Background
In this study we have focused on potential determinants of healthy working conditions in two departments in a Swedish university hospital. In previously conducted longitudinal studies at the present hospital (1994–2001), Hertting and colleagues studied working conditions and health outcomes among health care personnel in conjunction with downsizing processes during the 1990s. This downsizing period was characterised by personnel reductions; the hospital staff was reduced by 22% (1000 persons) between 1995–1997, and 10% were relocated to other departments. Other structural changes during the study period were mergers of departments and outsourcing of service units, along with continuous demands for cutting costs [
1‐
5].
Biological stress markers, measured on 31 female medical secretaries, registered nurses and assistant nurses, indicated that protective and anabolic functions had suffered, from the adjustment phase (1997) to the reconstruction in 1998. The continuing adaptation process indicated increasing difficulty for the women to mobilise energy [
1]. Repeated interviews (1997, 1998, 2000 and 2001) with the same respondents confirmed these difficulties [
2‐
4].
A third study, based on a questionnaire and hospital register data (1994–2001), found evidence for negative trends in mental health and in long-term sick leave at the hospital, corresponding to negative trends in working conditions [
5]. In international research, increasing work demands and reduced control [
6], combined with job insecurity and loss of trust [
7], were identified during periods of downsizing. Further, downsizing has been associated with subsequent high rates of sickness absence [
8].
Petterson and her colleagues [
5] also found that increasing demands to work hard, conflicting demands, and increasing lack of time to plan work, were strongly associated with overall deteriorating health. It was not possible to identify health-promoting departments in terms of positive health development. However, compared with the generally negative hospital trend, four of the 24 departments studied might be labelled more 'health-promoting', since they showed stable trends both in mental health and in short- and long-term sick-leave rate. Two of these departments were selected for this current interview study.
A health-promoting hospital has been considered to be a 'healthy organisation' in the sense of having an effective relation-oriented management and active staff participation [
9], which means a workplace where people are able to produce, serve, grow and be evaluated [
10]. Accordingly, in the context of working life, health promotion should be a matter of supporting peoples' resources by enhancing job control, encouraging social support, networks and relations at the workplace, and providing a meaningful job.
Health promotion is often based on the salutogenic model [
11], where health is seen as being created by a sense of coherence, including comprehensibility, meaningfulness and manageability. When applied to working life, comprehensibility implies that work changes have to be predictable. Work assignments must be meaningful in the sense of being perceived as socially rewarding and stimulating. Manageability means access to the necessary resources for handling work pressure, which includes own ability as well as material and supportive resources provided by the environment. Health promotion at the workplace could be a question of enhancing such resources by strengthening the individual's internal control and ability to act, i.e. room for manoeuvre [
12].
Ever since the demand-control model was introduced [
13], increased decision latitude has been perceived as an important element in health promotion in the workplace. In a longitudinal study an improved relationship between decision latitude and psychological demands has been shown to be related to a rising serum concentration of testosterone, which is an index of increasing regenerative bodily activity [
14]. In different controlled experiments it has been shown that efforts to improve decision latitude for employees are associated with improvements in morning serum cortisol [
15], decreased staff turnover and decreased sick leave [
16].
Health outcomes could be predicted, as there is a correlation between positive self-rated health and a lower risk of future sickness and death [
17]. Research has also found that satisfaction with one's place of work and profession are important predictors for positive good health [
18]. In a longitudinal participatory worksite intervention, job control was recognised as the mediator for increased mental health, less sick leave and a higher level of self-rated performance [
19]. In another extensive longitudinal study in a health-care setting it was found that workmates or managers freezing out employees, and employees' experiences of negative and threatening changes at the workplace are of importance for long-term sick leave [
20].
In a survey study, Noblet [
21] confirmed that job control and social support at work had a health-promoting value. Job stressors accounted for as much as 25% of explained variance in mental health. The factor most strongly associated with mental health and job satisfaction was time to do the job as well as you would like. Time-related pressure was strongly associated with job strain.
Skill variety, autonomy, social contact and learning were confirmed as determinants of intrinsic work motivation in a study of specific work-setting determinants for contributing to the motivation and good health of nurses. These factors made their work challenging and meaningful. Emotional exhaustion can be reduced if attention is paid to workload [
22].
Leadership and employee health
Transformational leadership contains elements of charismatic leadership, inspirational motivation, intellectual stimulation and individual consideration [
23]. Bass and Avolio found that leaders with a transformational style are capable of empowering employees to stretch their limits, and of being innovative to create solutions [
24]. Empowering management could contribute to extended decision latitude, as power in the organisation transfers to co-workers [
25]. A workplace environment characterised by such empowerment strategies can improve productivity as well as cohesion and job satisfaction for the employees [
26,
27]. The relation between health outcome and job satisfaction has been confirmed [
28], and job satisfaction among nursing staff has been found to be positively correlated with transformational leadership style [
29].
The relationship between organisational efficiency and transformational leadership style was confirmed by Marks-Moran [
30]. However, transformational leadership was found to be most efficient when management by team is a reality and the organisation is development-oriented [
31]. Bass [
23] concluded that transformational leaders are more successful, in terms of efficiency, than leaders using a transactional style, which includes management-by-expectation, and contingent reinforcement and rewards. In a study among Belgian head nurses, fewer work stressors and lower levels of emotional exhaustion were found among staff when a transformational leadership style was used [
32]. However, in a study of Swedish health centres, Bernin and Theorell were not able to confirm any impact of leadership style on subordinates' health [
33]. From the review of research in the field of management, there are studies supporting the view that leadership is one factor that influences job satisfaction. However, there are different and inconclusive findings concerning leadership style and its impact on employees' health.
In the present study the purpose was to understand how employees succeeded in retaining their health and going beyond the stable (positive) health trends in the two selected departments in a period of turbulence [
5]. By focusing on experienced health determinants in management at department levels, we expect to acquire knowledge about health-promotive factors for employees working in health care organisations. In this study we identify management as a phenomenon where both managers and co-workers participate.
The aim of the study was to identify and analyse experiential determinants of healthy working conditions from the perspectives of hospital managers and staff in key positions.
Discussion
In the results the picture of the departments might be considered too positive. Actually booth departments have gone through several difficulties such as mergers, and never-ending cuts in resources. Other difficulties have been conflicts about the philosophy of caring, as well as ongoing problems with organisational structural reconstruction. Consequently, these departments faced problems in the same way as others did. However, the intention of this study has been to concretise and increase understanding of what contributes to a healthy working life during a period of downsizing and restructuring. The results cannot provide definite answers concerning what are generally seen as determining factors for a healthy workplace, since there are certain given conditions for the two departments being studied with regard to the cooperation-oriented nature of their care and their small scale. Nevertheless, it is necessary to once again point out that these departments have faced the same demands for economic cuts and restructuring processes as the other departments at the hospital [
38]. As a consequence of this, the proportion of their original staff has diminished from 1994, which has amongst other things meant an increasing trend to work hard. On the other hand, relatively fewer assistant nurses were laid off at the two selected departments compared with the rest of the hospital. In spite of this, the health of the personnel was more stable than that of other staff at other departments [
5]. It is against this unstable organisational structure that the results are to be understood.
The informants comment on the value of belonging to a small department. According to Hodson [
39], organisational size is a key determinant for job satisfaction and being able to feel pride in relation to one's work. Due to their size the departments in this study can continuously review, get to know each other and build up a sense of loyalty towards each other. In addition to this they have been able to develop a professional attitude with a clear professional identity. The opportunities for recurring personal interaction at small workplaces seem to increase the social capital at the workplace. A high degree of social capital, i.e. that the work team has a social network, norms and trust that facilitates cooperation, implies greater levels of satisfaction and quality of life at work [
40,
41]. The loyalty that is developed can also be explained in terms of social cohesion, i.e. a sense of belonging to a friendly, cohesive community [
42]. Social contacts are thus a motivating factor at work and a determinant of health [
22]. At the hospital in this study as a whole it emerged among other things that low group cohesion and low satisfaction with workmates were significantly associated with short-term sick leave during the period of organisational instability [
5]. In other words, social capital and cohesion may have contributed to a stable health development at the departments in question, as it is known that work-related social support contributes to lower levels of work stressors [
43]. Another contributing factor to the sense of cohesion may be that those who do not fit into the small department leave the organisation. A recently published study of long-term sick leave among women found that there was a greater risk of women tumbling out of the system in big and hierarchically organised workplaces [
44]. From that perspective the small departments studied might be seen as protectors from long-term sick leave.
Both departments are highly specialised, and the staff are united by the clear common goal of providing the patients with care of high quality. Departmental goals are not enough in themselves; they must permeate the work of the department. According to Bass and Avolio [
24], the ability of managers to empower their employees contributes to developing a climate where everyone works together to reach the common goals. The managers in this study, both at department level and ward level, appear to have the ability to get their co-workers to stretch their limits. Being given the opportunity to stretch yourself at work is considered stimulating. The managers seem to empower the co-workers to take responsibility for their work. Such an empowering leadership style [
23] makes it easier for the employees to experience their competence and power to fulfil common goals [
25]. The employees are given a more active role from their managers and thereby an opportunity to expand their decision latitude [
13,
14]. An empowering leadership style contributes to a more equal manager – employee relation. However, it is easy to exceed the limit for what is a reasonable workload when, as in this study, co-workers are willing and interested in their work, and prepared to take on extra tasks. There is a risk that important and stimulating work tasks become so motivating that they lead to illness instead of healthy motivation [
2]. The managers in this study are aware of the danger of over-stimulating, but state that they may nevertheless fail to pay attention to the limits of individual co-workers' capacity.
In order to live up to the ambition of providing patients with specialised care of high quality, professional knowledge and skills are required, as well as well-developed cooperation, where everyone's competences are valuable contributions. The heads of department give their co-workers the opportunity to share the responsibility so that they can develop their competence. In this way the work environment can be characterised as empowerment-oriented, which can develop efficiency and job satisfaction at the workplace [
26]. At a small and furthermore reduced work unit, the value and usefulness of each co-worker's efforts appear to be even more obvious.
Learning has high status at the departments. The management has realised the importance of competence development and, despite cuts, invests in integrating learning in the everyday work. Learning in everyday work is a resource that contributes to increasing the co-workers' sense of manageability [
11]. In this way the individual is given the opportunity of having control over situations and his/her actions [
12]. A learning organisation is also a positive determinant for increasing work motivation and making the work challenging as well as comprehensible and meaningful [
11,
12]. The results from the departments in this study are reminiscent of those that appeared in the interview studies conducted at the same hospital [
2‐
4], where the female informants expressed a strong desire to work towards the same goal in a cooperating and learning team. For them this highly valued request was not a reality; however, this was the case for the two health-promoting departments. The competence development that the two departments invest in is directed towards the core activities of their respective departments. In order to bring about effective everyday learning there must be an opportunity for dialogue [
45]. The management at the departments makes a conscious effort to provide opportunities for dialogue between individuals, within and between groups, and between different levels in the hierarchy. In this way they appear to have managed to break the hierarchical structures. At the same time as the teamwork has been developed, they have managed both to create confidence in each other and to retain the authority of the professional groups without creating jealously guarded territory. A possible interpretation of the result of this study is that the communication between the hierarchies is both top-down and bottom-up, which means that the management appears to have broken the communication pattern which the head nurses in Nilsson's study considered to be mostly top-down [
46].
The style of management at the departments can be described as transformational, since the management strives to inspire and motivate co-workers to learn and develop. Intellectual stimulation as one aspect of transformational leadership deals with motivating employees to tax their resources to be innovative and creative, both in developing work tasks and solving problems [
23]. The leadership style used in the departments leads in turn to the important components active problem-solving, support for coping, good communication and learning organisation. The managers are prepared to give their co-workers support and recognition. Personal recognition [
47] could also define transformational style. In this respect the small size of the studied department could be an advantage, as managers and co-workers have many opportunities to communicate. By applying 'management by walking around' they could more easily pay attention to the individual employee [
23].
When the organisation is in the middle of an unstable period, as is the case here, with increasing and conflicting work demands and less time to plan work, the co-workers' need for recognition, will probably be even more apparent. Recognition through feedback from the management can serve as an energy-giving activity [
2‐
4] and thus a health promotion determinant. During the adjustment and restructuring phases, there has been an obvious trend that the personnel have worked harder and harder with a risk of overload [
5]. At the present departments there is an awareness of these risks. There is a conscious managerial responsibility to keep a watchful eye on overload and to provide opportunity for recovery and time for reflection. Within this there is also the importance of integrating a certain measure of social activities in order to strengthen the group feeling.
There is a balancing act between giving co-workers responsibility and relieving them of it, as the management of the departments has done in a delicate way. Allowing co-workers to take responsibility for their work and their own development is good for productivity and efficiency [
23], for work satisfaction [
26,
30] for decision-making [
46] and as stress prevention [
32]. The positive effects of being given, and taking, responsibility must be weighed against the risk of overloading the co-workers. In this balancing act the management uses empowerment strategies to delegate responsibility for carrying out the work parallel to strategies for prioritising work tasks. The support, which the co-worker perceives, helps him/her to gain control over the work, and this may have contributed to the health trend being stable at the departments [
19,
21].
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
KN: Study design, data collection, data analysis, writing the manuscript
AH: Study design, co-analyser, participating in writing the manuscript
ILP: Participating in writing the manuscript
TT: Contributed with discussions of consistence in the analysis