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This article draws on theories of normative control and critical management studies to investigate caseworkers' strategies in correspondence to a new leadership philosophy in the Swedish Public Employment Service called self-leadership. Based on 43 interviews and observations at two local offices, we find that managerial models are arbitrary and cause uncertainty at the local level as caseworkers both comply and resist managerial talk of self-leadership. Based on a distinction between types of and grounds for strategic responses, we identify four subject positions defined as "personal embracement", "personal detachment", "professional recognition" and "professional dismissal". The study shows that newly employed comply through practices of personal embracement, while senior employees resist based on professional dismissal. The article concludes that caseworkers are not docile bodies, who adjust to managerial talk, but derive their identity, engagement and esteem linked to a shared-work identity as organisational professionals. This demonstrates the relevance of closing the gap between street-level bureaucracy and critical management studies to further explore the tension between governing "employees" or "professionals" in contemporary public welfare governance.

Abstract
Officials in welfare state bureaucracies face the challenge of negotiating their role identities in the context of changeable organizational priorities and managerial styles. Previous studies have found that the professional values may mediate top-down demands and enable the preservation of professional autonomy also under public management reforms. But how do street-level bureaucrats who lack a common professional or occupational training respond to shifting organizational demands? Based on comparative ethnography, the present article investigates how caseworkers' role identities are conceived and practised in two of the largest state bureaucracies in Sweden, the Social Insurance Agency (SIA) and the Public Employment Service (PES). The article identifies two radically different agency cultures, resulting in rather opposite caseworker role identities. These role identities affect how front-line staff respond to organizational demands, either by focusing externally on client-related outcomes (PES) or internally on organizational output (SIA). The analysis suggests that agency culture may shape caseworker responses to governance in patterned ways, also in the absence of joint professional training or strong occupational communities.

AbstractThe Swedish Social Insurance Agency (Försäkringskassan– SSIA) and its frontline staff have a key role in the implementation of activation policy. Drawing on ethnographic research conducted at local offices, this article investigates how the transparency ideal, as an integral part of the organizational governance of the activation policy, is negotiated and enacted in the everyday life of a welfare bureaucracy. The analysis shows the central role that the transparency ideal plays in the alignment of frontline staff with the normative regime of the agency. While the transparency ideal is central to the internal organizational life of the SSIA, the analysis shows how transparency is much less salient in relation to clients and other relations with the outside world.

Purpose: The aim was to analyze the role and activities of employers with regard to return to work (RTW), in local workplace practice. Method: Semi-structured interviews were conducted with sick-listed workers and their supervisors in 18 workplaces (n = 36). The analytical approach to study the role of employers in RTW was based on the three-domain model of social corporate responsibility. The model illustrates the linkage between corporations and their social environment, and consists of three areas of corporate responsibility: economic, legal and ethical. Results: Employers had difficulties in taking social responsibility for RTW, in that economic considerations regarding their business took precedence over legal and ethical considerations. Employers engaged in either "RTW activities" or "transition activities" that were applied differently depending on how valued sick-listed workers were considered to be to their business, and on the nature of the job (e.g. availability of suitable work adjustments). Conclusions: This study suggests that Swedish legislation and policies does not always adequately prompt employers to engage in RTW. There is a need for further attention to the organizational conditions for employers to take social responsibility for RTW in the context of business pressure and work intensification. Implications for Rehabilitation Employers may have difficulties in taking social responsibility for RTW when economic considerations regarding their business take precedence over legal and ethical considerations. Rehabilitation professionals should be aware of that outcomes of an RTW process can be influenced by the worker's value to the employer and the nature of the job (e.g. availability of suitable work adjustments). "Low-value" workers at workplaces with limited possibilities to offer workplace adjustments may run a high risk of dismissal. Swedish legislation and policies may need reforms to put more pressure on employers to promote RTW.

Background Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing disease patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can be challenging because they contradict humans' basic need for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful. Methods The study was based on semi-structured interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health care system. An inductive approach was applied using questions based on the existing literature on organizational change and change responses. The questions concerned the interviewees' experiences and perceptions of any changes that they considered to have affected their work, regardless of whether these changes were "objectively" large or small changes. The interviewees' responses were analysed using directed content analysis. Results The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the need for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients. Conclusions Organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients.

Background Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing disease patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can be challenging because they contradict humans' basic need for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful. Methods The study was based on semi-structured interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health care system. An inductive approach was applied using questions based on the existing literature on organizational change and change responses. The questions concerned the interviewees' experiences and perceptions of any changes that they considered to have affected their work, regardless of whether these changes were "objectively" large or small changes. The interviewees' responses were analysed using directed content analysis. Results The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the need for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients. Conclusions Organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients. ; Funding Agencies|Linkoping University; National Center for Advancing Translational Sciences, National Institutes of HealthUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Center for Advancing Translational Sciences (NCATS) [KL2TR002490]

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

Background Implementation of evidence-based practices in health care implies change. Understanding health care professionals' change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals' responses to organizational and workplace changes that have affected their work. Methods We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants' change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral. Results Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework. Conclusions We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care. ; Funding agencies: Linkoping University

Objective The aim of this study was to explore how the COVID-19 pandemic changed the working conditions of physicians in Swedish primary healthcare. Design This is a descriptive, qualitative study with individual semistructured interviews. Data were analysed using inductive content analysis. Setting Swedish primary healthcare units in both rural and urban areas. Participants A total of 11 primary care physicians fulfilled participation. Results Two main categories emerged: work organisation and routines and psychosocial work environment, containing three and five subcategories, respectively. The pandemic enforced changes in work organisation and routines. Increased flexibility, including more patient-oriented delivery of care, and novel means of interorganisational and intraorganisational interactions were perceived as positive by physicians. The pandemic also caused several changes in physicians psychosocial work environment. Increased workload, information overload, as well as ethical considerations and feelings of uncertainty made the work environment stressful for physicians. Conclusions The COVID-19 pandemic affected the working conditions of physicians in Swedish primary healthcare in numerous ways. The pandemic enforced changes in work organisation and routines for physicians in primary healthcare. Further research is needed to investigate how the pandemic will affect primary healthcare in the longer term. Learning from the pandemic is important because this will not be the last crisis that primary care and its healthcare professionals will face. ; Funding Agencies|AFA Forsakring (AFA Insurance) [200130]

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

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

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

Social distancing measures have been a key component in government strategies to mitigate COVID-19 globally. Based on official documents, this study aimed to identify, compare and analyse public social distancing policy measures adopted in Denmark and Sweden regarding the coronavirus from 1 March 2020 until 1 October 2020. A key difference was the greater emphasis on laws and executive orders (sticks) in Denmark, which allowed the country to adopt many stricter policy measures than Sweden, which relied mostly on general guidelines and recommendations (sermons). The main policy adopters in Denmark were the government and the Danish Parliament, whereas the Public Health Agency issued most policies in Sweden, reflecting a difference in political governance and administrative structure in the two countries. During the study period, Sweden had noticeably higher rates of COVID-19 deaths and hospitalizations per 100,000 population than Denmark, yet it is difficult to determine the impact or relative effectiveness of sermons and sticks, particularly with regard to broader and longer-term health, economic and societal effects.