Working hours and recovery in crisis : insights from the Swedish healthcare sector during the COVID-19 pandemic

Background and aim

The COVID-19 pandemic contributed to increased pressure on healthcare systems, which impacted the working conditions of healthcare workers. Recovery may be a key factor for maintaining health and safety during periods characterized by high stress, as insufficient recovery can lead to fatigue and impaired health over time. Recovery can however be disturbed or deprioritized during stressful periods, which has been referred to as the recovery paradox. Working hours can be an important determinant for recovery, as long working hours for example limit the time for recovery outside work, while night work and quick returns (<11 h between shifts) can disrupt or shorten sleep. Other aspects such as how well working hours enable social activities outside work and the level of influence that employees have over their working hours could also be important. The ways in which working hours impact recovery, health and safety may determine how sustainable they are over time. Promoting health and safety in organizations likely requires a systems approach, where actions are taken at several organizational levels. The knowledge around how working hours and recovery are managed within the healthcare sector remains limited, particularly within the context of the COVID-19 pandemic. There is also limited knowledge on how working hours and recovery among healthcare workers were affected during the pandemic, especially within the Swedish healthcare sector. The overall aim of the thesis was to investigate how working hours and possibilities for recovery (including sleep) amongst healthcare workers were affected during the COVID-19 pandemic, as well as how sustainable working hours and recovery can be supported both at the individual and organizational level during a crisis.

Methods

Semi-structured interviews were conducted with HR representatives working in the Swedish healthcare sector during the pandemic. 19 HR representatives from 16 out of 21 Swedish regions were included. Interviews were also conducted with 22 registered nurses/certified nursing assistants who had worked with COVID-19 patients across four hospitals during the pandemic. Data was analyzed using reflexive thematic analysis. Furthermore, objective working hour data from nursing staff working in 24/7 operations between December 2018 - September 2023 was extracted from one Swedish region. Paired t-tests were conducted to compare working hours before and after the onset of the COVID-19 pandemic.

Results

The results showed that, at the organizational level, working hours were maximized by implementing new scheduling solutions, limiting vacation, and providing economic compensation for employees to work more. Reorganization of employees, care and HR also took place, where employees were redeployed, some types of care was downscaled, and work at the HR level went from being mostly strategic to more operative. Different support functions were implemented, such as crisis support in the workplace. Issues relating to working hours, recovery and employee well-being were mainly attributed to first-line management. Insufficient staffing and skill mix contributed to the need to maximize working hours, reorganizing employees, care, and HR, and limited the ability to provide recovery for employees. At the employee level, results showed that the organization of working hours was perceived as suboptimal, which was related to demanding working hours, little room for recovery and poor management of working hours. Nursing staff also experienced loss of control in terms of lost influence over working hours, unpredictability in relation to working hours and the new schedules, and blurred boundaries between work and leisure. Participants described declining health and well-being in terms of impaired sleep, mental and physical changes, and extreme fatigue. Analyses of objective working hour data from one Swedish region showed that, at group level, there were few changes in working hours following the onset of the pandemic compared to before. However, the use of a new scheduling solution, which followed a continuous pattern of two day shifts, two evening shifts and two days off, increased the proportion of weekend work, and decreased the proportion of quick returns and single free days (i.e., having only one day off between work periods).

Conclusions

The findings from the present thesis suggest that at the organizational level, short- term solutions such as maximizing working hours and redeploying staff were used to manage the situation at hand. While organizations may be particularly dependent on their human capital during a crisis, the use of short-term solutions could deplete the human capital by contributing to for example fatigue, sick leave, and turnover, creating an organizational recovery paradox.

How working hours interact with employee's private life and recovery processes during free time may be important to consider during crises, as for example on- call duties and weekend work could be a hindrance for important recovery activities and processes. Furthermore, maintaining some level of employee influence over working hours could be important during a crisis. Other important aspects relate to individual prerequisites and contextual factors. It could for example be problematic for individuals with poor tolerance to night work to be scheduled to work night shifts, and high workload could impact individuals' capacity to work long shifts. Given that the working conditions of healthcare workers worsened during the pandemic, previous research relating to working hours may not be directly applicable in this new context.

Overall, having a more holistic approach to working hours and recovery in the Swedish healthcare sector could be important. Much of the responsibility for working hours, recovery and employee well-being was allocated to first-line management, and there was little follow up of working hours at higher organizational levels. This suggests that the support to first-line management has to be strengthened, especially during a crisis, but also that there may be a need to take more responsibilities for working hours and recovery at the organizational level. This could include both more guidance on how working hours and recovery should be managed, but also to evaluate how working hours influence fatigue, health, and safety. To increase preparedness for future crises, long term strategic efforts towards increasing staffing levels and skill mix could be important, and the software solutions for scheduling working hours may need to be improved. It could also be beneficial to develop a plan for how to manage working hours and recovery during crises, preferably with involvement from employees.

List of scientific papers

I. Hernandez, I., Arakelian, E., Rudman, A., & Dahlgren, A. (2024). An Organizational Recovery Paradox in Managing Working Hours, Staffing, and Recovery During the COVID-19 Pandemic-A Qualitative Study. Scandinavian Journal of Work and Organizational Psychology, 9(1), 6. https://doi.org/10.16993/sjwop.286

II. Hernandez, I., Söderström, M., Rudman, A., & Dahlgren, A. (2024). Under pressure - Nursing staff's perspectives on working hours and recovery during the COVID-19 pandemic: A qualitative study. International Journal of Nursing Studies Advances, 7, 100225. https://doi.org/10.1016/j.ijnsa.2024.100225

III. Hernandez, I., Rudman, A., Tucker, P., Kecklund, G. & Dahlgren, A. (2024). A Longitudinal Study of Nursing Staffs' Shift Schedules during the COVID-19 Pandemic. [Submitted]