Social capital in healthcare A resource for sustainable engagement in organizational improvement work MARCUS STRÖMGREN

Doctoral Thesis (No. 8, 2017) KTH Royal Institute of Technology Technology and Health Unit of Ergonomics SE-141 57 Huddinge, Sweden

TRITA-STH Report 2017:8 ISSN 1653-3836 ISRN/KTH/STH/2017:8-SE ISBN 978-91-7729-463-4 © Marcus Strömgren, 2017 Print: US-AB, Stockholm Academic dissertation which with permission from Kungliga Tekniska Högskolan (Royal Institute of Technology) in Stockholm is presented for public review for passing the doctoral examination on Friday 29 September at 13:00 in lecture hall T1 (Emmy Rappesalen), Hälsovägen 11C, Huddinge, Sweden.

Abstract

Social capital, work engagement, working conditions, and leadership are concepts that have been studied previously, but there is lack of knowledge about what processes promote sustainable organizational improvement work in hospitals, and specifically, what leads healthcare professionals to engage in clinical developments. The overall aim of this thesis is to increase knowledge of how social capital and engagement contribute to organizational improvement work in hospitals and how social capital and engagement are created during organizational improvement work. In Study I, the aim was to assess dimensions of engagement among healthcare professionals and to investigate how these are related to work conditions during organizational redesign of care processes. In Study II, the aim was to assess working conditions and social capital association with intention to leave, and to investigate if social capital moderates the association between job demands and intention to leave. Study III aimed to investigate the importance of social capital for job satisfaction, work engagement, and engagement in clinical improvements among healthcare professionals. In Study IV, the aim was to explore whether qualities of leadership have impact on social capital among employees in hospital settings over time, and if so, what those qualities are. The empirical material is based on data from one research program including three research projects. Data were collected by a questionnaire at three times over a period of two years, and all studies are quantitative. The studies are based on a hospital cohort including five hospitals. In Study II, cross-sectional data were analysed. In studies I, III, and IV, longitudinal data were analysed. The results show that improved working conditions and employees’ attitudes to engagement in improvement work are associated with and have importance for healthcare professionals’ work engagement and clinical engagement in improving care processes (Study I). Job demands, social capital, and other job resources are associated with healthcare professionals’ intention to leave their jobs, whereas high levels of social capital are associated with low levels of intention to leave (Study II). Increased social capital predicted healthcare professionals’ job satisfaction, work engagement, and engagement in patient safety (Study III). Leadership is shown to be important for healthcare professionals’ social capital, and levels of leadership quality correlate with levels of social capital over time (Study IV). In conclusion, social capital, increased job resources, and decreased job demands are important conditions for healthcare professionals’ engagement in organizational improvement work. To develop social capital, leadership quality is an important precondition. Social capital can be regarded as a resource for sustainable organizational improvement work in healthcare, because of its importance for healthcare professionals’ engagement, job satisfaction, and intention to leave.

Keywords Healthcare, social capital, engagement, leadership, sustainability.

Sammanfattning

Socialt kapital, arbetsengagemang, arbetsförhållanden och ledarskap är begrepp som har studerats tidigare men det saknas kunskap om vilka processer som främjar hållbar verksamhetsutveckling i sjukhus, specifikt vad får hälso- och sjukvårdspersonal att engagera sig i kliniskt utvecklingsarbete. Det övergripande syftet med den här avhandlingen är att öka kunskapen om hur socialt kapital och engagemang bidrar till verksamhetsutveckling och hur socialt kapital och engagemang skapas under pågående verksamhetsutveckling. I Studie I var syftet att identifiera dimensioner av engagemang bland hälso- och sjukvårdspersonal och att undersöka hur dessa är relaterade till arbetsförhållanden under pågående utveckling av vårdprocesser. I Studie II var syftet att analysera samband mellan arbetsförhållanden och socialt kapital i relation till vårdpersonalens intention att sluta sitt arbete och att undersöka om socialt kapital modererar förhållandet mellan arbetskrav och intention att sluta sitt arbete. Den tredje studien (III) syftade till att undersöka vikten av socialt kapital för arbetstillfredsställelse, arbetsengagemang och engagemang i kliniskt utvecklingsarbete bland hälso- och sjukvårdspersonal. Studie IV syftade till att utforska om och vilka ledarskapskvalitéter som har inverkan på socialt kapital över tid bland anställda i hälso- och sjukvården. Det empiriska materialet bygger på data från ett forskningsprogram som inkluderar tre forskningsprojekt. Data samlades in via enkät vid tre tillfällen över en period av två år och samtliga studier är kvantitativa. Studierna är baserade på en sjukhuskohort från fem sjukhus. I Studie II analyserades tvärsnittsdata. I studierna I, III och IV analyserades longitudinella data. Resultaten visade att förbättrade arbetsförhållanden och anställdas attityd till engagemang var associerade till och var viktiga för hälso- och sjukvårdspersonals arbetsengagemang och kliniska engagemang i utveckling av vårdprocesser (Studie I). Arbetskrav, socialt kapital och andra arbetsresurser är associerade till hälso- och sjukvårdspersonals intention att sluta sitt arbete samt att hög nivå av socialt kapital är associerat till låg nivå av intention att sluta sitt arbete (Studie II). Ökat socialt kapital visade sig predicera hälso- och sjukvårdspersonals arbetstillfredsställelse, arbetsengagemang och engagemang i patientsäkerhet (Studie III). Ledarskap var viktigt för hälso- och sjukvårdspersonals sociala kapital och nivåer av ledarskapskvalitét korrelerade med nivåer av socialt kapital över tid (Studie IV). Slutsatsen är att socialt kapital, ökade arbetsresurser och minskade arbetskrav är viktiga förutsättningar för hälso- och sjukvårdspersonals engagemang i verksamhetsutveckling. För att utveckla socialt kapital är ledarskapskvalitét en viktig förutsättning. Genom det sociala kapitalets betydelse för hälso- och sjukvårdspersonals engagemang, arbetstillfredsställelse och intention att sluta sitt arbete kan det sociala kapitalet betraktas som en resurs för hållbar verksamhetsutveckling i sjukvården.

Nyckelord

Sjukvård, socialt kapital, engagemang, ledarskap, hållbarhet.

Preface

This thesis is most certainly influenced by my background and previous experiences. I have been practicing sports for most part of my life and I have also been involved from the coaching side. I believe this is where my interest for leadership and the ability to create group engagement started. During my bachelor’s studies in health promotion, I identified several issues regarding leadership, health and group engagement. This increased my interest for the topic and left me with unanswered questions regarding the subject. After my bachelor’s degree I started my career as a Health Planner where I worked with public health in a county council. This meant analyzing and communicating results of epidemiologic studies to politicians and managers within healthcare and municipalities.

In 2003 I was given the opportunity to attend a leadership course, Understanding Group and Leader (UGL). This was a real eye-opener and provided me with valuable insights of the importance of leadership in relation to group development. A few years later I became a licenced UGL-trainer, and have since then worked with employees and managers from different kinds of organizations. These experiences have provided me with the knowledge of the need for leadership and the importance of human relations for both organizational outcomes and for well-being.

In 2007 I earned my master’s degree in leadership, which added theoretical insights to my experiences of working with leadership development. This also inspired me to search for future possibilities to study the concepts of leadership and engagement within healthcare. In 2012, while working on a project to evaluate an intervention of health-promoting leadership, I met with a research team that made it possible for me to start studying the concepts of engagement, leadership, and social capital. In this thesis, theoretical knowledge and my practical experiences have been combined to investigate social capital, engagement, and leadership with respect to organizational improvement work in healthcare. Although I have come across new questions during this journey, I am about to bring closure to some of the previous ones.

Köping, August 2017

Marcus Strömgren

List of studies

This thesis is based on the following studies, which are referred to in the text by their

Roman numerals.

Study I

Dellve L., Strömgren M., Williamsson A., Holden R., Eriksson A. Health care clinicians’

engagement in organizational redesign of care processes: The importance of work and

organizational conditions (In review process).

Study II

Strömgren M. (2017). Intention to leave among health care professionals: The importance

of working conditions and social capital. Journal of Hospital Administration, 6(3), 58-66.

Study III

Strömgren M., Eriksson A., Bergman D., Dellve L. (2016). Social capital among healthcare

professionals: A prospective study of its importance for job satisfaction, work engagement

and engagement in clinical improvements. International Journal of Nursing Studies, 53,

116-125.

Study IV

Strömgren M., Eriksson A., Ahlstrom L, Bergman D., Dellve L. (2017). Leadership quality:

a factor important for social capital in healthcare organizations. Journal of Health

Organization and Management, 31(2), 175-191.

Strömgren´s contribution

Study I: Strömgren contributed in the writing and the analyses. Strömgren contributed in

revising the manuscript throughout the process.

Study II: Strömgren is the corresponding author, no co-authors.

Study III: Strömgren is the corresponding author. Strömgren designed and wrote the

paper. Strömgren performed the analyses.

Study IV: Strömgren is the corresponding author. Strömgren designed and wrote the

paper. Strömgren performed the analyses.

In all studies, Strömgren participated in collecting the empirical data.

Summary of studies: aims, designs, and conclusions

Study Aim Design Conclusion

I To assess dimensions of engagement among healthcare professionals and to investigate how these are related to work conditions during organizational redesign of care processes.

Quantitative study over time T1: n = 865 T2: n = 908

The study contributes to the knowledge about how and when healthcare professionals are mobilized to engage in healthcare improvement work. Increased work and organizational resources have importance for healthcare professionals’ clinical engagement in improving care processes.

II To assess the association of working conditions and social capital with the intention to leave, and to investigate whether social capital moderates the association between job demands and intention to leave.

Cross-sectional study n = 849

Social capital was associated with healthcare professionals’ intention to leave their jobs. Social capital did not interact with job demands with respect to intention to leave. Working conditions and social capital had different importance among occupational groups regarding intention to leave.

III To investigate the importance of social capital for job satisfaction, work engagement, and engagement in clinical improvements among healthcare professionals.

Quantitative, prospective cohort study n = 477

Social capital predicted healthcare professionals’ general work engagement, engagement in clinical improvements in patient safety and job satisfaction.

IV To explore whether qualities of leadership have impact on social capital among employees in hospital settings over time, and what those qualities are.

Quantitative study over time T1: n = 865 T2: n = 908 T3: n = 632

Leadership was an important factor for building social capital. Levels of leadership quality correlate with levels of social capital over time.

Study II has been reprinted with the kind permission of Sciedu Press.

Study III has been reprinted with the kind permission of Elsevier Ltd.

Study IV has been reprinted with the kind permission of Emerald Group Publishing

Limited.

Abbreviations

COPSOQ Copenhagen psychosocial questionnaire

HCWs Healthcare workers

JD-R model Job demands resources model

LP Lean production

MWQ Modern work-life questionnaire

NPM New public management

RN Registered nurse

SWEBO The Swedish scale for work engagement and burnout

Contents

1. Introduction ..................................................................................................................... 11

2. Background ..................................................................................................................... 13

2.1. Bio ecological system ............................................................................................... 13

2.2. System approach to organizational improvement work ......................................... 14

2.2.1. Organizational improvement work in Swedish healthcare ............................... 15

2.2.2. Sustainability perspectives on organizational improvement work .................. 16

2.2.3. Sustainable organizational improvement work in healthcare ......................... 16

2.3. Social capital ............................................................................................................. 17

2.3.1. Social capital in healthcare ............................................................................... 18

2.3.2. Social capital as a resource for organizational improvement work ................. 18

2.4. Work engagement ................................................................................................... 19

2.5. Intention to leave ..................................................................................................... 20

2.6. Importance of working conditions for engagement ................................................ 20

2.6.1. Challenges in engaging healthcare professionals ............................................. 21

2.7. Leadership ............................................................................................................... 22

2.7.1. Leadership in healthcare .................................................................................. 24

3. Aim .................................................................................................................................. 27

3.1. Specific aims ............................................................................................................ 27

4. Method ............................................................................................................................ 28

4.1. Research design ....................................................................................................... 28

4.2 Sample ...................................................................................................................... 28

4.3. Data collection ......................................................................................................... 30

4.4. Measures.................................................................................................................. 30

4.4.1. Attitudes to engaging in organizational improvement work (I)....................... 30

4.4.2. Work engagement (I, II) .................................................................................. 31

4.4.3. Engagement in clinical improvements (I, III) ................................................. 31

4.4.4. Working conditions (I, II) ................................................................................ 32

4.4.5. Top-down initiative to implement LP (I) ......................................................... 32

4.4.6. Organizational improvements at units (I) ....................................................... 32

4.4.7. Quality of leadership (I, IV) ............................................................................. 32

4.4.8. Social capital (II, III, IV) .................................................................................. 33

4.4.9. Job satisfaction (III) ........................................................................................ 33

4.4.10. Intention to leave (II) ..................................................................................... 34

4.4.11. Control variables ............................................................................................. 34

4.5. Analyses ................................................................................................................... 34

4.5.1. Study I ............................................................................................................... 34

4.5.2. Study II ............................................................................................................. 34

4.5.3. Study III ........................................................................................................... 35

4.5.4. Study IV ............................................................................................................ 36

4.6. Ethics ....................................................................................................................... 36

5. Results ............................................................................................................................. 37

5.1. Study I ...................................................................................................................... 37

5.2. Study II .................................................................................................................... 38

5.3. Study III ................................................................................................................... 39

5.4. Study IV ................................................................................................................... 39

6. Discussion ....................................................................................................................... 41

6.1. Employee engagement in organizational improvement work ................................. 41

6.2. Social capital as a resource for employee engagement ........................................... 42

6.3. Leadership, a factor important for social capital .................................................... 44

6.4. From a systems perspective .................................................................................... 45

6.5. Practical implications .............................................................................................. 46

6.6. Method discussion ................................................................................................... 47

7. Conclusions and future research ..................................................................................... 51

7.1. General conclusion .................................................................................................... 51

7.2. Specific conclusions .................................................................................................. 51

7.3 Future research .......................................................................................................... 51

Acknowledgements ............................................................................................................. 52

References ........................................................................................................................... 53

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1. Introduction

The intention of this thesis is to investigate aspects that may contribute to explaining

healthcare professionals’ engagement in organizational improvement work. The focus is to

investigate possible promoting factors for sustainable organizational improvement work in

healthcare.

Public hospitals are facing challenges of how to develop care processes with high quality

and at the same time decrease costs. Influenced by new public management (NPM), many

Swedish hospitals have carried out a number of changes with the purpose to decrease costs

and increase efficiency while maintaining good quality of care and the well-being of

healthcare professionals (Bezes et al., 2012; Hood, 1995; Jansson von Vultée et al., 2007;

Pollitt and Bouckaert, 2004). Employee engagement is described as crucial to reaching

success in organizational improvement work in healthcare (Riches and Robson, 2014).

Knowledge of factors promoting healthcare professionals’ engagement in organizational

improvement work need therefore to be revealed. Previous research shows that there are

challenges in engaging healthcare professionals in organizational improvement work, and

also that there is a lack of knowledge and research about conditions that lead employees to

engage in improvement work (Braithwaite et al., 2007). There is also lack of knowledge

about processes that promote sustainable organizational improvement work, and

specifically, what leads healthcare professionals to engage in clinical improvements.

For the improvement work to be sustainable, previous research indicates that it depends

on how the organization manages to engage healthcare professionals in clinical

improvements (Ham, 2003; Riches and Robson, 2014) and argues for approaching system

perspectives to gain deeper knowledge about how conditions interact (Bakker and

Demerouti, 2007; Dellve and Eriksson, 2017; Porras and Robertson, 1992; Riches and

Robson, 2014). Sustainable work organizations are characterized by good health,

enthusiasm, and cooperation springing from promotion of employees’ resources to perform

and develop their professional work (Kira et al., 2010). However, consequences of top-

down initiation of reorganization in healthcare have shown it to be less sustainable because

of increased job demands, work pace, stress, absenteeism (Koukoulaki, 2014; Westgaard

and Winkel, 2011), low engagement (Ham, 2003), and turnover (Hertting et al., 2004).

Before the actual turnover happens, a prior state—intention to leave—has been recognized

as an indicator of future staff turnover (Cho et al., 2009). The potential risk of turnover

among healthcare professionals as a consequence of strategic initiation of changes in

healthcare makes it vital to understand the factors that may influence healthcare

professionals’ intention to leave, when a top-down initiative to organizational improvement

work is implemented. Engagement, social capital, and job resources could possibly balance

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intention to leave and are in this thesis considered as promoting factors related to

sustainable organizational improvement work.

The importance of job resources and job demands for employees’ job satisfaction as well as

their work engagement is known (Demerouti et al., 2001). There is, however, a gap in

knowledge of how work conditions during organizational improvement work in hospitals

relate to dimensions of healthcare professionals’ engagement. This argues for investigating

job resources and job demands related to healthcare professionals’ engagement in clinical

improvement work as well as their attitudes to engaging in strategic initiative of

improvement work.

A potential resource, as a complement to other forms of capital and resources, that may

contribute to promoting healthcare professionals’ engagement in organizational

improvement work is social capital. Previous studies of social capital indicate that social

capital is associated with organizational advantages, cooperation, job satisfaction, well-

being, and patient safety (Hofmeyer and Marck, 2008; Nahapiet and Ghoshal, 1998;

Ommen et al., 2009; Putnam et al., 1994; Waisel, 2005). However, the knowledge of its

association with and impact on healthcare professionals’ work engagement, job

satisfaction, clinical engagement, and intention to leave during ongoing organizational

improvement work is deficient. To study social capital in such context would increase the

knowledge of its potential impact on healthcare professionals’ engagement in

organizational improvement work.

Leadership is suggested to be associated with social capital (Kristensen, 2010). Based on

previous studies of leadership (Day, 2001; Day et al., 2004; De Clercq et al., 2014; Li, 2013),

there are arguments for considering that leadership can have an impact on social capital,

but this has not yet been investigated longitudinally with prospective analyses. Most

knowledge of the relation between leadership and social capital has been derived the other

way around, that is, from looking at how social capital and social networks influence

leadership (Day et al., 2004; De Clercq et al., 2014; Li, 2013). This argues for investigating

and increasing knowledge of the potential impact of leadership on social capital.

This thesis focuses on gaining knowledge of how social capital and engagement can

contribute to sustainable organizational improvement work in healthcare. In the framing

of this thesis, I have chosen a systems theory approach, because investigated factors and

the specific aims of the thesis concern mechanisms at individual, workplace, and

organizational levels. The thesis also focuses on well-being, which gives reason to choose a

systems theory approach that relates to health and well-being (Dellve and Eriksson, 2017).

The thesis can contribute to increased knowledge of important factors with respect to

healthcare professionals’ engagement in organizational improvement work.

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2. Background

As background, models based on systems theories of health, work engagement,

organizational improvement, and sustainable working conditions are described and related

to the overall aim and also contextualized to organizational improvement work in Swedish

healthcare. Thereafter, the concepts and conditions of social capital, work engagement, and

intention to leave, as well as of leadership, are described in relation to healthcare and

organizational improvement work.

2.1. Bio ecological system

Ecological systems theory considers different structures attached to each other. A systems

approach aims to consider different subsystems as interlinked and able to influence one

another. Research with a systems approach puts forward questions as to whether there are

other possible explanations for the phenomena found in subsystems other than where the

outcomes are studied. Also, it is suggested to have a holistic approach, which takes into

account all the different systems and therefore the contextual conditions that may influence

what is studied. Taking such an approach allows for a broader understanding of the

multiple factors involved in employee health and sustainability (Dellve and Eriksson,

2017).

Building on Bronfenbrenner’s bioecological model (Bronfenbrenner, 1999), Bone (2015)

made a conceptual model of workplace health. Dellve and Eriksson (2017) extended the

model to include how well-being could be crafted through managerial work. This model

contains structures such as individual, micro, meso, exo, macro, and chrono systems. A

basic assumption of the model is that an interaction takes place between the different

systems and that they influence each other. For example, individuals’ perceptions of their

health and well-being are influenced by factors in the micro system, that is, relationships

at work. The individual is also influenced by environmental settings such as the society,

culture, community, organization, and workplace (Bone, 2015).

The chrono level is described as trends in society, trends in organizational development,

and managerial systems being implemented in organizations that have importance

regarding occupational health, sustainability of change processes, and workers’ health and

well-being (Dellve and Eriksson, 2017). New public management is one example of a trend

that has influenced Swedish healthcare in the last decades. In Sweden there are policies

and legislation (The Swedish Work Environment Authority’s Statute Book) making

organizations responsible for the health and well-being of their employees and referring to

structures in the exo level (Bone, 2015) or macro level (Dellve and Eriksson, 2017). The

meso-system level can be described as where the organizational structures (work

organization) and culture lie. Organizational preconditions for managerial practice, and

health and safety management systems, are examples of factors that refer to the meso level.

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The micro-system level is directly experienced by the employees, and interaction occurs on

a daily basis and reflects whether the employees perceive the workplace as supportive or

detrimental (Bone, 2015). On the micro-system level the interaction between colleagues

and between manager and subordinates is to be found. Interactions between people in

different roles, as well as how the demands, resources, control, social support, and

engagement are distributed and perceived, further describe the micro-system level (Bone,

2015; Dellve and Eriksson, 2017). Previous research stresses the need to critically examine

the social relations within the work context at the micro-system level (Bone, 2015). The

individual level includes the people handling strategies related to work and the person’s

identity, work engagement, health, and well-being. The individual level further reflects the

person’s knowledge, capability, attitudes, values, lifestyle, and behavior (Dellve and

Eriksson, 2017).

2.2. System approach to organizational improvement work

Applied to the organizational context, a systems approach may be helpful to understand

and reflect upon when performing research within organizations. One example is the

opportunities to analyze whether results in one system have possibly been influenced by

interaction with another system or level. In organizations, work settings can be described

by four key subsystems (1) organizing arrangements, (2) social factors, (3) technology, and

(4) physical settings. Of these four subsystems, social factors contains five specific

elements: culture, management style, interaction processes, informal patterns and

networks, and individual attributes (Porras and Robertson, 1992). These subsystems are

highly interdependent in the sense that a change in one subsystem will affect the others.

For example, a change in management style (element in the social factors category) can

occur as a new reward system (element in the organizing arrangements category)

(Robertson et al., 1993). It is stressed that the five elements in the social factors subsystem

are the most difficult to change and that they are crucial for successful organizational

improvement work when managed right (Porras and Robertson, 1992). Within the

subsystem of social factors, both social capital and engagement are developed regarding

the social interaction between manager and employees, between employees themselves,

and between the individuals and their networks. The systems approach with respect to

organizational improvement work is in this thesis aligned to Dellve and Eriksson’s (2017)

model as well as Porras and Robertson’s (1992) framework of systems within organizations.

The argument for that is that the aims of the thesis concern different levels with respect to

systems theory and the models described. Also, having hospitals with ongoing

organizational improvement work initiated at a strategic level makes the systems approach

useful for understanding possible consequences at different organizational levels. Dellve

and Eriksson’s (2017) model, with an integrated well-being approach as well as

perspectives on practice, is suitable to use with respect to this thesis aims and investigated

15

variables, which also concern well-being (i.e., job satisfaction) and practice (i.e.,

engagement in clinical improvements).

2.2.1. Organizational improvement work in Swedish healthcare

A number of reforms and organizational changes in healthcare organizations have been

carried out during the last decades. In the 1990s, Swedish public hospitals were facing

major challenges, including how to decrease healthcare costs without comprising quality of

care (Magnussen et al., 2009) or employee well-being (Elstad and Vabø, 2008; Jansson

von Vultée et al., 2007). These changes have been influenced by ideals from NPM, focusing

on customer orientation, rationalization, process flow, efficiency, and economics (see, e.g.,

Blomgren, 2003, or Bezes et al., 2012). The implementation of NPM has resulted in a

strengthened administration because of the different techniques implemented, such as new

forms of control, measuring and evaluating performance, and results management to

achieve objectives (Bezes et al., 2012). This development has proceeded since the 1980s

and has inspired many reforms in a number of national public administrations in western

countries (Pollitt and Bouckaert, 2004). Sweden is considered to be one of those countries

that has adopted NPM to a high degree (Hood, 1995). Inspired by NPM, most hospitals in

Sweden are working to develop their care processes using the management concept lean

production (LP) (Weimarsson, 2011), and these processes need healthy and engaged

employees. Previous research has shown that healthcare professionals have criticized the

NPM reforms and have actively resisted them (Bezes et al., 2012). The reforms, influenced

by NPM, in Swedish healthcare during the 1990s were no exception. The criticism raised

by the healthcare professionals concerned, for example, standardization and control by

managers, which were seen as threats to their professional autonomy and judgment on the

job (Bezes et al., 2012; Blomgren, 2003). However, research shows that the reforms have

not changed power structures, and physicians still have great impact within healthcare

organizations (Kuhlmann and Burau, 2008). On the other hand, consequences related to

the reorganizations were a decrease in numbers of employees, especially assistant nurses

and assistant staff, job insecurity, increased job demands, reduced job control, and sickness

absence (Hertting et al., 2005; Kivimäki et al., 2000; Landsbergis et al., 1999; Petterson et

al., 2005; Vahtera et al., 1997). In contrast, there was an increase in numbers of physicians

and of registered nurses (RNs) (Federation of Swedish County Councils, 2002). Many of

the effects of the changes in Swedish healthcare during the 1990s were negatively

associated with staff well-being (Hertting et al., 2004). This could possibly have led to

negative attitudes towards organizational improvement work, and it is likely that these

attitudes are still present in the memories of healthcare staff. Earlier experience from, or

threats of employee redundancies have shown to reflect adverse consequences for health

(Ferrie et al., 1998), and Lindberg and Trägårdh (2000) concluded that a future threat of

savings could increase anxiety among staff. Hence, there could be connections between the

past and the future regarding organizational improvement work.

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2.2.2. Sustainability perspectives on organizational improvement work

Viewing organizational improvement work from a sustainability perspective, the resources

should be developed parallel to the consumption of them. Employees, for example, are a

human resource, and to maintain or increase their engagement and health could be an

example of a parallel process of developing a resource. In this sense, one cannot risk the

employees’ health when developing the healthcare organizations with respect to the ideas

of sustainability. Research shows that engaged employees are a precondition for success in

organizational improvement work (Demerouti et al., 2010). What is the key to promoting

engagement in organizational improvement work in healthcare and to reaching

sustainability? When creating sustainable work systems in healthcare, models of human

factors take into consideration goals of improving both well-being and human performance

(Carayon, 2006; Docherty et al., 2009; Holden, 2011). Sustainability refers to parallel

development of ecological, economic, human, and social resources used in work processes

(Docherty et al., 2009).

Research on employees with high work engagement has shown better individual (job

satisfaction) as well as organizational (efficiency and quality) outcomes compared to

employees with low work engagement. Job satisfaction has shown to be associated to

employee health (Dellve et al., 2007; Grawitch et al., 2007; Shain and Kramer, 2004) and

intention to leave (Ommen et al., 2009) and is therefore connected to sustainable

organizational improvement work. Increased efficiency and quality could also be associated

with sustainable organizational improvement work (Lindskog, 2016). Research shows that

to reach sustainability in organizational improvement work, there is a need to balance job

resources and job demands and to support employees with resources to increase job

satisfaction and engagement (Lindskog, 2016).

2.2.3. Sustainable organizational improvement work in healthcare

Healthcare systems can be viewed as complex work systems with several dimensions of

complexity (Carayon, 2006). A challenge for those involved in organizational improvement

work and design of work systems is to manage increased complexity. To work across

organizational, cultural, and temporal boundaries is a trend that has contributed to

increasing the complexity in the work system (Carayon, 2006). Two of the dimensions of

complexity described in the literature are social system and heterogeneous perspective. The

former refers to many people having to work together as, for example, healthcare providers,

staff, and patients and their families. The latter refers to professionals having different

disciplines, cultures, and backgrounds (Carayon, 2006).

In the healthcare context, the complexity could manifest when different professional

groups from different care providers have to work together. Different views of, for example,

patient pathways may obstruct improvement work. To pass this obstructing condition is

time-consuming but necessary, and even considered as a key factor of successful

17

collaboration because of increased mutual understanding developed between professional

groups (Docherty et al., 2009). The development of sustainable work organizations can be

defined as promoting employees’ resources to perform and develop professional work with

cooperation, good health, and enthusiasm (Kira et al., 2010), and organizational

improvement work in this thesis is related to engagement in improvements of care

processes in hospitals.

2.3. Social capital

Social capital has been studied by researchers within different scientific disciplines (e.g.,

public health, social science, economy) and at different levels: individual, organizational,

and societal levels, and a cause of that is a variety of definitions (Adler and Kwon, 2002). A

common theme of the earlier research on social capital is such key factors as trust,

recognition, and norms of reciprocity (Bourdieu, 1985; Coleman, 1988; Macinko and

Starfield, 2001; Putnam, 2000).

Social capital seems to be an important aspect of relations, systems, and trusting

relationships (Nahapiet and Ghoshal, 1998; Tsai and Ghoshal, 1998) and has been

variously used among researchers (Ahnquist et al., 2010). Within these relationships

respect, friendship and gratitude are cornerstones for obligations (Bourdieu, 1985), and in

the networks of recognition and mutual acquaintance social capital is found embedded

(Nahapiet and Ghoshal, 1998). Social capital is a resource both for individuals (Poortinga,

2006; Portes, 2000) as well as for communities (Kawachi et al., 1997; Putnam et al., 1994).

These two approaches are both acknowledged (Lin, 2001; Rostila, 2011), and adding the

organizational level (Kristensen et al., 2007) of social capital, one can conclude three

approaches. Social capital at work has been viewed as a relational resource, for example,

the occurrence of networks, norms, and trust, promoting coordination and collaboration

for a common good (Olesen et al., 2008). Literature often describes social capital in positive

terms, but there are also critics. The criticism refers to what is called the dark side of social

capital (Gargiulo and Benassi, 1999; Putzel, 1997). An example is that when a group has

built high levels of social capital, that is, high trust for each other in the group, high and

strong norms of social reciprocity and recognition, then social capital can be protective and

resilient. A negative consequence could be that this type of constellation might not

cooperate with others, not engage in changes that could pose a threat to the group, and so

forth (Gargiulo and Benassi, 1999; Putzel, 1997). When managing organizational

improvement work, social capital that is too strong could hinder the necessary influence of

the manager. In this case, strong social capital in a group could obstruct instead of support

organizational improvement work (Gargiulo and Benassi, 1999). This thesis focuses on

social capital as employees’ perceptions of trust in and norms of reciprocity for each other,

trust in managers, and recognition in relation to both co-workers and managers.

18

2.3.1. Social capital in healthcare

Previous research stresses that there is a possibility of building and increasing social capital

in healthcare organizations by forging relations to foster bonding, bridging and linking

social capital within and between healthcare professional groups; to build solidarity and

trust; to foster collective action and cooperation; to strengthen communication and

knowledge exchange; and to create capacity for social cohesion and inclusion (Hofmeyer

and Marck, 2008). However, more empirical studies would increase knowledge of the

potential beneficial qualities of social capital in healthcare. Promotion of social capital is

associated with increased patient safety (Hofmeyer and Marck, 2008) and collaboration

between professional groups for the common good (Waisel, 2005). Both job satisfaction

and intention to leave are mentioned as two important aspects linked to sustainability. In

healthcare, social capital has shown to be important for job satisfaction, especially for

physicians (Ommen et al., 2009). With respect to intention to leave and negative health

consequences among healthcare professionals, both positive social climate and ties

between co-workers have shown to be protective factors (Garrett and McDaniel, 2001;

Mossholder et al., 2005). This reflects the importance of having good relations, and trust,

recognition, and social reciprocity, which constitute social capital in this thesis, and may

facilitate a positive social climate as well as strengthening the ties between co-workers.

2.3.2. Social capital as a resource for organizational improvement work

One potential job resource to consider with respect to organizational improvement is social

capital. Based on trust, recognition, and social reciprocity, it is most likely that social capital

among healthcare professionals can be a resource that promotes employees’ well-being and

engagement in organizational improvement work as well as associated with employees’

intention to leave their jobs.

As social capital is found in both the vertical dimension (linking) as well as in the horizontal

(bonding and bridging), it has the potential to move between employees and between

employees and their manager. This could also manifest at the organizational level, where

social capital can be spread within and between professional groups. Social capital has

shown potential for bridging organizational challenges within healthcare (Gittell, 2009)

and contributing to more sustainable work organizations, including increased well-being

of employees and of employees’ engagement in clinical improvements (Eriksson and

Dellve, 2014). It is also suggested that social capital is an important determinant of health

and well-being (Ahnquist et al., 2012). However, there is a lack of knowledge based on

empirical studies in this subject. Much of the previous research on social capital and health

has focused on risks and negative outcomes such as stress, burnout, and poor self-rated

health (Oksanen et al., 2008), which calls for studies with positive health-related outcomes

(i.e., job satisfaction). Although, social capital has a dark side (Gargiulo and Benassi, 1999;

Putzel, 1997), previous research on social capital suggests considering it as a positive

19

resource (Ahnquist et al., 2012; Garrett and McDaniel, 2001; Gittell, 2009; Hofmeyer and

Marck, 2008; Ommen et al., 2009; Waisel, 2005). In this thesis, social capital is regarded

as a positive resource that may enable engagement of professionals in organizational

improvement work.

There are not only obstacles in healthcare organizations working with development of their

care processes but also possibilities. To gain knowledge of social capital as a resource

regarding improvement work in hospitals would be a contribution to previous research.

This doctoral thesis provides increased understanding of how social capital and

engagement contribute to sustainable organizational improvement work and how social

capital and engagement are created during organizational improvement work.

2.4. Work engagement

In recent years, there has been a growing interest and recognition of work engagement

(Eldor, 2016; Saks, 2006). Maslach et al. (1997) described work engagement as one end of

a continuum between engagement and burnout, consisting of three parallel but opposite

dimensions. Vigor, involvement, and efficacy constitute engagement, and exhaustion,

cynicism, and ineffectiveness, burnout. Based on Maslach, Jackson, and Leiter’s work,

Schaufeli et al. (2002) defined work engagement as a state of mind characterized by vigor,

dedication, and absorption. Vigor involves high levels of energy and mental resilience while

working. Dedication refers to being deeply involved in one’s work and experiencing

inspiration, pride, enthusiasm, and challenge. Lastly, absorption means full concentration

on the work, experiencing that time flies and having difficulties detaching from work

(Schaufeli et al., 2006).

Work engagement is stressed to be associated with positive employee outcomes and

organizational success (Saks, 2006) and several studies in the last decade have stressed the

importance of work engagement. High work engagement has, for example, been associated

with positive organizational outcomes (i.e., organizational commitment, good job

performance, lower levels of staff turnover) and individual outcomes, that is, low levels of

depression (Hakanen and Schaufeli, 2012), physical/psychosomatic health, sleep quality

(Kubota et al., 2010), and proactive behavior (Salanova and Schaufeli, 2008). In a recent

study, Eldor (2016) argues that work engagement can create a competitive advantage for

organizations. Work engagement can help increase energy and may boost initiative to work

towards the goals of the organization (Frese and Fay, 2001; Grant and Ashford, 2008). As

a consequence of being engaged, the staff experience positive emotional responses,

including enthusiasm, joy, and inspiration (Bindl and Parker, 2010). This have shown to be

associated with proactive initiative (Fritz and Sonnentag, 2009) and creative solutions

(Cropanzano and Wright, 2001). Staffs that are engaged are in some way also more involved

in their work, which differs from those less engaged (Demerouti et al., 2010), in how they

pay attention and use their energy to achieve goals. According to the potential of work

20

engagement, there has been an increased focus on identifying work conditions (job

resources and job demands) that influences employees’ engagement in their work (Bakker

and Demerouti, 2008; Demerouti et al., 2001; Eldor, 2016).

Previous research in hospitals have shown that clinicians’ attitudes towards engagement in

organizational improvement work can be an antecedent factor for their general work

engagement (Lindgren et al., 2013). Also, it seems that clinicians’ active engagement in

improving clinical practice is closely associated to their work engagement (Greenfield et al.,

2011). In sum, when studying the concept of work engagement in hospital context, it could

be important to consider clinicians attitudes to engagement (Lindgren et al., 2013), their

general work engagement as a cognitive state (Schaufeli et al., 2006) and their active

engagement in clinical practice (Greenfield et al., 2011).

2.5. Intention to leave

Cost savings and rationalization in Swedish public hospitals have led to work-related illness

(Hasselhorn et al., 2005) caused by increased workload and stress (Westgaard and Winkel,

2011). The negative effects of increased workload and stress are associated with an

imbalance between job resources and job demands (Jourdain and Chenevert, 2010). A

potential risk is the healthcare professionals’ leaving the organization (voluntarily or

through sick leave), which could be detrimental for sustainability of the organizational

improvement work. Because of the risk of staff turnover, a prior state, intention to leave,

would be of interest to study when working with organizational improvements. There are,

however, other reasons for staff turnover and intention to leave that might be considered.

Private issues and personal desires to try a new job or to reduce travel time to work have

shown to be reasons for healthcare professionals’ intention to leave their jobs (Gardulf et

al., 2005). Intention to leave has in previous research been shown to indicate and predict

future staff turnover (Cho et al., 2009). Intention to leave in this thesis refers to the

subjective estimation of the likelihood of leaving the organization in the near future

(Mowday and Porter, 1982). To minimize healthcare professionals’ intention to leave their

jobs, there is a need to gain knowledge of preconditions that may influence intention to

leave. To decrease staff turnover and intention to leave, there has been a focus on increased

engagement and increased job resources (Carter and Tourangeau, 2012; Collini et al.,

2015). Whether social capital is a resource that has potential to reduce healthcare

professionals’ intention to leave their work during organizational improvement work is

limited in research. Studies that could increase knowledge of the associations between

social capital and intention to leave could therefore contribute to filling the gap in research.

2.6. Importance of working conditions for engagement

Specific contextual factors, also known to influence work systems, are seen as a key

principle in human factors models and have been stressed to be important when studying

21

organizational improvement work in healthcare (Holden et al., 2015). A model that

considers contextual factors of job resources as well as demands is the job demands–

resources (JD-R) model (Demerouti et al., 2001). According to the JD-R model, every

organizational context as well as occupation has its specific resources and risks. Job

resources can be related to physical, psychological, social, or organizational sides of the job.

They refer to different aspects of the job required to achieve organizational goals, to reduce

job demands to decrease both psychological as well as physical costs, and to facilitate

personal development and growth (Bakker and Demerouti, 2007). Job resources shown to

be important for engagement during organizational improvement work in healthcare are

leadership, development opportunities, predictability, recognition, and influence of work

(Dellve et al., 2015). The job demands that have shown to be important for engagement

during organizational improvement work are quantitative demands and work pace (Dellve

et al., 2015). The JD-R model also considers how job resources in the work environment

are connected to staff health and engagement in work (Demerouti et al., 2001). Job

resources can be found at different levels in the organization, and according to the model,

the job resources can contribute to decreasing job demands and increasing goal

achievement and personal engagement. The job resources and job demands interplay, and

job resources have been shown to buffer job demands’ negative influence related to staff

work engagement and organizational outcomes. The model takes into consideration

research on both work engagement and specific job characteristics perspectives on stress.

Previous research has shown that job demands are associated with many negative

outcomes, namely, high stress, low job satisfaction, low work engagement, and staff’s

intention to leave their jobs (Demerouti et al., 2001; Hayes et al., 2006). On the other hand,

job resources can balance job demands and by themselves facilitate changing work

engagement as well as health-related outcomes in a positive direction (Bakker, 2011). The

model provides a framework for understanding how job demands and job resources are

associated and gives opportunities to study them. As it has its roots in positive psychology

(Seligman and Csikszentmihalyi, 2014), focus can be maintained on what is creating

positive qualities (i.e., work engagement) as opposed to negative. Research on work

engagement in healthcare organizations has shown to be associated with more patient-

oriented care with high quality (Abdelhadi and Drach‐Zahavy, 2012). However, healthcare

professionals may have certain preconditions for engaging in organizational improvement

work. Further knowledge is needed of what conditions play an important role for healthcare

professionals to engage in improvement work.

2.6.1. Challenges in engaging healthcare professionals

Glouberman and Mintzberg (2001) describe four different logics, cure, care, control, and

community, of how the work in hospitals is performed. These logics have their own

languages, forms of culture, and ways of understanding the work. The logics are connected

to different stakeholders: cure to physicians, care to registered nurses (RNs) and allied

22

healthcare staff, control to management and administration and community to citizens.

When developing healthcare, it is necessary for these different logics to cross and to bridge

with each other so that the institutions can functions more collaboratively and use the

resources more effectively (Glouberman and Mintzberg, 2001). However, earlier research

has identified limited trust in the culture of healthcare organizations as well as limited

collaboration between different groups of professionals and between different

organizational levels (Glouberman and Mintzberg, 2001; Mitchell et al., 2010). Conflicts of

interests with respect to how healthcare should be managed can arise between the logics

(Glouberman and Mintzberg, 2001). These four logics feature a complex organization

where several interests play important roles and can have considerable impact on the

outcomes of organizational improvement work. Previous research indicates that a key

aspect of developing more sustainable healthcare organizations depends on successfully

engaging healthcare professionals in clinical improvements (Eriksson and Dellve, 2014).

When redesigning care processes, the engagement of healthcare professionals is crucial for

sustaining the change (Riches and Robson, 2014). However, there could be difficulties in

engaging healthcare professionals in organizational improvement work to redesign care

processes (Braithwaite et al., 2007; Riley et al., 2010). The use of business logic to justify

changes has been described as increasing healthcare professionals’ frustration and

hesitancy to support the changes (Choi et al., 2011). Physicians in particular have been hard

to engage (Ahgren, 2007; Choi et al., 2011; Eriksson, 2005; McNulty and Ferlie, 2004). As

they have considerable power and influence in the organization, they are important to

engage. This could be an example of where Glouberman and Mintzberg's (2001) logic

“control” (managers and administrators) encounters the logic “cure” (physicians). In the

Swedish context there is also a risk of negative experiences of reorganization (downsizing)

from the mid-1990s creating lots of mistrust for these kinds of changes (Hertting et al.,

2004). To overcome the barriers within the culture of healthcare organizations is a

challenge to consider when expecting engagement in redesign of care processes. The

described theories and empirical experiences assume participation, and that requires

involvement of the staff, which could be manifested in their engagement at the clinical level.

Why healthcare professionals choose to engage in clinical improvements and what

processes promote sustainable organizational improvement work in healthcare needs

further research (Lindgren et al., 2013).

2.7. Leadership

In the literature there is a distinction between management and leadership (Yukl, 2006).

Management is usually described as having focus on control, evaluating plans and goals,

administering formal systems. Leadership, on the other hand, is often described in terms

of handling human relations, culture, and informal systems (Bryman, 2013, Kotter, 2008).

Leadership is founded in a social understanding and acceptance of differences among

23

humans. Most scholars seem to agree on an integration of management and leadership and

acknowledge that leadership is crucial for the success of a manager (Yukl, 2006).

Leadership has many definitions, and when researchers define leadership the definition is

often influenced by the researchers’ own perspectives and by the phenomenon they are

interested in studying (Yukl, 2006). However, many of the definitions have in common the

assumption that it is a process of influence of one person over other people to give structure

and guidance and to facilitate relations and activities (Yukl, 2006). Critics of the many

definitions of leadership raise the question whether it can be used in science (Alvesson and

Sveningsson, 2003); however, both practitioners and scientists stress the importance of

leadership regarding organizational effectiveness (Yukl, 2006). Leadership, viewed as a

resource within the context of an organization, can be defined as “a process whereby an

individual influences a group of individuals to achieve a common goal” (Northouse, 2010).

Northouse’s definition of leadership seems to align with the common assumption of an

influential process. In contrast to the traditional view of leadership (formal managerial role

influencing the employees), there are other, complementary, approaches to leadership.

Concepts of distributed and collective leadership argue that leadership is a function of the

group and an outcome of team effort (Day et al., 2004; Friedrich et al., 2009). According

to these theories, leadership may alternate among the members of the team. However, in

this thesis leadership is viewed in a more traditional perspective, that is, as a leader

influencing employees.

Some of the most studied leadership theories are transactional, transformational, and

authentic leadership (Avolio et al., 1999; Bass and Avolio, 1994; Gardner et al., 2005).

These theories have been described and included in a model called developmental

leadership (Larsson et al., 2003; Larsson and Eid, 2012). Transactional leadership can be

referred to as conventional leadership, including control, demand, and rewards. Typical

leadership behaviors connected to transactional leadership are to seek agreements by

demand and rewards and to measure by control (Larsson and Eid, 2012). In contrast, the

main focuses of transformational leadership are individualized consideration through

caring and confronting, and inspiration and motivation through promoting creativity and

participation. The authentic leadership theory contributes to the developmental leadership

model with focus on the leader as an exemplary role model, acting in line with values,

setting a good example, and taking responsibility (Larsson and Eid, 2012). In the

developmental leadership model, relational focus as well as structure are important

dimensions of necessary leadership behaviors.

According to the JD-R model, leadership may be counted as a job resource (Demerouti et

al., 2001), and leadership is attached to the healthcare logic “control” (Glouberman and

Mintzberg, 2001). Whether and how leadership is associated with social capital is rarely

24

described in previous research. The studies performed indicate that there are associations

between leadership and social capital, and leadership quality and social capital. However,

a common presumption is that leadership is influenced by social capital and social network

(Day, 2001; Day et al., 2004; De Clercq et al., 2014; Li, 2013), which points to a need for

knowledge of whether social capital can be influenced by leadership. Taking into account

the three most-researched leadership theories (transactional, transformational, and

authentic leadership) makes it possible to distinguish between two different approaches to

leadership influence. One approach focuses on relationships between leaders and followers

to reach the common goal. The other approach focuses on the tasks to be accomplished

(Cummings et al., 2010). This is associated with social capital as a relational resource that

promotes coordination and collaboration for a common good (Olesen et al., 2008).

2.7.1. Leadership in healthcare

Leadership has been studied by different academic disciplines, including the military,

management, and psychology fields, and in different organizational settings, including

healthcare. Research findings shows that leadership is of importance for staffs’ health and

well-being and affects factors in the work environment such as job satisfaction and work

engagement (Cummings et al., 2010). Also, how experienced the manager is, has shown to

be of importance for employee engagemen in redesign of care processes (Palm et al., 2015).

With respect to positive effects on staff job satisfaction, engagement, and productivity, both

relation-oriented leadership as well as a combination of relation-oriented and task-

oriented types have proven to be successful (Boumans and Landeweerd, 1993).

In the context of healthcare, previous research investigating different forms of leadership

shows that relational leadership (resonant, supportive, and considerate), was associated

with greater levels of all investigated outcomes, while task-oriented leadership was

negatively associated with investigated outcomes (Cummings et al., 2010). The investigated

outcomes were staff’s work environment factors—job satisfaction, role and pay—and staff’s

relationships with work, health and well-being, productivity, and effectiveness, with

respect to a nursing workforce. Characteristics of relations between employees and their

manager can be revealed by employees’ perceptions of leadership quality (Kristensen et al.,

2007). With respect to social climate as well as to trust at work places, leadership has shown

to play an important role (Alimo-Metcalfe et al., 2008; Gittell et al., 2013; Luria, 2008;

Wheelan, 2005). However, when employees assess leadership qualities of their leaders, the

assessments have shown to be influenced by factors of group dynamics (Larsson and

Hyllengren, 2013). Studies of group development have revealed that when there are

problems of group dynamics the group can project these problems onto their leader

(Wheelan, 2005). Also shown in previous research, is that different leadership behaviors

fit better or worse, according to what the group (Wheelan, 2005) or the individual (Hershey

and Blanchard, 1988) needs.

25

Whether and how social capital can be influenced are still novel areas in research, but as

there are indications that leadership is an important factor to aspects related to social

capital, there lies an interest in further investigations. Such investigations could lead to

increased knowledge and practical use for leaders.

In sum, healthcare organizations have to consider many different logics of management

and at the same time work with organizational improvement work to increase efficiency

and quality. A precondition to success is having engaged staff working to develop the

organization and the care processes. Previous consequences of improvement work in

hospitals bear witness to the opposite, that is, disengagement, exhaustion, stress, and high

workload. Previous research in the literature of organizational improvement work and of

occupational health has provided extensive knowledge of such negative consequences. This

knowledge is important, but knowledge of the important factors and resources that create

the opposite (i.e., job satisfaction, engagement, well-being) of the negative have also to be

considered important. It is most likely that healthcare in the future will still need engaged

employees with good well-being and enthusiasm for their work and in future organizational

improvement work. Less research has been devoted to knowledge of what creates health,

well-being, and engagement in organizational improvement work and how this relates to

sustainability. There is a need of knowledge of the important resources that contribute to

positive outcomes and engagement during organizational improvement work while

maintaining healthcare professionals’ health and well-being. Inspired by the JD-R model

(Demerouti et al., 2001), social capital, along with other job resources and job demands, is

hypothesized to be a resource associated with sustainable organizational improvement

work in healthcare. This is manifested by its association with job satisfaction, general work

engagement, and attitude to engagement, and with healthcare professionals’ intention to

leave their jobs, and their clinical engagement in patient safety and quality of care.

Leadership is suggested as a precondition for social capital.

26

Figure 1. Solid lines shows associations which was hypothesized and investigated in this thesis. Dotted lines indicate

associations found in previous studies. Roman numbers links to each of the studies in the thesis. The model was adapted

and modified from the Job Demands Resources model (Demerouti et al., 2001).

27

3. Aim

The overall aim of this thesis is to understand how social capital and engagement contribute

to organizational improvement work in hospitals and how social capital and engagement

are created during organizational improvement work.

3.1. Specific aims

The specific aims are

to assess dimensions of engagement among healthcare professionals and how these

are related to work conditions during organizational redesign of care processes

(Study I);

to assess the association of working conditions and social capital with the intention

to leave, and to investigate whether social capital moderates the association

between job demands and intention to leave (Study II);

to investigate the importance of social capital for job satisfaction, work engagement,

and engagement in clinical improvements among healthcare professionals (Study

III); and

to explore whether qualities of leadership have impact on social capital among

employees in hospital settings over time, and what those qualities are (Study IV).

28

4. Method

4.1. Research design

In this thesis a quantitative approach has been used to answer the overall and specific aims.

All studies are based on the same hospital cohort and have used the full sample when

appropriate. Prospective analyses of the cohort have been made in three studies, in studies

I and III with data from two years and in Study IV from three years. Study II had a cross-

sectional design and analysis performed with data from baseline. Hypothesis-driven

analysis was used in studies I, II and III, while Study IV had an explorative approach. The

hypothesized parts in studies I, II and III were generated based on previous knowledge and

theories. The explorative parts in Study IV were conducted to elaborate knowledge.

Material from one research program including three research projects has been used to

fulfill the aim of this thesis. One project focused on the implementation of the lean

management model in hospitals and the consequences for work environment, quality of

care, and efficiency. The second project focused on the reorientation of healthcare towards

a health-promoting and -developing work environment by strengthening learning,

enthusiasm, and well-being during organizational improvement work. A third project

focused on how intention to leave and turnover are predicted by and interact with

organizational demands and resources, work engagement, and health.

4.2 Sample

A sample was made of five hospitals with ongoing developments and redesign of processes

of care (Fig. 2). The following criteria were used in the sampling process: similar size, urban

area, implementing a model to develop processes of care, and interested in participating in

a four-year study. Five small (approximately 100-bed) or midsize (approximately 500-bed)

hospitals were selected, with the number of employees varying between 700 and 4200.

Three hospitals had started to implement concepts and methods related to the LP model to

develop their care processes; this initiative was labeled as strategic implementation of lean.

The other two hospitals were not using LP as a model to develop their care processes;

however, LP approaches and tools were to some degree applied at the operative level in all

five hospitals. This knowledge was gained from structured interviews with operative

managers (Dellve et al., 2015) and was labeled as degree of LP at operative unit. Among the

hospitals, different types of units were selected and included. The emergency department

was selected at all hospitals. The other inclusion criteria were one medical and one surgical

ward, and the medical and surgical emergency intake units that shared a patient flow with

the emergency unit, the medical unit and surgical wards. In the small hospitals the

intensive care unit replaced the medical/surgical intake units. The specific units to be

included in the study were identified by the hospital management in consultation with the

29

research group. One of the hospitals did not consent to include a surgical unit due to lack

of time with respect to ongoing participation in other research development projects.

Figure 2. Schematic diagram of the study sites and subjects.

The hospitals were invited to include all their employees working in the selected units and

all physicians at the hospitals (because physicians often work across several units). To be

eligible for the survey, the employees had to have had a minimum of six months’

employment in the actual unit. In total 224 physicians, 381 RNs, 233 assistant nurses, and

16 administrative workers (HCWs) participated in the study at baseline (of 1602 invited to

participate, 865 participated, a 54% response rate). At the one-year follow-up 260

physicians, 355 RNs, 239 assistant nurses, and 14 HCWs participated (of 1548 invited to

follow up, 908 participated, a 59% response rate). At the two-year follow-up only those who

had answered the questionnaire earlier were invited to participate (of 947 invited to follow

up, 632 participated, a 67% response rate). The average number of employees at the units

was 45 (range 23–87). The response rate at the units varied from 37% to 96%. In Study I

30

the group of HCWs was not included in the analyses because they are not as a profession

involved in the care processes. In Study III the group of HCWs was included in the overall

analysis to investigate social capital but not as a single group, due to the few respondents.

Most participants were women, and nearly 50% at baseline and 40% at one-year follow-up

had worked for more than 14 years in their profession. Each participant was given a unique

code to enable the research team to follow the same respondents over time and perform

longitudinal analyses.

4.3. Data collection

Data were collected through questionnaires at baseline, and at one- and two-year follow-

up. The questionnaires were distributed by e-mail, or, if the participants preferred, a sealed

envelope (with a stamped reply envelope) was sent to them. Non-responding participants

received two reminders, which were sent in paper form. Data collection at baseline

occurred during April to May 2012 (for two of the hospitals) and October to November 2012

(for three of the hospitals), during October to November 2013 for all five hospitals, and

during October to November 2014 for all five hospitals. Five validated tools were used to

collect data. The Copenhagen Psychosocial Questionnaire (COPSOQ II) is an instrument of

psychosocial work environment factors, for example, quality of leadership and dimensions

of social capital. The indices in COPSOQ II could be used as both independent and

dependent variables (Pejtersen et al., 2010). The Swedish Scale for Work Engagement and

Burnout (SWEBO) was used to assess data on work engagement (Hultell and Gustavsson,

2010a), and the Modern Work-life Questionnaire (MWQ) was used to assess one of the

dimensions of social capital (Oxenstierna et al., 2008). The instrument Attitudes to

engagement was used to assess data on positive and negative attitudes to engaging in

organizational improvement work (Dellve et al., 2012). The instrument Clinical

engagement in patient safety and quality of care was used to assess healthcare

professional’s engagement in clinical improvements of patient safety and quality of care

(Strömgren et al., 2016).

4.4. Measures

4.4.1. Attitudes to engaging in organizational improvement work (I)

The instrument used to measure attitudes to engaging in organizational improvement work

was developed from a qualitative study (Lindgren et al., 2013). With respect to attitudes,

beliefs, and motivation, substantive codes and central statements were formulated into

items with a 4-point Likert scale (1, do not agree at all; 4, fully agree). Both items and scale

were tested for construct validity as well as for clarity and the test was performed with

healthcare professionals (Dellve et al., 2012).

In total, 11 statements symbolizing attitudes to participating in organizational

improvement work were grouped into indices, and all showed satisfactory internal

31

consistency. The attitudes to engaging in organizational improvement work were further

formed into two indices, positive attitude (six items, Cronbach’s alpha 0.83) and negative

attitude (five items, Cronbach’s alpha 0.71). Positive attitudes to engaging in organizational

improvement work consisted of the indices Participating in a continuous process for

improvements (three items, Cronbach’s alpha 0.70) and Learning about and improving

healthcare (two items, Cronbach’s alpha 0.73), and the single item Performing according

to one’s assignment. Negative attitudes to engaging in organizational improvement work

consisted of the indices Risking time conflicts (three items, Cronbach’s alpha 0.74) and

Being part of a meaningless process (two items, Cronbach’s alpha 0.74).

4.4.2. Work engagement (I, II)

Work engagement was measured with SWEBO (Hultell and Gustavsson, 2010b). The

instrument has its origin in the theoretical frameworks of work engagement (Schaufeli and

Bakker, 2004; Watson and Clark, 1984) and burnout (Demerouti et al., 2001; Maslach et

al., 1986; Shirom, 1989; Watson and Clark, 1984). The scale consists of two separate

dimensions, one of which captures the state mood of work engagement, and the other which

captures burnout through work-related items based on adjectives describing a perceived

state during the last two weeks. The aim of the thesis was to focus on the positive

engagement and therefore the dimension of burnout was left out. The work engagement

instrument consists of three dimensions: vigor (three items, Cronbach’s alpha 0.83),

dedication (three items, Cronbach’s alpha 0.84), and attentiveness (four items, Cronbach’s

alpha 0.85). As suggested by Hultell and Gustavsson (2010b), the original dimension

absorption was replaced by attentiveness, as it better reflects a cognitive state. Answers

were given on a five-point Likert scale (1, not at all; 5, all of the time).

4.4.3. Engagement in clinical improvements (I, III)

Two indices were developed to assess engagement in clinical improvements, patient safety,

and quality of care, and the indices were tested for internal consistency. The test was

conducted through individual interviews with physicians, RNs and assistant nurses (n =

11). Both the understanding of the questions and the understanding of the response scale

was tested. Participants were asked to answer the questions, and then they were asked to

describe how they had interpreted the questions and why they had answered as they did,

and also to describe how they would interpret another person’s answer to the same

question. All items were assessed on a five-point Likert scale (1, disagree; 5, agree

completely). The results of the pilot testing showed reasonably good face validity of both

the questions and response scale. Engagement in clinical improvements of patient safety

consisted of four items, with an introductory statement: “At our clinic, we (a) work actively

to improve patient safety; (b) discuss how to avoid errors; (c) work actively to improve

reporting of errors; and (d) report directly and without hesitation when we see something

that can harm patients’ safety” (Cronbach’s alpha 0.80). Engagement in clinical

32

improvements of quality of care consisted of three items, namely: “At our clinic (a) we have

an active dialogue about how to improve good care for the patients; (b) we have the

possibility to meet patients’ needs; and (c) the values of providing good care are my own

values (Cronbach’s alpha 0.72).

4.4.4. Working conditions (I, II)

All variables of working conditions (job resources and job demands) were selected from

COPSOQ II (Kristensen et al., 2005). Each item was assessed on a five-point Likert scale

(1, to a very small extent; 5, to a very large extent). Regarding job resources, the following

validated indices were used: predictability (two items, Cronbach’s alpha 0.61), role clarity

(three items, Cronbach’s alpha 0.78), recognition (three items, Cronbach’s alpha 0.85),

influence (four items, Cronbach’s alpha 0.70), possibilities for development (four items,

Cronbach’s alpha 0.69), and quality of leadership (eight items, Cronbach’s alpha 0.93). For

job demands, the following validated indices were used: quantitative demands (four items,

Cronbach’s alpha 0.83) and work pace (three items, Cronbach’s alpha 0.83). The

investigated job resources and job demands were assessed in two overall indices.

4.4.5. Top-down initiative to implement LP (I)

Hospitals starting to implement concepts and methods related to the LP model were

considered as hospitals with top-down implementation of LP. Information about this was

obtained from hospital top management.

4.4.6. Organizational improvements at units (I)

The degree of organizational improvement at the clinical unit was measured through

structured interviews with all ward managers of the investigated units, using the LP Index

Questionnaire (Ståhl et al., 2015). The 11 items assessed to what degree the work at the unit

could be characterized by improvement work in terms of continuous improvements,

standardized work practice, patient orientation, working with values, teamwork, cost

reductions, value-stream mapping, visual management of processes, results, and

improvements. All items were assessed on a five-point Likert scale (1, not at all; 5, to a very

high degree). All items were summed into a mean score referred to as degree of

organizational improvement at the unit.

4.4.7. Quality of leadership (I, IV)

Quality of leadership was measured by using an index from COPSOQ II consisting of eight

items (Cronbach’s alpha 0.94): “To what extent would you say that your immediate

superior (a) appreciates the staff and shows consideration for the individual? (b) makes

sure that the individual member of staff has good development opportunities? (c) gives high

priority to further training and personnel planning? (d) gives high priority to job

33

satisfaction? (e) is good at work planning? (f) is good at allocating the work? (g) is good at

solving conflicts? (h) is good at communicating with the staff?” The items were assessed on

a five-point Likert scale (1, to a very small extent; 5, to a very large extent).

4.4.8. Social capital (II, III, IV)

Social capital was measured by the sum of four indices: reciprocity, trust regarding

management, mutual trust between employees, and recognition (Cronbach’s alpha 0.73).

Reciprocity was measured using an index from the MWQ (Oxenstierna et al., 2008). The

indices trust regarding management, mutual trust between employees, and recognition

were from COPSOQ II. All items were rated on a five-point Likert scale (1, to a very small

extent; 5, to a very large extent).

Reciprocity was assessed with a three-item scale from the MWQ (Oxenstierna et al., 2008),

(Cronbach’s alpha 0.89): (1) At my workplace we care for each other, (2) At my workplace

we treat each other with respect, and (3) At my workplace I feel safe and accepted. All items

were rated on a five-point Likert scale (1, to a very small extent; 5, to a very large extent).

Trust regarding management was assessed with two items: (1) Can you trust the

information that comes from the management? and (2) Does the management withhold

important information from the employees? (reversed score). Mutual trust between

employees consisted of two items: (1) Do the employees withhold information from the

management? (reversed score) and (2) Do the employees in general trust each other? The

items of trust were rated on a five-point Likert scale (1, to a very small extent; 5, to a very

large extent).

Recognition was measured using a three-item scale as an index consisting of three items

(Cronbach’s alpha 0.82): (1) Is your work recognized and appreciated by the management?

(2) Does the management at your workplace respect you? (3) Are you treated fairly at your

workplace? All items used a five-point Likert scale (1, to a very small extent; 5, to a very

large extent).

4.4.9. Job satisfaction (III)

Outcome of job satisfaction was measured by an index consisting of six items from the

COPSOQ II (Cronbach’s alpha 0.82): Regarding your work in general. How pleased are you

with: (1) your work prospects? (2) the physical working conditions? (3) the way your

department/clinic is run? (4) the way your abilities are used? (5) the interest and skills

involved in your job? (6) your job as a whole, everything taken into consideration? All items

were rated on a four-point Likert scale (1, Very unsatisfied; 4, Very satisfied).

34

4.4.10. Intention to leave (II)

Outcome of staffs’ intention to leave was assessed by a single item: How often have you

thought about applying for another job? The response scale had five grades (1,

Never/Almost never; 5, Always).

4.4.11. Control variables

In some analyses, when appropriate, we controlled for contextual conditions such as top-

down initiative to develop care processes, managerial conditions such as managerial

experience, and group conditions such as problems of group dynamics. Analyses were also

controlled for such variables as gender and years in the profession. Analyses performed

stratified to occupational groups can be regarded as controlled for different professions

(assistant nurses, RNs, and physicians).

4.5. Analyses

In the studies (I, II, III, and IV), the data were approximately normally distributed. In the

analyses, statistical significance was considered when p < 0.05. The correlation was

considered to be very strong at r = 0.81–1.00, strong at r = 0.61–0.80, moderate at r =

0.41–0.60, fair at r = 0.21–0.40, and weak at r ≤0.20 (Altman, 1990). All statistical

calculations were performed using JMP version 10.0.2 (SAS Institute, Cary, NC, USA).

4.5.1. Study I

Study I was based on data from an employee questionnaire performed at two occasions,

baseline and one-year follow-up. Descriptive statistics, stratified to occupational groups,

were conducted to assess knowledge of why healthcare professionals engage in

organizational improvement work. To investigate differences between occupational

groups, Student’s t-test was performed. Bivariate Pearson’s correlation between variables

of kinds of engagement was computed. Work conditions was stratified to occupational

groups and was then compared using Student’s t-test. Kinds of engagement, work

resources, and work demands were stratified to occupational groups, and associations

between them were analyzed using Pearson’s correlation. To investigate the contribution

of work-related resources and work-related demands, resources for kinds of engagement,

and top-down initiation of LP, a linear regression model was used. The variables were

stratified to occupational groups.

4.5.2. Study II

Study II was based on data from an employee questionnaire performed at a single occasion.

Descriptive statistics of job demands, social capital, other job resources, and intention to

leave, stratified into occupational groups, were conducted. Student’s t-test was used to

investigate differences between occupational groups. Pearson’s correlation was performed

35

for bivariate associations between investigated variables. Student’s t-test was used to

compare whether levels of social capital in relation to levels of intention to leave differed.

To test the hypothesized moderating effect of social capital in the relationships between job

demands and intention to leave, linear regression models were used. This was performed

stepwise. For example, to examine hypothesis 2, the simple effect of job demands was

added in the first step, and social capital was added in the second step. Finally, the product

of job demands and social capital was added in a third step. The predictors (job demands

and social capital) were centered by subtracting each value from its respective mean before

the creation of the interaction term. This was performed to achieve a better estimate of the

interaction term (Aiken et al., 1991). To investigate the contribution of social capital, job

demands, and other job resources for intention to leave, linear regression models were

performed, first, with the whole sample, and second, stratified into occupational groups. It

has been suggested that there might be a difference between older staff compared to

younger (Flinkman and Salanterä, 2015). Information on age was not present, but

information about how long the respondents had worked in the present occupation was

available. The variable was dichotomized into two approximately similar-sized groups (0 =

up to 14 years, and 1 = more than 14 years).

4.5.3. Study III

Study III was based on data from an employee questionnaire performed at two occasions,

baseline and one-year follow up. First, descriptive statistics of individuals, stratified to

occupational groups and units, were conducted. To investigate differences between

occupational groups, the Student’s t-test was performed. Second, bivariate Pearson’s

correlation between social capital and job satisfaction, work engagement, clinical

engagement in patient safety, and clinical engagement in quality of care was performed.

The third step was to investigate explanatory variance between social capital and the

outcome measurements, and analyses were performed using multivariate linear regression.

Lastly, a prospective analysis was performed, using logistic regression models, to assess

whether increased social capital predicts increased job satisfaction, work engagement,

clinical engagement in patient safety, and clinical engagement in quality of care. The

variables were dichotomized into categorical variables where increased magnitude from

baseline to one-year follow-up was labeled 1 and where there was no increase in magnitude

the variable was labeled 0. Tests and confidence intervals on odds ratios were likelihood

ratio based. Analyses were controlled for sex, occupation, and years in occupation. To

investigate whether the cohort (those participants who had responded at both baseline and

one-year follow-up) could be assumed to be a representative sample according to the

baseline sample, t-test was performed.

36

4.5.4. Study IV

The data in Study IV were based on employee questionnaires performed at three occasions:

baseline, one-year follow-up, and two-year follow-up. Descriptive statistics of quality of

leadership and social capital were conducted. Test of correlation between social capital and

quality of leadership was tested using Pearson’s correlation test. To further explore whether

different levels of leadership quality correlated with different levels of social capital,

leadership quality was divided into three groups: high, medium, and low levels of

leadership quality. The division was performed according to quantiles, and mixed-models

repeated measurements were performed. Mixed-models repeated measurements were

used to investigate within and between variance of both the independent variable

(leadership quality) and the dependent variable (social capital). The explanatory variable

for the different models was levels of leadership quality and time (baseline, one-year follow-

up, and two-year follow-up). Social capital was the outcome variable within groups as well

as between groups over time. Missing values were imputed as the average score of the other

items in the indices. To investigate different types of leadership quality, the indices were

divided into three categories (relation oriented, development oriented, and task oriented).

This was based on previous research (Avolio et al., 1999; Jacobs and Washington, 2003;

Judge et al., 2004). Because of multicollinearity between the different leadership

orientations, it was only possible to test each one of them separately with respect to social

capital. Finally, to explore the explanatory variance of relation-, development- and task-

oriented types of leadership quality for increased social capital, linear regression was used.

Because of possible influencing factors (contextual, managerial, and group factors) the

analyses were controlled for organization working with redesign of care processes

(contextual), degree of experience of the managers (managerial), and problems of group

dynamics (group).

4.6. Ethics

Ethical principles for research have been considered. All respondents were informed that

participation was voluntary and that they could choose not to participate at any time.

Information given on the first page of the questionnaire stated that by answering the

questionnaire the respondent agreed to participate in the study. Information was also given

on how the results would be used, on the funders of the study, and on how to contact the

persons responsible for the study. By this procedure, informed consent was fulfilled. The

study was approved by the Central Ethical Review Board at Karolinska Institutet,

Stockholm, Sweden (2012/ 94-31/5). The questionnaire responses in all studies as well as

the coded list for identification were handled confidentially. Between the occasions of data

collection, results were reported back to the participating wards. This was done at the ward

level to ensure that no participants could be identified.

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5. Results

5.1. Study I

The positive attitudes to engaging in organizational improvement work differed among the

professional groups. The positive attitudes were higher among RNs and assistant nurses,

while the summed negative attitudes were higher among physicians. Among all

occupational groups, the most common perceptions were increased learning and

understanding for the contribution to the development of a better healthcare service (see

Table 2 in Study I). The possibility of time conflicts was the most perceived risk among

physicians when engaging in organizational improvement work. Physicians also believed

to a higher degree that their engagement in developments would not lead to meaningful

results.

The summed work engagement was higher among assistant nurses (see Table 2 in Study I).

No significant differences could be found in levels of dedication between the groups of

professionals. The dimensions attentiveness and vigor were higher among RNs and

assistant nurses compared to physicians.

The association between positive or negative attitudes to improvements of processes of care

and work engagement showed fair positive and negative associations. Clinical engagement

to improve patient safety and quality of care rated highest among assistant nurses, while

this was rated equally high among RNs and physicians (see Table 2 in Study I). An

association was found between positive attitudes to organizational improvement work and

stronger clinical engagement in developing quality of care and patient safety. Negative

attitudes were associated with decreased clinical engagement. This occurred among all

professional groups. The impact of negative attitudes was, however, stronger among RNs

and physicians. Specifically, physicians’ negative attitude to organizational improvement

work was associated with their clinical engagement in development of quality of care.

The impact of improved work and organizational conditions on increased engagement

showed that all increased work resources were associated with all assessed kinds of

increased engagement (Table 3 in Study I). Decreased demands were not associated with

increased engagement in clinical improvement of patient safety and were weakly associated

with changed attitudes to organizational improvement work and engagement in clinical

improvements of quality of care. The same analyses were performed by occupational group.

The same patterns were shown, except for increased work demands, which was associated

with increased clinical engagement in patient safety matters among physicians and

increased clinical engagement in quality of care among RNs.

38

The importance of work conditions, attitudes to organizational improvement work, work

engagement, and degree of LP at operative levels for healthcare professionals’ clinical

engagement in patient safety and quality of care was analyzed (see Table 5 in Study I).

Among RNs, the models explained 32% of the variation in clinical engagement in quality of

care and patient safety. Among physicians, the model explained 34% of their clinical

engagement in patient safety but only 3% of their clinical engagement in quality of care.

Among assistant nurses, the model explained 17% of the variance of their clinical

engagement in patient safety but only 6% of their engagement in quality of care.

5.2. Study II

Intention to leave was associated with job demands, social capital, and other job resources.

Social capital and other job resources were about equal negatively associated with intention

to leave, while job demands was positively associated. Hypothesis 1, social capital is

negatively associated to intention to leave, was confirmed.

Among the occupational groups, physicians showed the highest ratings of job demands and

social capital compared to RNs and assistant nurses. The lowest perceived job demands

were found among the assistant nurses. Regarding intention to leave, there was no

significant difference between RNs and assistant nurses, while physicians reported the

lowest levels of intention to leave. Levels of other job resources were approximately equal

among the occupational groups.

The analyses of the moderating effect of social capital showed no interaction effect with job

demands with respect to intention to leave (see Table 2 in Study II). Social capital regarded

as a resource had no buffering effect on the job demands, and therefore, the second

hypothesis, social capital moderates the relationship between job demands and intention

to leave, was not confirmed.

The third hypothesis, levels of social capital are associated with levels of intention to leave

such that high levels of social capital are associated with low levels of intention to leave and

low levels of social capital are associated with high levels of intention to leave, was

confirmed. Analyses of both the whole sample and the sample stratified to occupational

groups supported the hypothesis. The results revealed that those with high levels of social

capital showed a lower level of intention to leave compared to those with low levels of social

capital, where the degree of intention to leave was higher.

Analyses made of the whole sample of the importance of job demands, social capital, and

other job resources revealed that all predictors had importance for intention to leave. When

stratified to occupational groups, the result showed that social capital had different

importance with respect to intention to leave. Among physicians, the explained variation

of intention to leave was highest, while it was lowest for RNs (see Table 3 in Study II). The

39

results also showed that the explained variation was higher for professionals who have

worked fewer years in their current profession.

5.3. Study III

The dimension of social capital that showed the highest level was reciprocity, and this

occurred among all groups of healthcare professionals (see Table 2 in Study III). The

dimension trust regarding management scored the lowest, especially among assistant

nurses and RNs, while approximately half of the physicians rated trust in management as

high. Among all health professionals, physicians reported the highest level of social capital.

Most of the healthcare professionals had high job satisfaction (see Table 2 in Study III).

With respect to work engagement, about half of all professional groups rated work

engagement as high. All aspects of social capital showed positive associations with job

satisfaction. Recognition was the strongest dimension of social capital associated with job

satisfaction, followed by reciprocity and trust regarding management.

Most healthcare professionals (approximately 60%) were engaged in clinical

improvements regarding patient safety. With regard to engagement in clinical

improvements of quality of care, half of the healthcare professionals were engaged. The

strongest association was found between engagement in clinical improvements of patient

safety and the dimension trust regarding management, followed by the dimension

recognition. Regarding engagement in clinical improvements of quality of care, the

dimension reciprocity had the strongest association as it did as well for work engagement.

Analyses on baseline data to assess the importance of social capital for the investigated

outcomes revealed that social capital explained 36% of the variation in job satisfaction and

12% of the variance in work engagement. Social capital explained 18% of the variance in

engagement in clinical improvements of patient safety work and 19% of engagement in

clinical improvements of quality of care (see Table 3 in Study III).

The importance of increased social capital for increased job satisfaction, work engagement,

and engagement in clinical improvements was analyzed. The results showed that increased

social capital predicted job satisfaction, work engagement, and engagement in clinical

improvements of patient safety. It also indicated to predict engagement in clinical

improvements of quality of care, but not at the level of significance (p < 0.05.).

5.4. Study IV

There was close to high correlation (see Table 3 in Study IV) between employees’ perceived

quality of leadership and employees’ perceived social capital. The strongest associations

40

with social capital regarding the single items in the index of quality of leadership were

appreciates the staff and shows consideration for the individual.

Differences in levels of social capital between the groups of low, medium, and high levels

in quality of leadership were found. These differences between the groups were maintained

over time (see Fig. 2 and Table 4 in Study IV). Differences within the groups over time only

revealed a change in the group categorized as high social capital, which increased from

baseline to the second follow-up.

All types of leadership qualities were associated with social capital (see Table 5 in Study

IV). The strongest association was found between the relation-oriented type and social

capital, while development- and task-oriented types were moderately associated with social

capital.

Leadership quality was shown to be an important resource for increased social capital, and

different types of leadership orientations had different importance with respect to

contextual, group dynamic, and managerial conditions. The importance of the relation-

oriented type of leadership quality for increased social capital decreased under the

contextual condition of redesigning care processes (see Table 6 in Study IV). In contrast,

the importance of task-oriented and developmental leadership quality for social capital

decreased with top-down-driven redesign of care processes. The results further reveal that

the importance of development-oriented leadership quality for social capital increased

where there was a low degree of problems with group dynamics. For all three types of

leadership quality the importance for social capital decreased when there were group

dynamics problems. Finally, the results showed that the importance of task-oriented

leadership quality for social capital increased when managers were inexperienced in their

roles as managers (see Table 6 in Study IV).

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6. Discussion

In this thesis, the overall objective was to understand how social capital and engagement

contribute to organizational improvement work in hospitals and how social capital and

engagement are created during organizational improvement work. The results showed that

working conditions (job demands and job resources) were important for healthcare

professionals’ work engagement and clinical engagement. Social capital, as a resource,

seemed to be crucial for employee work engagement and for employees’ job satisfaction

and clinical engagement in patient safety and quality of care. Quality of leadership was

shown to be an important factor for social capital and could partly explain how to influence

social capital positively. With respect to sustainability, the result showed that social capital

was associated with and influenced employee engagement and job satisfaction. Further,

social capital was also associated with employees’ intention to leave their jobs, such that

high levels of social capital were associated with low levels of intention to leave and vice

versa.

6.1. Employee engagement in organizational improvement work

Employee engagement has been described in previous studies as crucial to reaching success

in organizational improvement work in healthcare that is, developing care processes

(Riches and Robson, 2014). In Study I, engagement among the healthcare professionals

was explained differently according to working conditions. The possible explanations of

employee engagement could be decreased job demands and increased job resources as well

as individuals’ attitudes to organizational improvement work. In Study I, increased job

resources (leadership, recognition, role clarity, and predictability) and decreased job

demands (work pace and quantitative demands) were important for work engagement

during organizational improvement work. This is in line with previous research using the

JD-R model (Bakker and Demerouti, 2007). Previous research has shown that there are

difficulties in engaging healthcare professionals in organizational improvement of care

processes (Braithwaite et al., 2007; Hertting et al., 2004; Lindgren et al., 2013; Riley et al.,

2010). In Study I, the results revealed that physicians scored the lowest levels of

engagement among the occupational groups. A possible explanation could be that

physicians also scored the highest levels of negative attitudes to organizational

improvement work. Though earlier studies have stressed that physicians have considerable

impact on developments in healthcare, they are often hard to engage (Ahgren, 2007; Choi

et al., 2011; Eriksson, 2005; McNulty and Ferlie, 2004). In Study I, the physicians perceived

the risk of time conflicts as the greatest risk when engaging in organizational improvement

work, which is in line with previous research and could be a possible explanation of their

negative attitude to engaging in organizational improvement work. In contrast to

physicians, RNs and assistant nurses to a higher extent showed positive attitudes, which

could be beneficial for their clinical engagement in patient safety and quality of care. In

42

study I, associations between positive attitudes and stronger clinical engagement were

found, and also that negative attitudes were associated with decreased clinical engagement.

Previous studies of how to manage healthcare bring forward a picture of the healthcare

organization as a complex organization consisting of different logics (Glouberman and

Mintzberg, 2001). Healthcare professionals’ attitudes towards organizational improvement

work can possibly be explained according to these logics. If the logics of care (nurses), cure

(physicians), and control (management) can cross and bridge with each other, they will be

function well. However, this requires trust, and previous research has shown that trust is

limited in healthcare organizations (Glouberman and Mintzberg, 2001; Mitchell et al.,

2010). With respect to employees’ clinical engagement in patient safety and quality of care,

Study I showed that increased job resources had great impact for all occupational groups.

According to the JD-R model, both increased job resources and decreased demands can

have impact on increased work engagement (Bakker and Demerouti, 2007; Demerouti et

al., 2001). The results in Study I are in line with previous research and in contrast to the

idea of increasing engagement by decreasing demands: on one hand, in line because of the

positive influence of increased job resources on work engagement, and on the other hand,

in contrast because of the non-existent association between decreased job demands and

work engagement. Instead, results revealed an increase in clinical engagement in patient

safety among physicians where there was an increase in the job demands, and the same for

the nurses with respect to engagement in quality of care. A possible explanation could be

that it reflects the professional ethics related to the patients’ safety (Arries, 2014; Greenfield

et al., 2011). But to recommend an increase in job demands to increase engagement in

patients’ safety and quality of care would probably be wrong and lead to higher workload

and stress in a longer perspective (Demerouti et al., 2001). Both general work engagement

and engagement in clinical improvements of patient safety and quality of care were in Study

III shown to be associated with and influenced by social capital.

6.2. Social capital as a resource for employee engagement

According to the results in Study III, social capital was shown to influence employee work

engagement and clinical engagement in patient safety. Social capital has in previous

research rarely been described as a resource shown to be an important factor for work

engagement. However, one study of German physicians suggested that social capital could

play an important role for their work engagement (Susanne et al., 2013). In studies II, III,

and IV, social capital was operationalized as horizontal and vertical trust, recognition, and

social reciprocity, and is likely to indicate associations with understanding and

collaboration between different professional groups and between the different logics in the

organization (Glouberman and Mintzberg, 2001). As a resource, embedded in the relations

between individuals, between managers and employees, and between different groups in

the organization as well as between professional groups, social capital could possibly

facilitate the relational coordination and be beneficial for enhanced communication,

43

teamwork, and patient outcomes (Gittell, 2006). One previous study showed improved

trust, communication, and cooperation between professional groups as well as

improvements in work environment in surgical rooms generated from social capital

(Hofmeyer and Marck, 2008). In this thesis communication and teamwork were not

measured; however, as the mechanisms influencing enhanced communication and

teamwork lie in the dimensions of social capital, one can possibly conclude such an

association (Day et al., 2004).

The results in Study III revealed that most (60%) of the healthcare professionals were

engaged in clinical improvements of patient safety. The dimension of social capital that was

most important for engagement in clinical improvements of patient safety was trust

regarding management. Regarding employee engagement in clinical improvements of

patient safety, it seems that a focus on increasing trust in management would be a

promising strategy. In Study III, the results showed that half of the employees had high

work engagement, which indicates a potential to increase work engagement. This potential

also concerns engagement in clinical improvements. As the results of the logistic regression

of the cohort in Study III revealed, increased social capital is implied to predict increased

work engagement and engagements in clinical improvements of patient safety.

In Study II, the results revealed that social capital, job demands, and other job resources

had importance with respect to staffs’ intention to leave their jobs. According to research

on sustainable organizational improvement work, the resources should be generating new

resources in parallel, while using them in the development processes (Docherty et al.,

2009). This also includes having the employees enthusiastic and in good health (Kira et al.,

2010). Staff turnover and the prior state intention to leave could be outcomes of a

misconducted organizational improvement process, with consequences leading to non-

sustainable organizational improvement work. Results in Study II did not confirm the

hypothesized moderating effect of social capital between job demands and intention to

leave. As stressed in the framework of the JD-R model (Bakker and Demerouti, 2007), a

specific resource can buffer a negative influence of the effect a specific job demand, and the

interpretation of this is that social capital (as a specific job resource) does not interact with

quantitative demands or work pace (as specific job demands).

Results in Study II showed that the physicians reported the lowest levels of intention to

leave compared to other groups of healthcare professionals. Levels of job resources among

the healthcare professionals were approximately equal (Study II); however, levels of social

capital (studies II and III) differed among the professional groups, where physicians

perceived the highest level. Social capital could be a possible explanation of the lower

degree of intention to leave among physicians, but other possible factors not investigated

in this thesis could also account for this finding. Another possible explanation with respect

44

to results in Study I is that increased resources were shown to be especially important for

high engagement during organizational improvement work, which could be interpreted as

having a buffering effect on physicians’ intention to leave. The possible buffering effect of

job resources for the impact of job demands on, for example, work engagement would be

in line with previous research (Demerouti et al., 2001; Schaufeli and Bakker, 2004).

Job satisfaction and intention to leave have shown to be associated (Ommen et al., 2009).

The result in Study III revealed that social capital had a predictive influence on employees’

job satisfaction. This implies that social capital has not only a direct impact on intention to

leave but an indirect impact on intention to leave as well. Affecting job satisfaction is also

believed to have an effect on employees’ health and well-being (Grawitch et al., 2007; Piko,

2006; Shain and Kramer, 2004). That connects well to the thoughts on promoting

sustainability by contributing to more resources (i.e., health), while using them in

development processes (Docherty et al., 2009; Kira et al., 2010).

6.3. Leadership, a factor important for social capital

In this thesis, social capital was investigated, and results revealed its importance for

healthcare professionals’ intention to leave (Study II) and job satisfaction (Study III) (and

therefore also its importance for sustainability) as well as for work engagement and clinical

engagement (Study III). Because of its beneficial qualities, the question whether social

capital can be influenced is adequate. Based on the operationalization of social capital in

this thesis (mutual trust between employees, trust regarding management, recognition and

reciprocity), there is reason to believe that social capital can be influenced by leadership.

Previous research has shown that leadership is important to the social climate at

workplaces (Alimo-Metcalfe et al., 2008; Gittell et al., 2013; Luria, 2008; Wheelan, 2005),

and with respect to social capital, leadership and quality of leadership are indicated as

important (De Clercq et al., 2014; King, 2004; Kristensen, 2010; Oh et al., 2006). However,

previous studies showed deficiency in longitudinal designs and prospective analyses.

Previous research on leadership and social capital has examined how social capital

influences leadership, but few earlier studies have investigated how leadership influences

social capital. Leadership quality has in Study I shown to be important for engagement as

well as for social capital (in Study IV). Leadership seems to influence engagement both

directly and indirectly by its importance for social capital, which in turn has impact on

engagement. The results in Study IV showed that leadership quality is associated with levels

of social capital and lasts over time. High levels of leadership quality is associated with high

levels of social capital, and low levels of leadership quality to low levels of social capital.

This implies that leaders who function well in their leadership roles will probably have

higher social capital among employees.

45

According to the results in Study IV, different leadership orientations were shown to have

different impact on social capital. For instance, relation-oriented leadership had the

strongest association with social capital. A possible explanation could be that the

dimensions of social capital are related to their character. Previous research has stressed

that relation-oriented leadership is superior to task-oriented leadership with respect to

employee health and organizational outcomes such as productivity and effectiveness

(Cummings et al., 2010). With respect to the previously mentioned direct association with

employee engagement, previous research has shown that relation-oriented leadership

motivates the employees beyond their intention (Bass and Avolio, 1994). However, both

development- and task-oriented leadership were important to social capital, which is in line

with previous research on leadership. Task orientation has shown to be important for

relational-focused leaders to provide structure during conditions of pressure (Skakon et al.,

2010), and developmental orientation have been shown to be of importance to engage

employees in development programs (Judge et al., 2004). This also implies that different

leadership orientations are more or less suitable, depending on different conditions or

situations. In line with that, the results in Study I showed that increased leadership quality

was important for employee engagement during top-down initiation of organizational

improvement work in care processes. Also, the results in Study IV give support for

differential importance of leadership with respect to different conditions. For example, the

result indicates that task-oriented leadership was important for social capital when the

manager was inexperienced and that relation-oriented leadership had importance for

social capital when organizational improvement work was not initiated from the top down.

With respect to development-oriented leadership, it was shown to be less important for

social capital if there were problems of group dynamics. In research on, for example, group

development (Sloan et al., 2014; Wheelan, 2005), different types of leadership are adequate

with respect to different stages of the group development. Accordingly, one has to consider

that the leadership–social capital relationship possibly interacts with organizational,

group, and individual factors.

6.4. From a systems perspective

According to the theoretical framework of Bronfenbrenner (1999), and recently, Dellve and

Eriksson’s (2017) model, different levels in a system, that is, individual, micro, meso, exo,

macro, and chrono levels, are interlinked with each other. The levels are interlinked and

dependent on each other, and the results are connected to different levels. In Study III, the

outcome of job satisfaction, work engagement, is, according to systems theory, based on

the micro level and connected to the interfaces between the individual, micro, and meso

levels, while dimensions of social capital are based on the micro level and connected to the

micro and meso levels, where other social dynamics also manifest (e.g., co-worker ship and

social support) (Bone, 2015; Dellve and Eriksson, 2017). The results in Study IV showed

that leadership (operating from the meso level) is important to support social capital. This

46

can be considered as an example of an outcome at one level (work engagement at the

individual level) associated with at least two other levels (dimensions of social capital at

micro level and leadership at meso level), according to systems theory. Further on, the risk

of healthcare professionals’ intention to leave their jobs (individual level) was shown to be

correlated to levels of social capital (bridged from the micro level). Dellve and Eriksson

(2017) in their review argue that some leadership approaches (e.g., servant, authentic,

transformational, and relational) bridge more successfully over system levels having

positive impact on employees’ health and engagement. This is supported by results in the

present thesis (Study IV) regarding the impact of relational leadership approaches on social

capital. Also, job demands and job resources (micro level) had impacts on healthcare

professionals’ engagement (individual level). The organizational context (meso level) was

hospitals, and Glouberman and Mintzberg (2001) have problematized that four logics of

how to manage healthcare are important in matters of efficiency and collaboration. The

results in Study I reflect differences between the professionals’ work conditions and

engagement, and this could be related to these different logics. Swedish hospitals have been

highly influenced by NPM (macro level) and management concepts such as LP. These

trends in developments over the last decays could also have impact on what was studied in

this thesis, and the changes and developments are connected to the chrono level (Bone,

2015). When implementing concepts of rationalization in hospitals, there is an increased

risk for negative consequences of increased demands and work pace and worsened working

conditions (Westgaard and Winkel, 2011). However, the results regarding risks vary due to,

for example, occupational groups and contexts. For instance, RNs experienced increased

influence two years after rationalization was implemented, while physicians gained

increased role clarity through standardization (Dellve and Eriksson, 2017). Developments

(chrono level) for different professional groups also are thus interlinked with the other

levels, according to systems theory and the bioecological model. Yet, this gives support for

the results in this thesis to be viewed in a systems perspective, as they are interlinked with

each other and for explanations and consequences to be found at various levels. With

respect to the development of sustainable work organizations (Kira et al., 2010), there is a

need to take into consideration and to develop different levels in the organization to reach

success and not just one of them. This harmonizes well with a view of the individual

healthcare professional as connected to a complex system where different levels are

interlinked and influence each other.

6.5. Practical implications

The results stress the need to consider social capital, job demands, and other job resources

as important factors when working with organizational improvement work within

healthcare. Their importance concerns possibilities to engage employees in the

development of care processes, which is crucial for the success of the changes. Further, to

improve the effect and the sustainability of the organizational improvement work,

47

enhanced social capital and increased job resources as well as decreased job demands are

important factors to focus on.

With respect to sustainability, social capital has a direct impact on job satisfaction of staff

and therefore also on their health and well-being; it also has an indirect effect by its impact

on work engagement, which negatively influences staffs’ intention to leave. The use of the

resource social capital could render a positive process where the resources are strengthened

(not only consumed) and sustainability of organizational improvement work is created.

Leaders who function well are more likely to increase social capital at their workplaces. By

investing in the resource social capital, organizations could realize advantages of

developing good leadership because of the importance of leadership for social capital.

When healthcare organizations are developing leadership, they should also foster

interpersonal skills. At workplaces, ability to work to increase social capital should be

possible in terms of increased focus on factors such as social reciprocity, trust, and

recognition.

Knowledge of the results in this thesis could benefit other departments responsible for

attracting, recruiting, retaining, and developing employees in hospitals. This points to a

need to communicate and transfer results from research at one level in the organization to

other organizational levels within the hospital.

6.6. Method discussion

A potential limitation of this thesis is the possibility to generalize the results to other

organizations beside healthcare. With respect to external validity, precautions have to be

taken when interpreting results for sectors other than healthcare. Also, the sample

contained data mostly (but not only) from wards that had connections to the emergency

department, which can present problems when in generalizing to other departments and

wards in hospital settings. However, much of the theoretical framework presented in this

thesis reveals that previous research on social capital, engagement, job satisfaction, and

leadership has been carried out in different sectors and in other types of wards, which

argues for social capital as a resource outside hospital settings.

A potential limitation of all studies in this thesis is that of self-reported data using

questionnaires, which could lead to common source bias (Podsakoff et al., 2003). However,

when studying working conditions, it has been stressed that self-rated working conditions

could be compared to working conditions that have been objectively measured (Härenstam

et al., 2003). Further, the four studies in this thesis used quantitative methods. One,

however, has to consider the advantages of using qualitative methods (i.e., interviews),

which offer the possibility of understanding the underlying complex relationships between

48

the investigated variables that could have biased the results of the quantitative analyses.

There could be other aspects in the organization that influence the variables, but using a

quantitative approach accounts for greater objectivity than qualitative approaches and also

provides support for generalizations about investigated phenomena, due to a larger amount

of data. However, this assumes a satisfactory response rate and a large sample size. Another

advantage of quantitative research is the reduction of personal bias by having the

researcher distanced from the respondents, which in an interview situation is nearly

impossible. However, the risk of structural bias can arise with the use of questionnaires. To

reduce such risk, it is important to use validated and reliable instruments and tools. In this

thesis, all measures came from validated scales, except for the indices clinical engagement

in patient safety and clinical engagement of quality of care. However, these indices were

tested using Cronbach’s alpha for reliability and face validity, where both questions and

response scale were tested for interpretation. Also to be mentioned, in Study I a comparison

was made between hospitals working to develop their care processes using the concept of

LP. This was labeled as top-down initiative. The other hospitals did not use top-down

implementation of LP. They were working to develop their care processes in other ways,

and accordingly, all hospitals were working with organizational improvement work to

develop their care processes (knowledge from interviews with key persons in the

organizations). However, when distinguishing between redesigning care processes or not

in Study IV, this should be understood as a top-down initiative to redesign care processes

from a strategic level. Another possible limitation concerns the analyses stratified to groups

of healthcare professionals. Knowledge of the response rate among the different healthcare

professional groups was difficult to reach. The results of the analyses stratified to

professional groups must therefore consider a possible selection bias, if the response rate

was low in a specific healthcare professional group. This possible issue concerns analyses

stratified to groups of healthcare professionals.

When having longitudinal design and performing analyses over time, one has to consider

respondents lost to follow-up. The respondents’ professions were self-reported in the

questionnaires, which increased the knowledge of the study population and the different

groups of healthcare professionals. Having this knowledge made it possible to detect

whether there were changes between baseline and follow-up with respect to groups of

healthcare professionals. The changes in the study population between baseline and one-

year follow-up were that the proportion of physicians increased from 26% to 29%, and the

proportion of RNs and assistant nurses decreased from 44% to 39% and 27% to 26%,

respectively. This indicates that the proportion of healthcare professionals was stable, and

the loss was less than 5% or equal, which could be interpreted as of little concern (Schulz

and Grimes, 2002). At second follow-up, questionnaires were only sent to those who had

answered at the previous occasion. The proportion among physicians was 28%, among RNs

34%, and among assistant nurses 25%. Having an overall satisfactorily response rate and a

49

stable proportion of physicians, RNs and assistant nurses could possibly reduce the risk of

attrition bias and of possible problems due to loss of respondents to follow-up.

The strength of Study I was the longitudinal design, where data were collected at two

occasions with approximately one year between. The questionnaires had a unique code

assigned to each participant, which was in favor of the reliability of the analyses because of

the knowledge of a real change at individual level. A possible limitation in Study I could be

the risk of common source bias because of omitted or false answers when using the self-

reported questionnaire. However, this risk was considered decreased by having the unique

codes of the participating respondents, making it possible to compare results over time.

Also, the informed consent was fulfilled and could possibly increase the reliability of the

answers given. Having data from two occasions and a satisfactorily sample size and

response rate made it possible to make some assumptions about relationships and

predictive values compared to a cross-sectional design. However, this had to be done with

caution because of other potential influencing factors not included in the analyses.

Study II had a cross-sectional design. The results should therefore be interpreted with

caution regarding the possibilities of causal conclusions. However, the aim of Study II was

not to come to a conclusion about causality. In its favor, Study II had a satisfactorily sample

size as well as response rate. A possible limitation in Study II could be the same as in the

other studies, where data derived from self-reported questionnaires were used. In cross-

sectional studies with large samples and high response rates there is a risk of finding

correlations between many variables. Based on a solid theoretical foundation and

hypothesis-driven research, there is a logic to what is to be tested or investigated. Other

factors that were not investigated in Study II could possibly explain healthcare

professionals’ intention to leave and have to be considered when interpreting the results.

These factors could be linked to private life or to other levels in the organization. Although

Study II was of cross-sectional design, it was theoretically hypothesis-driven, which may

have reduced the risk of inadequate correlations.

Study III had the strength of being longitudinal over a period of one year. Similar to Study

I, it had the benefits of the unique codes to be able to make reliable analyses of a predictive

value of social capital for investigated outcomes. When performing analyses of a cohort as

in Study III, there is a risk of having a selection bias. However, a comparison of levels of

social capital between the cohort and the remaining sample showed no difference, which

was satisfying in the sense of potential selection bias.

Study IV had a longitudinal set-up very similar to studies I and III, however, with data from

three occasions. This made it possible to perform repeated measures analyses over time. A

strength is that the method needs values from two out of three occasions and imputes an

50

average value where it is suitable. This allows the analyses to consider a larger amount of

the gathered data, but at the same time, caution has to be taken with respect to the degree

of imputed data. A possible limitation in Study IV was the multicollinearity between the

different leadership orientations. This made it impossible to include them in the same

statistical model.

51

7. Conclusions and future research

7.1. General conclusion

The results of this thesis have reach several conclusions. Important conditions for

healthcare professionals’ engagement in organizational improvement work were in this

thesis found to be social capital, increased job resources, and decreased job demands.

Leadership quality as a precondition is important for developing social capital. Social

capital can be regarded as a resource for sustainable organizational improvement work in

healthcare because of its importance for healthcare professionals’ engagement, job

satisfaction, and intention to leave.

7.2. Specific conclusions

Increased psychosocial work and organizational resources have importance for

healthcare professionals’ clinical engagement in improving care processes.

Social capital predicted healthcare professionals’ general work engagement,

engagement in clinical improvements in patient safety, and job satisfaction.

Social capital is associated with healthcare professionals’ intention to leave.

Levels of social capital are associated with levels of intention to leave, such that high

levels of social capital are associated with low levels of intention to leave.

Levels of leadership quality are correlated to levels of social capital.

7.3 Future research

Social capital was shown to be an important resource for healthcare professionals´

engagement and the results also showed that leadership quality was important for social

capital. There would be of interest to investigate this further by considering dimensions of

social capital as outcomes when working with leadership development programs in the

health care sector. Since social capital seems to be stable over the project period of three

years, one could ask if there is a greater variance in social capital if it was measured more

frequently than yearly. Combined with the idea to investigate if social capital can be

influenced as an effect of managers participating in a leadership development program,

dimensions of social capital could be measured more frequently. Moreover, the method

used in this thesis was quantitative, and the results produced can be further validated by

considering a qualitative approach in future research. The results in this thesis point on

social capital to be associated with healthcare professionals’ intention to leave. Interviews

with health care professionals about trust, recognition and reciprocity could validate these

results and extend knowledge of the connection between social capital and intention to

leave. Lastly, taking into consideration a system perspective, future research should focus

on elaborating knowledge of multilevel investigations because of the context dependency.

This could yield knowledge of how different levels in the organization support or hinder

employee engagement in organizational improvement work.

52

Acknowledgements

This has been an amazing experience and journey. It has been filled with hard work, fun

times and to be honest, some disparing moments. Self-support is needed, but also the

support from others. I would like to express my sincere gratitude to everyone involeved in

this thesis and say the following:

Thank you, Lotta Dellve, my main scientific supervisor, for noting my interest and

including me in your research team. You have been generous with time, support, and

academic brightness in a constructive and encouraging way. I cannot count the times my

partner in life has said: “How lucky you are to have Lotta.” I very much agree.

Andrea Eriksson and David Bergman, my co-supervisors, a sincere thank you—Andrea, for

your constructive advice, critical analyses, and valuable support, both in supervising and

as a co-worker in our research projects; David, for your support and valuable insights from

a different academic perspective and for believing in my ideas.

Anna Williamsson, for all the work with gathering data, for statistical discussions, and for

mutual support as PhD students and co-worker. Jörgen Andreasson, for our discussions

about managerial perspectives and our adventures at scientific conferences. Linda

Åhlström and Göran Jutengren for statistical tutorial and discussions.

I am sincerely grateful to the colleagues at the Ergonomics Unit for a creative academic

environment with good discussions and humor. Also, to my colleagues at the Competence

Center for Health at Region Västmanland, thank you for your support and interest in my

research, and a special gratitude to Fredrik Söderqvist for statistical discussions, to Anu

Molarius and Bo Simonsson for advices, and to Sevek Engström for creating space.

I would like to thank Lena Tell, the former HR director in Region Västmanland, for

including me in the meetings with the research team from KTH, and Ann-Sophie Hansson,

my former boss, for supporting the start of my PhD studies.

I am grateful to AFA Insurance and FORTE - Swedish Research Council for Health Working

Life and Welfare for the funding of the research projects that have supported me to fulfill

the aim of this thesis.

My parents, Ann-Marie and Bert-Olov, and my sisters, Marie-Louise and Matilda, thank

you for your love and support.

Susanne, my partner in life, your relentless support during this journey has been

inestimable. Sofia and Max, for your support and for reminding me of the important things

in life.

Friends and other colleagues, thank you!

53

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