The health care sector : a challenging or draining work environment : psychosocial work experiences and health among hospital employees during the Swedish 1990s

Health care personnel in a large Swedish hospital were followed over a period characterised by downsizing and related restructuring. The access to a research field, and research database between 1994 and 2001 provided an unusual opportunity to study longitudinally the consequences of structural instability in the work environment, as well as personnel health. The findings from this research project indicate the significance of the combination of methods for assessment of major organisational changes in working life.

The aim of the first study (on biological stress markers) was to assess whether there were physiological changes associated with the downsizing process. The participants, consisting of 31 women (medical secretaries, registered nurses and assistant nurses), had blood sampled in the morning and in the afternoon during a working day in 1997, in conjunction with the two-year layoff period, and were followed up one year later in 1998. This study indicated that protective and anabolic functions had suffered among the studied women. There was evidence of a flattening of the circadian cortisol rhythm, which could be a sign of physiological dysfunction coinciding with the enduring adaptation process. It could be speculated that this was a sign of increasing difficulty for the women to mobilise energy.

The aim of the second study (with the same 31 participants) was to explore experiential aspects of psychosocial 'stressors', balanced by 'motivators', and how the women managed different phases in the restructuring process. Repeated interviews were performed in 1997 and 1998, with additional follow-up interviews in 2000, and in 2001. The women discussed downsizing as an 'energy consuming' experience, which included continuing distrust towards the employer. It seems to be important to implement a good 'change-focused pedagogy', where staff managers need to be aware of the dimension of 'psychological contracts', and the dynamics of crises.

Job insecurity among the assistant nurses was expressed as fear of losing valued caring work tasks ('down-skilling'), while medical secretaries conveyed that expanded administrative functions, and their increased use of ICT might possibly mean future 'up- skilling'. At the same time as the registered nurses seemed to be assured of being able to strengthen their position in health care ('up-skilling'), they struggled with ambiguity and their complex deference-dominance relationship towards the physicians. The main stressor in the ongoing work was being behind in an insufficient organisation without power to change working routines. The main motivator was being a part of a comprehensive and learning team, associated with promotion and influence.

The aim of the third study was to identify (on an ecological level) trends in working conditions and health outcomes, as well as their interdependence, among health care staff in the hospital as a whole. The results (1994-2001) showed that the hospital staff reported a downward trend in mental health and a corresponding upward trend in long- term sick leave during the latter part of the study period. It was also found that the negative trends in the work environment, such as having less time to plan work, and conflicting demands, were accompanied by deteriorating mental health. Decrease in time for planning work was the factor that showed the strongest association with the delayed increasing long-term sick leave. Four stable 'healthy' departments were identified for future research.

List of scientific papers

I. Hertting A, Theorell T (2002). Physiological changes associated with downsizing of personnel and reorganisation in the health care sector. Psychother Psychosom. 71(2): 117-22.
https://pubmed.ncbi.nlm.nih.gov/11844949

II. Hertting A, Nilsson K, Theorell T, Larsson US (2003). Personnel reductions and structural changes in health care: work-life experiences of medical secretaries. J Psychosom Res. 54(2): 161-70.
https://pubmed.ncbi.nlm.nih.gov/12573738

III. Hertting A, Nilsson K, Theorell T, Satterlund Larsson U (2004). Demands, challenges and ambiguity in registered nurses - Experienced stressors and motivators during a period of downsizing and restructuring processes. Journal of Advanced Nursing. 45: 2b.

IV. Hertting A, Nilsson K, Theorell T, Satterlund Larsson U (2003). Assistant nurses in the Swedish health care sector during the 1990s - A hard-hit occupational group with a tough job. [Submitted]

V. Petterson IL, Hertting A, Hagberg L, Theorell T (2003). Are trends in work and health conditions interrelated? A study of hospital employees in the Swedish 1990s. [Manuscript]