employees in implementation work. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: Implementation models for improving care processes require a coaching leadership built on close manager-employee interaction, mindfulness regarding the pace of change at the unit level, managers with the competence to share responsibility with their teams and engaged employees with the competence to share responsibility for improving the care processes, and organisational structures that support process-oriented work. Implications for nursing management are the importance of giving nurse managers knowledge of change management.

Healthcare managers in negative media focus: a qualitative study of personification processes and their personal consequences.

BACKGROUND: Over the last decade healthcare management and managers have increasingly been in focus in public debate. The purpose of the present study was to gain a deeper understanding of how prolonged, unfavorable media focus can influence both the individual as a person and his or her managerial practice in the healthcare organization. METHODS: In-depth interviews (n = 49) with 24 managers and their superiors, or subordinate human resources/information professionals, and partners were analyzed using a grounded theory approach. RESULTS: The conceptual model explains how perceived uncertainties related to the managerial role influence personification and its negative consequences. The role ambiguities comprised challenges regarding the separation of individual identity from the professional function, the interaction with intra-organizational support and political play, and the understanding and acceptance of roles in society. A higher degree of uncertainty in role ambiguity increased both personification and the personal reaction to intense media pressure. Three types of reactions were related to the feeling of being infringed: avoidance and narrow-mindedness; being hard on self, on subordinates, and/or family members; and resignation and dejection. The results are discussed so as to elucidate the importance of support from others within the organization when under media scrutiny. CONCLUSIONS: The degree of personification seems to determine the personal consequences as well as the consequences for their managerial practice. Organizational support for managers appearing in the media would probably be beneficial for both the manager and the organization.

Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development.

UNLABELLED: The need for trans-professional collaboration when developing healthcare has been stressed by practitioners and researchers. Because physicians have considerable impact on this process, their willingness to become involved is central to this issue. OBJECTIVE: This study aims to gain a deeper understanding of how physicians view their engagement in healthcare development. METHOD: Using a grounded theory approach, the study developed a conceptual model based on empirical data from qualitative interviews with physicians working at a hospital (n = 25). RESULTS: A continual striving for experiences of usefulness and progress, conceptualized as 'striving for professional fulfilment' (the core category), emerged as a central motivational drive for physician engagement in healthcare development. Such experiences were gained when achieving meaningful results, having impact, learning to see the greater context and fulfilling the perceived doctor role. Reinforcing organizational preconditions that facilitated physician engagement in healthcare development were workplace continuity, effective strategies and procedures, role clarity regarding participation in development and opportunities to gain knowledge about organization and development. Two opposite role-taking tendencies emerged: upholding a traditional doctor role with high autonomy in relation to organization and management, clinical work serving as the main source of fulfilment, or approaching a more complete 'employeeship' role in which organizational engagement also provides a sense of fulfilment. CONCLUSION: Experiencing professional fulfilment from participation in healthcare development is crucial for sustainable physician engagement in such activities.

Workplace rehabilitation and supportive conditions at work: a prospective study.

PURPOSE: To investigate the impact of rehabilitation measures on work ability and return to work (RTW), specifically the association between workplace rehabilitation/supportive conditions at work and work ability and RTW over time, among women on long-term sick leave. METHODS: Questionnaire data were collected (baseline, 6 and 12 months) from a cohort of women (n = 324). Linear mixed models were used for longitudinal analysis of the repeated measurements of work ability index (WAI), work ability score and working degree. These analyses were performed with different models; the explanatory variables for each model were workplace rehabilitation, supportive conditions at work and time. RESULTS: The individuals provided with workplace rehabilitation and supportive conditions (e.g. influence at work, possibilities for development, degree of freedom at work, meaning of work, quality of leadership, social support, sense of community and work satisfaction) had significantly increased WAI and work ability score over time. These individuals scored higher work ability compared to those individuals having workplace rehabilitation without supportive conditions, or neither. Additionally, among the individuals provided with workplace rehabilitation and supportive conditions, working degree increased significantly more over time compared to those individuals with no workplace rehabilitation and no supportive conditions. CONCLUSION: The results highlight the importance of integrating workplace rehabilitation with supportive conditions at work in order to increase work ability and improve the RTW process for women on long-term sick leave.

Partner relationships and long-term sick leave among female workers: consequences and impact on dimensions of health and return to work.

Few efforts have been made to prospectively identify resources and obstacles outside work that may predict regained work ability and return to work when workers are on sick leave. This study investigates the association between partner relationships and sick leave. Our research questions were as follows: (i) What is the influence of sick leave, pain, stress and domestic strain on the quality of the dyadic partner relationship?, and (ii) What is the influence of the partner and social relationship on pain, stress, work ability, self-rated health and return to work? A cohort of female workers (n = 225) on long-term sick leave (>60 days), all in a partner relationship, at 6-month intervals completed a questionnaire based on the Quality of Dyadic Relationship (QDR) instrument, the Interview Schedule of Social Interaction (ISSI), the Work Ability Index (WAI) and the Copenhagen Psychosocial Questionnaire (COPSOQ). Univariate and multivariate analyses of baseline and prospective data were performed. The results showed that decreased partner relationship quality was related to having major responsibility for household work despite being on sick leave, having pain and having decreased social integration. Among younger individuals on sick leave, a reduction in the quality of the partner relationship was shown already at the first (6-month) follow-up, while among middle-aged women, such a reduction was seen only at the 12-month follow-up. No dimensions of partner relationship quality at baseline were related to dimensions of return to work, either as a resource or as an obstacle. Consequently, our results show that a good relationship does not keep the woman from returning to work. Having main responsibility for household work, which implies domestic strain while on sick leave, predicts lower partner relationship quality. The practical implications are that healthcare professionals treating women on sick leave should emphasize the importance of keeping a social network as well as making sufficient adjustments at home for the relationship quality to be safeguarded. Special attention should be given to the young woman on sick leave as being on sick leave seems to influence her partner relationship considerably.

The school nursing profession in relation to Bourdieu's concepts of capital, habitus and field.

AIM: The aim was to define the work and professional role of school nurses, in terms of Bourdieu's key concepts of capital and habitus. METHOD: A qualitative study with a deductive approach, based on data from six focus-group interviews with 24 school nurses and 15 individual interviews with school nurses. Thus, a total of 39 school nurses participated in the study. The data were analysed using content analysis. RESULTS: The results explain, in terms of Bourdieu's key concepts of capital and habitus, how school nurses experience their work in the educational setting. A model including different aspects of school nurses' work is shown. CONCLUSION: The new Swedish Education Act focuses on promoting students' general health, so that they are able to reach their academic potential. In this task, the school nurse is to be one of a group of several professionals working together. The present study shows how school nurses experience their professional role and their work in relation to Bourdieu's concepts of capital, habitus and field. To strengthen the school nursing profession, school nurses need to show their competence in promoting students' health.

A prospective study of managers' turnover and health in a healthcare organization.

AIMS: To assess turnover and health of Swedish healthcare managers, and identify important supporting factors relating to work and individual resources. BACKGROUND: Individual managers' own sustainability in terms of turnover and health may be influenced by managerial working conditions and individual resources. METHODS: A 4-year prospective questionnaire study of 216 healthcare managers. Turnover and indicators of good health (healthy work attendance and no burnout) were related to work factors and individual resources using Cox regressions with constant time at risk. RESULTS: Forty per cent of the healthcare managers had left after 4 years. Fifty-two per cent had a healthy work attendance record and the proportion with no burnout had increased. Experiencing moderate/high job control was a predictor of remaining in the managerial position. Good health was predicted by having energy left for domestic work and being thoroughly rested after sleep. CONCLUSIONS: Managerial turnover seems high in Swedish healthcare and linked to working conditions, while sustained health are linked to individual resources. IMPLICATIONS FOR NURSING MANAGEMENT: Healthcare organizations should focus not only on developing individuals in their managerial role but also on strengthening the conditions that allow managers to exercise their leadership and to ensuring that the managers most suitable for their posts do not leave.

Development Work in Swedish Eldercare: Resources for Trustworthy, Integrated Managerial Work During the COVID-19 Pandemic.

The extensive needs for developments of eldercare addressing working conditions, care quality, influence, and safety was highlighted during the pandemic. This mixed-method study contribute with knowledge about capability-strengthening development work and its importance for trustworthy managerial work, before and during the COVID-19 pandemic. Questionnaire data and narratives from first-line managers immediately before (n = 284) and 16 months into the pandemic (n = 189), structured interviews with development leaders (n = 25), and documents were analyzed. The results identify different focuses of development work. Strategic-level development leaders focused the strengthening of old adults' capabilities. While operational-level leaders approached strengthening employees' capability. First-line managers' rating of their trustworthy managerial work decreased during the pandemic and was associated with their workload, development support and capability-strengthening projects focusing employees' resources. The study demonstrates the gap between strategic and the operational levels regarding understanding of capability set and needed resources for strengthening capabilities and trustworthy, integrated managerial work regarding safety, influence, and quality conditions for old adults and employees.

Silence Among First-Line Managers in Eldercare and Their Continuous Improvement Work During Covid-19.

Eldercare sector faced severe needs, and unexplained difficulties, to manage daily work and the continuous improvement of routines at operative levels during Covid-19. First-line managers in eldercare have a key role to facilitate learnings but may be hindered in public, hierarchical organizations. This is the first study on the conditions and importance of silence for managerial work in terms of daily operations and continuous improvement work. To identify first-line managers' silence in eldercare, its contextual and supportive conditions, its reasons and its implications for managerial work with regard to daily operations and continuous improvement work. Mixed-method study based on a questionnaire to first-line managers (n = 189) in Swedish public eldercare in 33 randomly selected municipal organizations and one city. The instruments Communication of Critical Issues at Work, Managers Stress Inventory and Managerial Work and an open question were analyzed using: (1) qualitative coding to explore organizational conditions, (2) descriptive statistics, and (3) stepwise regressions to identify associations. The most common forms of silence were quiescent (based on fear of the consequences of speaking up) and acquiescent (based on resignation and demotivation). Organizational conditions shaping managerial silence were due to strict governance and control in a hierarchical organization, lack of support and participation in decision-making and the experience of not being valued. Managers' silence had a negative impact on managerial work and especially work on continuous improvements. The pandemic also offered space for values of occupational professionalism and learning at operational levels. Organizational conditions of support through superiors and management teams decreased silence. Manager silence is detrimental for continuous improvement work and may arise in organizations with dominant values of organizational professionalism. Supportive conditions based on trust and space for occupational professionalism may be important and should be improved to decrease managerial silence and better support continuous improvements.

How Conditions and Resources Connected to Digital Management Systems and Remote Work Are Associated with Sustainable Work.

The current state of work-life transformation will see more white-collar work being performed remotely using digital management systems. There is, however, a lack of research on factors and resources contributing to sustainable work when working remotely using digital management systems. The aim of this study was to study the conditions and resources connected to digital management systems and remote work, and their associations with sustainable work, in terms of process quality, trust, and sense of coherence, when working remotely during the COVID-19 pandemic. An analytical cross-sectional study was performed. Questionnaire data from white-collar employees (n = 484) in two private companies were analyzed with regression models, focusing on the importance of the conditions and resources connected to digital management systems and remote work, stratified by working from home or at the office. The results showed digital conditions and resources being associated with indicators of sustainable work. Furthermore, the results showed that social work relations were additional important explanatory factors for sustainable remote work. This study contributes to the development of a new post-pandemic work-life balance by concluding that sustainable remote work needs to be ensured by functional digital management systems and adequate leadership supporting the development of a positive team and learning climate.