A Qualitative Study on Distributed Leadership in Integrated Care: Exploring the Experiences of Elderly Multimorbid Patients with GP Collaboration.

Objective: This study explores how the collaboration between elderly multimorbid patients and general practitioners contributes to the patient's experience of integrated care in the municipality. The research also investigates whether the municipality's integrative mechanisms creating integrated care can be understood as distributed leadership. Method: In this qualitative study, we conducted a thematic analysis of semi-structured interviews with twenty elderly multimorbid patients living at home and their general practitioners. Results: Analysis of patients' and general practitioners' experience of healthcare service characterized by collective efforts identified four themes: 1) an impression of collective processes as difficult for patients to access and influence; 2) that the fluidity and location of leadership is dependent on the individual patient and his or her health condition; 3) that collective implementation of healthcare services is separated in time, geography and between organizations; and 4) that patients experience individual healthcare workers as specialized and unable to support the medical and holistic goals of the collective. The Direction, Alignment, and Commitment or DAC framework, is used to investigate the capabilities of the collective. Conclusion: To promote distributed leadership and create a patient experience of integrated care in the municipality, healthcare organizations must develop collective processes that enhance patient participation to a greater extent. General practitioners and other healthcare personnel should be encouraged to play a more central role in solving elderly multimorbid patients' healthcare needs in the municipality.

Older Adults' Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting.

BACKGROUND: Owing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults' health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination. OBJECTIVE: This study aimed to explore multimorbid older adults' experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs). METHODS: The study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation. RESULTS: We identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults' information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination. CONCLUSIONS: Being in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers.

Understanding registered nurses' career choices in home care services: a qualitative study.

BACKGROUND: The anticipated growth in number of older people with long-term health problems is associated with a greater need for registered nurses. Home care services needs enough nurses that can deliver high quality services in patients' homes. This article improves our understanding of nurses' career choices in home care services. METHODS: A qualitative study using individual semi-structured interviews with 20 registered nurses working in home care services. The interviews were audio-recorded, transcribed and thematically analyzed. RESULTS: The analysis resulted in three themes emphasizing the importance of multiple stakeholders and contextual factors, fit with nurses' private life, and meaning of work. The results offer important insights that can be used to improve organizational policy and HR practices to sustain a workforce of registered nurses in home care services. CONCLUSION: The results illustrate the importance of having a whole life perspective to understand nurses' career choices, and how nurses' career preferences changes over time.

General practitioners' perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study.

BACKGROUND: Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs' leadership actions in collaboration with patients and health care professionals contribute to DL. METHODS: We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. RESULTS: GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. CONCLUSION: Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel.

Competence Development and Collaborative Climate as Antecedents of Job Performance, Job Commitment and Uncertainty: Validation of a Theoretical Model across Four Hospitals.

Knowledge is lacking regarding how organizational factors are associated with uncertainty in patient treatment. Thus, the aim of the current study was to investigate how competence development and collaborative climate relates to job performance and job commitment, and further whether job performance and job commitment relate to uncertainty. Additionally, we examined whether these associations differed between four different hospitals. We applied data from 6445 hospital workers who provided care to patients. Basic statistics and structural equation modelling (SEM) were used to test the validity of the theoretical model developed in the study and the hypothesized associations. All hypothesized paths between the latent variables were significant and in accordance with the model across the four hospitals. The current study has implications for practical human resource management and indicates that competence development should be strengthened at the individual level and collaborative climate should be strengthened at the ward level. Strengthening competence development and collaborative climate can increase job performance and job commitment of individual workers and reduce uncertainty during care in hospital settings.

The association between supervisor support and ethical dilemmas on Nurses' intention to leave: The mediating role of the meaning of work.

AIM: To examine the association between supervisor support and ethical dilemmas on nurses' intention to leave health care organisations, both directly and through the mediating role of the meaning of work. BACKGROUND: The shortage of nurses makes it vital that organisations retain nurses and so reduce the costs associated with replacing experienced nurses. METHODS: This cross-sectional study samples 2,946 registered nurses from a selected health region in Norway. Structural equation modelling was used to test a hypothesized model. RESULTS: Social support from the supervisor and ethical dilemmas is associated with nurses' intention to leave, both directly and indirectly through the mediating role of the meaning of work. CONCLUSION: Health care organisations should enhance social support from supervisors and the meaning of work, and reduce the level of ethical dilemmas in hospitals. IMPLICATIONS FOR NURSING MANAGEMENT: Health care organisations should continuously develop and offer training in nurse manager skills, such as being empathic, understanding employees' needs and how to communicate and handle ethical dilemmas. Managers should value staff contributions, encourage staff involvement in ethical questions and highlight the impact of nurses' work on improving the welfare of others.

Development and Investigation of a New Model Explaining Job Performance and Uncertainty among Nurses and Physicians.

The purpose of this paper is to develop and investigate a new theoretical model explaining variance in job performance and uncertainty among nurses and physicians. The study adopted a cross-sectional survey. Data was collected from 2946 nurses and 556 physicians employed at four public hospitals in Norway. We analysed data using descriptive statistics, correlations, Cronbach's alpha, confirmatory factor analyses and structural equation modelling. To explain job performance and uncertainty, two sets of explanatory variables were used: first, satisfactions of three psychological needs-namely autonomy, social support and competence development-and second, employee perceptions of hospital management quality (HMQ) and local leadership quality (LLQ). The results supported the theoretical model among nurses and physicians; (1) HMQ was positively associated with LLQ; (2) LLQ was positively associated with psychological needs; (3) the majority of psychological needs were positively associated with job performance and negatively associated with uncertainty, but more of these relations were significant among nurses than physicians. The results suggest that job performance and uncertainty among nurses and physicians can be improved by helping personnel meet their psychological needs. Improving job design and staff involvement will be important to strengthen need satisfaction. Results suggest enhancement of HMQ and LLQ will be positively related to need satisfaction among nurses and physicians and will strengthen job performance and reduce uncertainty.

Changing to improve? Organizational change and change-oriented leadership in hospitals.

PURPOSE: This paper aims to fill gaps in one's knowledge of the impact of organizational change on two outcomes relevant to hospital service quality (performance obstacles and physician job satisfaction) and in one's knowledge of the role of middle manager change-oriented leadership in relation to the same outcomes. Further, the authors aim to identify how physician participation in decision-making is impacted by organizational change and change-oriented leadership, as well as how it mediates the relationships between these two variables, performance obstacles and job satisfaction. DESIGN/METHODOLOGY/APPROACH: The study adopted a cross-sectional survey design including data from Norwegian hospital physicians (N = 556). A hypothetical model was developed based on existing theory, confirmatory factor analysis was carried out in order to ensure the validity of measurement concepts, and the structural model was estimated using structural equation modelling. FINDINGS: The organizational changes in question were positively related to performance obstacles both directly and indirectly through participation in decision-making. Organizational change was also negatively related to job satisfaction, both directly and indirectly. Change-oriented leadership was negatively related to performance obstacles, but only indirectly through participation in decision-making, whereas it was positively related to job satisfaction both directly and indirectly. ORIGINALITY/VALUE: The authors developed a theoretical model based on existing theory, but to their knowledge no other studies have tested these exact relationships within one model. These findings offer insights relevant to current and ongoing developments in the healthcare field and to the question of how hospitals may deal with continuous changes in ways that could contribute positively towards outcomes relevant to service quality.

Making a career in hospitals: Determinants of registered nurses' aspirations to become a manager.

AIM: To examine seven determinants of Registered Nurses' aspirations to become a manager in four Norwegian public hospitals. BACKGROUND: Research evidence shows that nurses submit few applications to management positions. Understanding the determinants that influence nurses' aspirations to become managers can provide healthcare organizations with important knowledge on the drivers and barriers in recruitment and on the development of nurse managers. DESIGN: This study adopted a cross-sectional web-based survey design. METHOD: Logistic regression analysis based on 2,630 Registered Nurses' responses to a self-completion survey in a Norwegian regional health authority collected during October 2014. The overall response rate was 40%. RESULTS: Findings indicate that men and younger nurses are most likely to report an aspiration in management. The social support of an immediate supervisor and institutional stress are positively associated with an aspiration to become a manager; however, high experienced workloads have the opposite effect. CONCLUSION: Healthcare organizations should work strategically to develop a human resource management policy that ensures that the organization develops the nurse managers it needs now and in the future. IMPACT: This study addresses the challenge of having enough qualified nurse managers. The main findings indicate that job demands can have both a negative and positive impact on nurses' aspirations to become a manager. Healthcare organizations should, however, reduce demands and consider increasing job resources. The results should have an impact on the human resource department, managers, and other key personnel in healthcare organizations.

The influence of change-oriented leadership on work performance and job satisfaction in hospitals - the mediating roles of learning demands and job involvement.

PURPOSE: The purpose of this paper is to examine the mechanisms through which change-oriented leadership in hospitals influences job performance and employee job satisfaction. The authors examine the direct and the mediating effects of perceived learning demands and job involvement. DESIGN/METHODOLOGY/APPROACH: This cross-sectional study is based on a survey of four public hospitals in a regional health authority in Norway. FINDINGS: The findings illustrate how change-oriented leadership directly and indirectly influences work performance and job satisfaction. Learning demands and job involvement play mediating roles. Higher levels of change-oriented leadership decrease learning demands and increase job involvement, work performance and job satisfaction. Learning demands have a negative influence on work performance and job satisfaction. Job involvement has a positive influence on work performance and job satisfaction. The strongest relationship in the structural modelling is between change-oriented leadership and job involvement. RESEARCH LIMITATIONS/IMPLICATIONS: This study is based on cross-sectional data. Future studies should therefore explore this further using a longitudinal design. PRACTICAL IMPLICATIONS: The practical implication of the study is to show how leaders by change-oriented behaviour can influence work performance and job satisfaction by reducing learning demands and increasing job involvement. SOCIAL IMPLICATIONS: This study illustrates different paths towards influencing job performance and job satisfaction from change-oriented leadership. It is important to use the potential of reducing learning demands and increasing job involvement, to improve job performance and job satisfaction. ORIGINALITY/VALUE: The authors have developed and validated a new theoretical mediational model explaining variance in job performance and job satisfaction, and how this is related to change-oriented leadership, job involvement and learning demands. This knowledge can be used to increase the probability of successful change initiatives.

Establishing a multidisciplinary day-care surgery department: Challenges for nursing management.

AIM: To increase our understanding of challenges in implementing multidisciplinary organisational models in hospitals. BACKGROUND: Health-service policies internationally are pushing for multidisciplinary and patient-centred organising models but there are challenges involved in moving from profession- and discipline-based organising to the new solutions. METHOD: Qualitative case study, interview and document data collected in real time following the implementation process. RESULTS: It was possible to argue for and against the new department applying either a business-like logic or a professional logic. The respective logics gave different prescriptions for how a hospital department should be organised. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: The institutional logics perspective enables managers to understand resistance to new ways of organising work and may be useful in trying to foresee and handle challenges in implementing new organisation models. Managers need to analyse models carefully in terms of which parts may be seen as problematic in their own organisation, and invite all relevant stakeholders into participatory change processes. If the goal is to gather multiple professions and disciplines under one manager in order to increase patient centredness, arrangements must be made for professionals to stay connected to the wider community of practice centred around their specialized knowledge and skills.

Learning Climate Perceptions as a Determinant of Employability: An Empirical Study Among European ICT Professionals.

This study investigated the role of age in the relationship between perceptions of learning climate and self- and supervisor-rated employability among European Information and Communication Technology (ICT) professionals. The psychological climate for learning was operationalized by three indicators, namely the perceptions that employees have of the learning value of their job, supervisor support for learning, and the organizational support for learning. As hypothesized, a Structural Equation Model demonstrated that the relationship between age and perceptions of learning climate was negative. The model also showed a strong positive relationship between learning climate and self-reported and supervisor-rated employability. Furthermore, learning climate perceptions appeared important for employability irrespective of life or career stage. An explorative bootstrapping-based test suggested that older workers with managerial responsibilities profit less from psychological learning climate for self-reported and supervisor-rated employability than older workers at non-managerial levels. These findings have important implications for human resource practices that aim to increase lifelong employability.

Work climate and the mediating role of workplace bullying related to job performance, job satisfaction, and work ability: A study among hospital nurses.

AIM: To increase understanding of workplace bullying and its relation to work climate and different outcomes among nurses. Examine a proposed bullying model including both job resource and job demands, as well as nurse outcomes reflected in job performance, job satisfaction, and work ability. BACKGROUND: Workplace bullying has been identified as some of the most damaging mechanisms in workplace settings. It is important to increase understanding of workplace bullying in relation to work climate and different outcomes among nurses. DESIGN: This study adopted a cross-sectional web based survey design. METHOD: A sample of 2946 Registered Nurses from four public Norwegian hospitals were collected during October 2014. We analysed data using descriptive statistics, correlations, Cronbach's alpa, confirmatory factor analyses, and structural equation modelling. RESULTS: The majority of work climate characteristics confirmed to influence workplace bullying, and additionally had direct influence on nurse outcomes; job performance, job satisfaction, and work ability. Bullying had a mediational role between most of the work climate dimensions and nurse outcomes. CONCLUSION: This study increases our understanding of organizational antecedent of bullying among nurses. Workplace bullying among nurses functions as a mediator between the majority of work climate dimensions and outcomes related to job satisfaction and work ability. Strategies to reduce bullying should look at the study finding and specifically job resources and job demands that influence bullying and nurse outcomes.

Measuring patient participation in surgical treatment decision-making from healthcare professionals' perspective.

AIMS AND OBJECTIVES: To develop, empirical test, and validate an instrument measuring patient participation in surgical treatment decision-making from healthcare professionals' perspective. BACKGROUND: Since the advent of New Public Management in many Western countries, patient participation in healthcare decision-making has been considered to be a best practice. A common notion is that well-educated and well-informed public want to choose their own treatments and providers and want to ask questions about the quality of their health services. DESIGN: Survey. METHODS: A self-report-measuring instrument was designed and administered to 620 healthcare professionals. Items were developed, validated and tested by 451 nurses and physicians working in six surgical wards in a University Hospital in Norway. RESULTS: A 16-item scale with the following four dimensions was developed: information dissemination, formulation of options, integration of information and control. Factor analysis procedures and reliability testing were performed. A one-way, between-groups analysis of variance was conducted to compare doctors' and nurses' opinions on four dimensions of patient participation in surgical treatment decision-making. CONCLUSIONS: This article shows that patient participation in surgical treatment decision-making can be measured by a 16-item scale and four distinct dimensions. The analysis demonstrated a reasonable level of construct validity and reliability. Nurses and physicians have a positive attitude towards patient participation overall, but the two groups differ in the extent to which they accept the idea of patient participation in treatment decision-making. RELEVANCE TO CLINICAL PRACTICE: The instrument can be a tool for managers and healthcare professionals in the implementation of patient participation in clinical practice. Data from the instrument can be useful to identify health services being provided and what areas that could strengthen patient participation.

Models, phases and cases of patient participation in decision-making in surgical treatment in Norway: a qualitative study.

This study improves our understanding of patients' participation in hospital treatment-decision processes. We explored the degree of patient participation perceived by both patients and healthcare professionals in four phases of the decision process: information dissemination, formulation of options, integration of information, and control within four models of interactions between healthcare professionals and patients: the paternalistic model, the shared model, the informed model, and the non-paternalistic model. The analysis was based on 18 in-depth, exploratory interviews with patients and healthcare professionals in six surgical units in Norway. Knowledge about how patients and healthcare professionals interact in the surgical-decision process is important for developing systems and arenas for patient participation in practice, and for a climate and culture to further support the implementation.

Patient participation in surgical treatment decision making from the patients' perspective: validation of an instrument.

The aim of this paper is to describe the development of a new, brief, easy-to-administer self-reported instrument designed to assess patient participation in decision making in surgical treatment. We describe item generation, psychometric testing, and validity of the instrument. The final scale consisted of four factors: information dissemination (5 items), formulation of options (4 items), integration of information (4 items), and control (3 items). The analysis demonstrated a reasonable level of construct validity and reliability. The instrument applies to patients in surgical wards and can be used to identify the health services that are being provided and the areas that could strengthen patient participation.

Supervisor-subordinate age dissimilarity and performance ratings: the buffering effects of supervisory relationship and practice.

Using 394 pairs of employees and their immediate supervisors working in the Information and Communication Technology (ICT) sector in three northern European countries, this study examined the effect of workplace moderators on the link between relational demography and supervisor ratings of performance. Directional age differences between superior and subordinate (i.e., status incongruence caused when the supervisor is older or younger than his/her subordinate) and non-directional age differences were used as predictors of supervisor ratings of occupational expertise. The quality of the supervisor-subordinate relationship and the existence of positive age-related supervisory practices were examined as moderators of this relationship. The results provide no support for a relationship between directional age differences and age-related stereotyping by supervisors in ratings of performance, neither for the effects of age-related supervisory practices. However, high quality supervisor-subordinate relationships did moderate the effects of age dissimilarity on supervisory ratings. The implications of these findings for performance appraisal methodologies and recommendations for further research are discussed.

User involvement in in-patient mental health services: operationalisation, empirical testing, and validation.

AIMS: This study presents development, empirical testing and validation of an instrument measuring service user involvement in in-patient mental health from the mental health professionals' perspective. BACKGROUND: Service user involvement is high on the agenda in European mental health policies. In Norway, focus is on enhanced service user involvement at both the individual and organisational levels of in-patient mental health services. Mental health professionals are in an important position to ensure opportunities for real user involvement in in-patient mental health care. However, there is a need for more empirical knowledge on how mental health professionals attend to service user involvement. DESIGN: Survey. METHODS: A self-report questionnaire was designed and administered to 121 mental health professionals, with 98 responses, working in a community-based mental health centre in western Norway. Factor analysis procedures together with reliability testing were performed. RESULTS: A 30-items instrument was developed. The instrument contains four components/subscales: (1) Democratic patient involvement (mean score 3·74, Cronbach's alpha 0·81), (2) Carer involvement (mean score 3·67, Cronbach's alpha 0·82), (3) Assisted patient involvement (mean score 4·05, Cronbach's alpha 0·78) and (4) Management support (mean score 4·10, Cronbach's alpha 0·75). These subscales were found to be essential to service user involvement in the context of in-patient mental health care. The total mean score for the instrument was 3·88, Cronbach's alpha 0·88. CONCLUSION: Empirical testing of the instrument demonstrates that the measurement of mental health professionals' perception of service user involvement has a reasonable level of construct validity and reliability. RELEVANCE TO CLINICAL PRACTICE: We have developed a measurement instrument with items reflecting essential characteristics to user involvement in in-patient mental health services. We believe that answering this questionnaire on the subject user involvement can act as one step towards enhancing awareness of this issue and to assess user-oriented practices in treatment and services.

Career stage and police cynicism.

This study examined the relationship of police tenure and career stage and cynicism among 766 Norwegian constables and managers. Constables with less tenure and in an early career stage, but not managers, scored lower on cynicism.

Benefits to police officers of having a spouse or partner in the profession of police officer.

This exploratory study of police officers examined potential effects of having a spouse or partner who is also in police work on levels of work-family conflict and spouse or partner concerns. Data were collected from 776 police officers in Norway using anonymously completed questionnaires. Police officers having spouses or partners also in police work reported significantly lower spouse or partner concerns but the same levels of work-family conflict. Possible explanations for these findings are offered.