The Swedish health care system is reorienting towards horizontal organization for care processes. A main challenge is to engage health care clinicians in the process. The aim of this study was to assess engagement (i.e. attitudes and beliefs, the cognitive state and clinical engagement behaviour) among health care clinicians, and to investigate how engagement was related to work resources and demands during organizational redesign. A cohort study was conducted, using a questionnaire distributed to clinicians at five hospitals working with care process improvement approaches, two of them having implemented Lean production. The results show that kinds of engagement are interlinked and contribute to clinical engagement behaviour in quality of care and patient safety. Increased work resources have importance for engagements in organizational improvements, especially in top-down implementations. An extended work engagement model during organizational improvements in health care was supported. The model contributes to knowledge about how and when clinicians are mobilized to engage in organizational changes.

Hälso- och sjukvårdens arbetsmiljö är viktig för både medarbetare och patienter. Syftet med denna artikel är att beskriva vad som karaktäriserar en hälsofrämjande arbetsmiljö, varför den är viktig inom hälso- och sjukvården och hur en hälsofrämjande arbetsmiljö kan utvecklas. Resultat från vår forskning och tidigare forskning, visar att medarbetares arbetsmiljö, hälsa och engagemang är viktigt för att ge bästa möjliga förutsättningar för att främja patienters hälsa. Viktiga arbetsmiljöfaktorer är i detta sammanhang ett starkt socialt kapital i form av erkännande, ömsesidighet och tillit mellan människor, ett verksamhetsnära ledarskap samt verksamhetsnära utveckling utifrån en systemteoretisk bas där man stödjer och förstår flera faktorer och förhållanden. Det sociala kapitalet kan liknas vid bränslet i ett kretslopp som skapar arbetstillfredsställelse, engagemang och nya arbetssätt. Det verksamhetsnära ledarskapet är viktigt för att skapa förutsättningar för hållbarhet i kretsloppet.

Work environment issues in health care have importance not only for employees but also for patients. The aim of this article is to describe important conditions for a health-promoting work environment, the significance of this for health care service, and how health-promoting work conditions can be developed. The results from our, as well as from others’, previous research show that employees’ work environment, health and engagement are critical for the improvements of quality of care and patient safety. Important factors are social capital (i.e. recognition, reciprocity and trust between humans), as well as practice-oriented approaches to developments based in system theory perspectives. The social capital can be compared to the fuel in a cycle creating work satisfaction, engagement and new ways of working and a practice-oriented and a servant leadership facilitates the development and the sustainability of this cycle.

Hospitals in Sweden are redesigning their care processes to increase efficiency. However, related to these changes, there is a risk of increased staff intention to leave and turnover due to increased workload and work pace. The literature on work engagement and job demands and resources suggests that specific job resources can buffer negative effects; i.e., intention to leave because of job demands. Social capital is suggested to have the potential to be a resource associated with staff intention to leave. The aim of this study was to investigate the associations between social capital and intention to leave and to test if social capital  moderates the relationship between job demands and intention to leave. A sample of five hospitals working under conditions of improvements of care processes were studied using a questionnaire administered to the healthcare clinicians (n = 849). High levels of social capital were associated with low levels of intention to leave. However, the moderating effect of social capital was not confirmed. Intention to leave among occupational groups was influenced differently by social capital, other job resources, and job demands.

Purpose - The purpose of this paper is to investigate the relation between leadership and social capital and what qualities of leadership are important for social capital among employees in hospital settings over time. Design/methodology/approach - A cohort of employees in hospitals answered a questionnaire at three occasions. Five small (approx. 100-bed) or mid-sized (approx. 500-bed) hospitals were included. The response rate was 54 percent at baseline (n = 865), 59 percent at one-year follow-up (n = 908) and 67 percent at two-year follow-up (n = 632). Findings - Repeated measures over time showed differences between groups in levels of social capital with respect to levels of leadership quality. Relation-oriented leadership had the strongest association with social capital. There was evidence that leadership was associated with social capital over time and that different kinds of leadership qualities were associated with social capital. Research limitations/implications - This study conducted and analyzed quantitative data, and therefore, there is no knowledge of managers' or employees' own perceptions in this study. However, it would be interesting to compare managers' decreased and increased leadership quality and how such differences affect social capital over time. Practical implications - The findings feature the possibility for healthcare leaders to build high quality leadership as an important resource for social capital, by using different leadership orientations under different circumstances. Originality/value - The paper showed that leadership was an important factor for building social capital and that different leadership qualities have different importance with respect to certain circumstances.

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 sustainable organizational improvement work in hospitals and how social capital and engagement are created during organizational improvement work. Data were collected by a questionnaire at three times over a period of two years at five hospitals and all studies are quantitative.

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.

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.

Background: Social capital can be an important resource to facilitate the needed improvements in quality of care and efficiency in hospitals. Objectives: To assess the importance of social capital (recognition, vertical trust, horizontal trust and reciprocity) for job satisfaction, work engagement and engagement in clinical improvements. Design: A prospective cohort design was used. Settings: Intensive care units and emergency, surgical and medical units at five Swedish hospitals with ongoing development of their processes of care. Participants: Healthcare professionals (physicians, registered nurses, assistant nurses) at five Swedish midsize hospitals. Methods: The participants answered a questionnaire at two occasions, NN = 1602 at baseline and NN = 1548 at one-year follow-up. Mean hospital response rate was 53% at baseline and 59% at follow-up. Univariate, multivariate and logistic regression analyses were performed, and the prospective analysis was based on 477 respondents. Results: Social capital was associated with healthcare professionals' general work engagement and job satisfaction. Analysis showed positive associations between all measured aspects of social capital and engagement in clinical improvements of patient safety and quality of care. The prospective analysis showed that increased social capital predicted increased job satisfaction, work engagement and engagement in clinical improvements of patient safety. Conclusion: Social capital is strongly related to job satisfaction and active engagement with clinical improvements. The findings contribute to a deeper knowledge of social capital as a predictive factor that influences patient safety and health among healthcare staff.

Healthcare organisations in Sweden are reorienting toward horizontal organisation around care processes. This paper's aim was to investigate how implementation approaches for improvements of care processes in line with lean production (LP), at hospital strategic and operative levels, are associated with working conditions and stress-related health among the employees. Five hospitals working with improvements to care processes were studied using questionnaires to employees (n = 1,303) and interviews at strategic and operative levels at baseline and follow-up. The process redesign implementation strategies varied between the strategic and operative levels. There were associations between a higher degree of LP at operative level and increased work resources and decreased work demands. Physical, cognitive and mental stress-related symptoms were only weakly associated with strategic or operative LP initiatives. There was evidence of more beneficial or improved working conditions in relation to higher degree of LP at operative levels.

Introduction

Social capital, operationalized as perceived trust, reciprocity and recognition has in earlier research shown to be important for employees´ job satisfaction and to health care staffs´ engagement in clinical improvements of patient safety and quality of care as well as job satisfaction, health and wellbeing. Since social capital has an impact, it is of interest to investigate which factors that influence workplace social capital. Research findings shows that leadership has great importance to staffs´ health and wellbeing, and affects a number of factors in the work environment factors as job satisfaction and work engagement. If and how leadership is associated with social capital is rarely described in previous research. However the few studies performed indicate that there are associated correlations between leadership and social capital, and leadership quality and social capital. Leadership within healthcare sector has been in focus when working with redesign of care processes and it would be of interest to investigate the role of leadership and the quality of leadership with respect to social capital. The aim was to assess the importance of leadership for workplace social capital in hospital settings.

Materials and methods

This study was a longitudinal cohort study. Questionnaires to physicians, nurses, assistant nurses at five Swedish midsize hospitals was used to collect data (T0, n=865, T1, n=908). Bivariate, multivariate analyses was used and a mixed model repeated measurement for the longitudinal analyses (n=477) were performed.

Results

Relationship between staffs perceived quality of leadership and staffs´ social capital was found (R = 0.58, p-value <0.0001). Results of the analysis showed significant differences in levels of social capital between the groups of low, medium and high levels in quality of leadership. The differences between the groups sustained over time where the group with high levels in quality of leadership remained higher in levels of social capital than the other groups. Same pattern were seen in the other groups.

Conclusion

Leadership quality were related to-, had importance for- and influenced workplace social capital among health care staff.