Introduction and theoreticalframework

The content of constructs such as ‘Good’ and ‘Evil’

has been the subject of controversy in research for a

long time, where ‘Evil’ has been studied more often

than ‘Good’. This holds especially for research in

work environment, where problems of ill health are

the prime targets, as well as problems arising from

the psychosocial work environment. This certainly

also holds for dentistry (1–8). In particular, mus-

culoskeletal symptoms, stress, and burnout among

dentists have been in focus (9). Such research is

important so as not to become mentally and

physically worn out due to the job. However, an

emerging centre of attention is the promotion of a

good work environment in itself. This implies

studies of job satisfaction, job resources and job

engagement. Still, little is known about what is

good in a dentist’s work and the following short

review covers the domain rather well.

Siegrist’s theory in psychosocial work-environ-

ment research, the Effort-Reward Imbalance Mod-

el, has been used to predict physical health

outcomes, behavioural outcomes and psychological

wellbeing (10, 11). The idea is that a balance exists

between efforts (related to the job situation and to

personality traits such as over-commitment) and

rewards, specified as money, esteem, and career

opportunities ⁄ job security (10, 11). Job satisfaction

literature within dentistry has traditionally posed

questions covering a broad range of aspects of

working life and often in direct relation to attitudes

to the actual health care system. Dentists have been

asked not only about their satisfaction with

several aspects of their job, such as the system of

Community Dent Oral Epidemiol 2010; 38: 159–170All rights reserved � 2009 John Wiley & Sons A/S

Good Work for dentists – aqualitative analysisBerthelsen H, Hjalmers K, Pejtersen JH, Soderfeldt B. Good Work for dentists –a qualitative analysis. Community Dent Oral Epidemiol 2010. � 2009 JohnWiley & Sons A ⁄ S

Abstract – Objective: This study explores dentists’ perceptions of Good Workin the meaning of positive and rewarding aspects in their work in contrast to atraditional problem-centred focus on work life. Methods: Nine informantswere selected among Danish and Swedish general dental practitioners to obtainvariation as to country of origin, gender, age and clinical work experience.Semi-structured, in-depth interviews were audio-recorded and transcribedverbatim in the original language. Statements concerning positive aspects ofwork were used for systematic text condensation according to the principles ofGiorgi’s phenomenological analysis, as modified by Malterud, generalizingdescriptions reflecting aspects of Good Work. Selection of participantscontinued until saturation of the emerging categories was achieved.Results: The core of Good Work emanates from the clinical encounter: from therelation with the patient and from the opportunity to carry out high qualityodontological handicraft. Social relations at the workplace, as well asorganizational values and conditions were perceived as influencing theopportunities to achieve the rewarding aspects from the clinical encounter.Conclusions: The results implicate a need for developing a work-environmentalmodel with intrinsic as well as extrinsic rewards when dealing with humanservice organizations. At policy level it is necessary to address the professionalculture.

Hanne Berthelsen1, Karin Hjalmers1, Jan

Hyld Pejtersen2 and Bjorn Soderfeldt1

1Department of Oral Public Health, Faculty

of Odontology, Malmo University, Sweden,2National Research Centre for the Working

Environment, Copenhagen, Denmark

Key words: dentistry; health care; humanservice organization; phenomenology;psychosocial working environment

Hanne Berthelsen, Department of OralPublic Health, Faculty of Odontology,Malmo University, S-20506 Malmo, SwedenTel.: +46 406658525Fax: +46 40925359e-mail: hanne.berthelsen@mah.se

Submitted 19 January 2009;accepted 2 October 2009

doi: 10.1111/j.1600-0528.2009.00517.x 159

remuneration, size of practice, level of income and

number of patients, but also about characteristics

such as personality traits and stress levels [e.g.

(12–16)]. Job satisfaction is a relevant outcome since

it concerns the psychological wellbeing of the

employee and is also related to customer satisfac-

tion (17). However, the conclusions often embrace

their opposite, namely work conditions leading to

dissatisfaction [e.g. (14, 15)]. Moreover, satisfaction

with a job is only one aspect of what could be

called Good Work. Motivation is another.

Herzberg argues in the Two-Factor Theory of job

satisfaction and motivation for a difference

between hygiene factors and motivators (18).

Motivators like responsibility, recognition and

challenging work give positive satisfaction, while

dissatisfaction arises from the absence of for

example, salary, status and job security (18). This

has been criticized by Hackman & Oldham (19).

They argue that even though the model has been

very influential for work redesign, there is scarcely

empirical support for it, nor does it take individual

differences into account. Instead, they developed

the Work Characteristics Model proposing that

experienced meaningfulness, and experienced

responsibility for the work, mediate the relation

between work characteristics and outcomes such as

high motivation, high quality performance and

high job satisfaction (19).

In dentistry, a Finnish study has described how

different job resources, such as contact with peers

and positive relations to patients, help dentists to

cope with high job demands and thereby to stay

engaged in the job (20). In the Job Demand-

Resources Model job resources are shown to have

a main effect as well as being a buffer between job

demands and different health outcomes. In this

tradition, engagement is used as a positively

charged word, which still has to be questioned as

to its correspondence to a good work life over time.

Dutch dentists emphasize how idealism and

patient care are good predictors of engagement

(21), corresponding with the idea that moral factors

form the foundation for work in human service

organizations (22). Hjalmers has concluded that in

a group of unpromoted female dentists those with

the greatest commitment to moral factors also

perceived the greatest differences between the

ideal and the real work situation (23). This calls

for paying attention to the relevance of applying a

nuanced and comprehensive view of what consti-

tutes Good Work as perceived by the practitioners

themselves.

The concept Good Work was first formulated in

1985 by the Swedish Metalworkers’ Union in a

congress report entitled ‘Det Goda Arbetet’ (‘The

Good Work’). The concept comprised the trade

union’s priorities for work organization and

favourable labour market conditions in order for

industrial work to become Good Work. Thus, Good

Work, besides merely dealing with conditions such

as working hours, also included issues such as

equality, democracy, and education as part of the

work and even fair-sharing of production earnings.

Good Work was seen as an organizational as well

as a societal project (24). Among others, Gardner,

Csikszentmihalyi and Damon took up parallel

thoughts as described in ‘Good Work –When

Excellence and Ethics Meet’ (25).

However, the content of what is Good Work for

dentists is hardly clarified, and it needs further

study. One may commence such a study of Good

Work with the assumption that it is a social

construct depending on individual as well as

external factors. Good Work is further set to be

more comprehensive than concepts such as healthy

work, job satisfaction and job engagement. The

basis of this study is captured by the remark by

Ezzy (26), that ‘The events of a person’s life, including

the influence of their family of upbringing, their

education, the organization of the work place, the work

task and financial remuneration shape and constrain the

understanding of working that is constructed…the

meaning of working is developed in an interpretive

process through a socially constructed and reconstructed

narrative’.

Good Work is thus a holistic and complex

concept and it will vary between individuals. Still,

we assume it is possible to find a core in this

complexity. The aim of the present study was to

begin the work for achieving a deeper understand-

ing of what constitutes and characterizes Good

Work for dentists. The study is by necessity

explorative, based on extensive interviews with

practitioners working in the field.

Material and methods

A qualitative approach was used to obtain a deeper

understanding of the content of Good Work as

perceived by people working as dental general

practitioners in Denmark and Sweden (27, 28).

Before any generalizing study using quantitative

data can be carried out, it is necessary to explore

the meaning of the concept. Therefore, during

160

Berthelsen et al.

2007–2008, participants were selected among a

larger group of dentists, whom we heard from

colleagues to have different attitudes to their work

and believed to be full of information on the

subject. None of the chosen dentists were close

colleagues to the researchers. The strategy for

selection of cases was a purposive sampling to

obtain maximum variation by inclusion of dentists

with different backgrounds as to country of origin,

gender, age and work experience (29). The ratio-

nale was to identify important common percep-

tions of Good Work across the variation in

background. The selection of informants was done

stepwise by choosing some informants from the

beginning and then after the first interviews,

threads that came up led to a selection of new

informants. Following emerging threads made it

possible to gain deeper and fuller information (29).

The selection process went on until analyses

showed that saturation was obtained in the result-

ing dimensions.

The work content differs among dentists working

in Denmark and Sweden even though dentistry in

both countries is organized in a private and a public

sector. Typically, in Denmark, the public dental

practitioner meets child patients and patients from

groups with special needs, while the private prac-

titioner takes care of adults and to some extent also

child patients. In contrast, dentists from Sweden see

children and adults in both sectors. The work

content may also differ due to the existence of only

two recognized specialities in Denmark, in contrast

to eight recognized specialities in Sweden (30).

Two out of four Swedish informants were

women, while two out of the five Danish infor-

mants were men. Two dentists lived as singles,

others had a family with children, one was single

mother with four children and some were grand-

parents. Four of the informants had work experi-

ence from a public as well as a private clinic, four

solely from a private practice and two from public

employment only. The age range of informants was

26–63 years. One of the dentists worked in a solo

practice, most worked in a practice unit with two

or three dentists, and one came from a large unit

with seven dentists. Two of the informants were

exclusively working with child patients. Five den-

tists had managerial responsibility as owners of

private clinics or managers of public clinics.

Interviews and transcriptionThe two Scandinavian languages, Swedish and

Danish are closely related due to the fact of a

common historical and cultural background

besides the geographical proximity of the coun-

tries. In the Scandinavian countries, it is compul-

sory for school children to learn about the other

Scandinavian languages. Even though there are

differences between the two languages it does not

constitute a real problem to communicate across

the borders. The command of both Swedish and

Danish is very good in the research group

and bilingual colleagues have been available for

consultancy.

Semi-structured, in-depth interviews based on

Kvale’s principles [chapters 7 and 8 in (31)] were

performed in the mother tongue of the informants

as well as the interviewer. As recommended by

Kvale, the intention with the interviews, the

questioning technique and the strategy for data

analysis were determined in advance (31). Places

and times for the interviews were chosen by the

participants. An open-minded and relaxed inter-

view situation was aimed at. Each interview

was started with a briefing and ended with a

debriefing (31). The interviews, lasting between

45 minutes and 3 hours, were conducted as a

conversation with open questions following the

track of the informant by asking follow-up ques-

tions to clarify and go deeper into the subject. The

interview guide was utilized to ensure knowledge

of the key areas, and the questions were used as

inspiration to openers in situations where the

informant did not go into an overall area. The

interview guide included open questions about

the informants’ experiences of positive and

rewarding aspects of work, the meaning of work,

relationship with significant others and patients,

organizational conditions and their private lives.

The interviewers attempted to verify their inter-

pretations of the answers during the interviews

(31). All interviews were audio-recorded and later

verbatim transcribed by the interviewers in the

original language. Before the interview, all partic-

ipants were informed of the aim of the study and

their right to withdraw their participation. Places

and times for the interviews were chosen by the

participants.

AnalysisA phenomenological analysis contributes to a

deeper understanding of the work-related life-

world and thereby captures the core of a phenom-

enon (32, 33). The method was chosen to discover

common meanings underlying empirical variations

of positive and rewarding aspects in work.

161

Good Work for dentists

The material identified as pertaining to aspects of

Good Work was used for systematic text conden-

sation according to the principles of Giorgi’s

phenomenological analysis (34), as modified by

Malterud (29). The analysis was conducted jointly

by the research group and followed Malterud’s

four steps: (i) reading the material to obtain an

overall impression, and bracketing preconceptions;

(ii) identifying units of meaning representing dif-

ferent aspects of Good Work, and coding for these

aspects; (iii) condensing and abstracting the

meaning within each of the coded groups; and

(iv) summarizing the contents of each code group

to generalize descriptions and concepts reflecting

perceived important aspects of Good Work. The

first two steps in the analysis were carried out by

all researchers individually and compared jointly.

Condensing and abstracting the meaning within

the code groups was done individually by the first

two authors, and then summarized before present-

ing to the research group for discussion and

adjustment before the final step. The concluding

formulation of general descriptions of the dimen-

sions of Good Work was made by the first author

and given consent by the research group as a

whole. Finally, for confirmation, the results were

re-applied to the individual interview transcrip-

tions and checked for any remaining important

information which could contradict the results (29).

The study was approved by The Regional Ethical

Review Board in Lund, Sweden (DNR 20 ⁄ 2008). In

Denmark, no such permission was required.

Results

The overall impression of data was that the

perception of Good Work emerged directly from

the clinical encounter: from the relation with the

patient and from the opportunity to perform high

quality odontological handicraft. Next, the dentists

described some basic conditions such as their

relations to workmates, peers and leaders, as well

as how organizational values and conditions influ-

enced the opportunities to achieve the perceived

rewarding aspects from the clinical encounter.

Subsequently, data were coded for different

aspects of two main categories: intrinsic and

extrinsic dimensions of Good Work.

Intrinsic dimensions resulted in descriptions of

emotions and rationales, presenting the moral

foundation of the clinical encounter (making a

difference by doing good, a positive interaction

over time, and the creative zest). Extrinsic dimen-

sions included psychosocial work-environmental

aspects (freedom to keep up odontological profes-

sionalism, and a positive work climate with trustful

relationships). Good Work and private life was

found linked through the moral foundation. An

overview of the results is presented in Fig. 1.

The understanding of Good Work appeared

primarily to be founded on human relations,

emerging from the work with patients. In the

clinical encounter, the patient and the dentist meet

each other in a professional transaction, in which

the dentist delivers a professional service and the

patient contributes with appreciation, cooperation,

acknowledgement, and payment. When dentists

refer to their personal experiences of Good Work,

they speak about internal self-satisfaction as well as

external rewarding aspects of the job.

Making a difference by doing good to otherpeopleThe question was asked, what is typical for a good

day? Many told us that a good day is when you

have got through the day and all the treatments

without troubles, and your patients are as happy

when they leave the clinic as they were previously.

The Good Work was described as whenever you as

a dentist help somebody and thereby give them a

good and reassuring experience of dentistry. A

newly graduated dentist expressed it: ‘Well, gener-

ally it is a good day when the children really feel happy

and at ease being here, then it gives you a feeling of self-

satisfaction to be here. You feel that you make a

difference and do a good piece of work’. Several dentists

emphasized helping patients with special needs as

enriching and considered ending their career as

a dentist for underprivileged populations. The

essence of this category was described by an older

dentist: ‘You feel good and at peace with yourself when

you are good for others.’

A positive interaction as time goes byTwo dentists with long work experience described

the interaction with the patients as releasing a kick.

One of them said: ‘It actually gives a number of kicks

every time you experience appreciation from the

patients’. Another dentist pointed out an internal

characteristic of the rewarding aspect: ‘It may even

be the encouraging internal feeling when things work

out well and you sense good vibrations’.

A further issue was emphasized as personally

meaningful: meeting the same patients again and

thereby in joint action achieving good results over

162

Berthelsen et al.

the years. ‘Meeting the patients over and over again is

exceptionally stimulating, important and precious. The

patients’ impression of being known by the dentist, and

the fact that you don’t need to read the medical record in

detail is of great value for the patient as well as for the

dentist.’ The dentists testified to the importance of

the patients knowing and trusting them, when once

in a while they needed to go beyond the personal

capacities of the patient. One example was stated,

when a patient wants and needs an injection, but is

anxious about syringes. A young dentist formu-

lated it: ‘I find it enriching when you see a patient

come…crawling…and then after five visits declares he is

able to manage dental visits’. Implicitly, these state-

ments also illustrate the dentists’ overall intention

of doing good by helping the patients.

Continuity in the relationship between dentist

and patient was described as providing the oppor-

tunity for developing a close and good professional

relation. A female dentist expressed the profes-

sional and mutual character of the relationship:

‘An encounter is that I feel: I give you something and

I receive something, we meet each other’. And then that

I give of what I know and she gives me something such

as….you know. Yes, it becomes like a circle that closes

itself in some way’.

The creative zestWhen talking about the daily work with the

patients a further aspect appeared. Many dentists

also emphasized Good Work as arising from the

positive sensation when creating a finely tuned

Fig. 1. An illustration of intrinsic and extrinsic dimensions of the phenomenon ‘Good Work in dentistry’.

163

Good Work for dentists

handicraft for itself, as well as the handicraft in

combination with the collaboration between dentist

and patient. Most of the informants described a

strong professional pride and a pleasure when they

had done high quality work. A female dentist even

said: ‘It is a pleasure to look into a mouth, where various

dentists have been working and then be able to recognize

one’s own fillings…and enjoy the good quality of the

work done’. A male dentist described it like this: ‘It is

just as if you were an artist and made a nice painting

which could decorate the walls in your home.’

In contrast, one of the informants had felt the

creative zest important earlier in his career, where

more technically complicated dentistry was part

of his tasks. He now perceived the psychological

interaction as the most personally enriching aspect

of his work. An aspect of the underlying

moral dimension was thus, as described above,

grounded in the emotions and feelings emanating

from the clinical encounter. The essence of Good

Work was thereby perceived by him as much

more than just delivering a good piece of work

and having a good meeting with the patient. It

was described as a kind of deal, where the patient

appreciates the work in her own behaviour as

shown by maintenance of, e.g. oral hygiene and

care as well as through direct verbal appreciation

or through payment.

Freedom to keep up odontologicalprofessionalismDentistry is work and having an income is natu-

rally considered as essential. A young dentist

expressed it: ‘The reward you get is satisfied patients,

and then of course you also want to earn money. This is

also a kind of reward not to be forgotten.’ A dentist

working in public dentistry in Sweden reflected on

the ethical problem of having an overall organiza-

tion with internalized economic incentives when

also taking care of groups with special needs.

However, when asking the informants about how

material factors such as income influenced their

perception of having Good Work, the talk often

changed direction to reflexions about what was

perceived as more important, namely the work-

related freedom to keep up odontological profes-

sionalism. A private practitioner stated: ‘You have to

let professionalism steer you in your work and not the

money. In other terms, to organize the work in a way

that gives room for giving the patients enough time, as

well as the necessary peace and concentration’. A

Swedish publicly employed dentist described a

similar reflexion as: ‘It is possible to earn a similar

wage working 30 or 50 hours a week, but surely the

quality of the work like the handicraft and the contact

with the patient, will not be comparable. It is essential to

have the freedom to decide how I work, with whom I

work, and when I work’. The relation between

economic incentives and organization was summa-

rized by a female dentist: ‘When responsibility and

authority go hand-in-hand it is possible to maintain a

high professional standard, which is of benefit to the

patient as well as the dentist’.

When talking in general about their work as a

dentist, many dentists considered it as great fun

having the opportunity to work to the utmost of

their competence. At the same time, it was under-

lined that you might also run a risk when working

in too a challenging way, and therefore control over

the time schedule was required as well. It was

expressed by a desire to leave time for thinking

between the appointments, and for having oppor-

tunities to meet colleagues and talk over problems.

A positive working climate with mutual trustA positive atmosphere at the workplace with

mutual trust was emphasized as extremely impor-

tant by all the informants. An employed dentist

said: ‘when the owner of the clinic delegates the tasks

and the responsibility, he shows us confidence. This

makes us take more responsibility for the clinic; the

clinic becomes more ‘‘our clinic’’’. Another dentist

mentioned a fair work pressure and having enough

time for the work as positive ways of reducing the

conflict level. The working climate was said to

influence the wellbeing of the dentist and staff, but

it was also considered to be important for offering

the patients good care. A young dentist said: ‘When

things work well and flexibly, and when people are well

matched, then you really become good for the patient.

That is important to me’.

Influence over the choice of workmates was

explained as essential and the intention of creating

a dream-team was mentioned. For some it meant

the opportunity to choose their own dental assis-

tants at the chair side, and for others it was mainly

a question of having influence over the choice of

other dentists with whom they got along. For the

elderly dentists, being together with peers was

mostly a question of enjoying a cosy and friendly

atmosphere with a possibility to talk things over

and have fun, while others emphasized the impor-

tance of having colleagues around, so one could

rely on mutual help if problems appeared. The

interaction with the chair-side assistant was

mentioned by many dentists as of particular

164

Berthelsen et al.

importance. A female dentist described it: ‘It was

exactly like a dance, a dance-play when I made teeth

together with her, that I worked with for 14 years…It

gave peace and reconciliation….I felt sure she could

manage a surgical procedure for example’.

Generally, responsibility for colleagues and the

other staff at the clinic was felt whenever work

days were lost because of absence due to sickness,

visits to the doctor, or changes to another work-

place. In a similar way, the informants emphasized

the importance of a common development of the

clinic and internal harmony and agreement.

A good working climate was perceived as shared

responsibility between the individuals, but with

awareness of the special role of the leader. It was

underlined that a leader being at peace with

him ⁄ herself influenced the working climate in a

positive way. A dentist with managerial responsi-

bility expressed it like this: ‘If I am in a bad mood it

affects the whole clinic. As manager –and my colleagues

agree to this- it is extremely important to have a positive

angle to everything, otherwise we destroy the atmo-

sphere from the first minute we are present.’ A

democratic, open and trusting relationship

between the leader and the others was regarded

as crucial to the atmosphere at the workplace.

The more experienced informants described how

they perceived it as meaningful and also as

personally rewarding to pass on knowledge and

personal experiences to younger colleagues. Sev-

eral dentists talked about the role of mentor. One

said: ‘My previous principal was a mentor for me. It

was really super for me to have somebody, who had tried

all the possible failures and found out you didn’t die

because of it. He could explain to me that it wasn’t a

problem I was handling but just another challenge. I

believe it is extremely important, so I have taken over

that role’.

Energy for a life besides workA frequent impression of the interviews was that

the sense of having Good Work spread into the

sphere of the private life of the informants. It was

described as a necessity to have a clear conscience,

and thus being mentally able to leave the job

behind when going home. Having a clear con-

science was also found important for having a

good night’s sleep and thereby energy for home life

and work life. It was stated as important to have

time, health, energy and vigour for the home life; to

have energy for one’s children and family, for

sports, to go for a walk and other leisure-time

interests. Especially the importance of having

energy to keep a healthy lifestyle with physical

activities was stated as important for maintaining

good health. A female dentist said: ‘When you find

energy for living an active private life, you also gain new

energy to put back into work’.

Discussion

The core of Good Work was found in positive human

relationships and in the possibilities of obtaining

and maintaining a good piece of odontological

handicraft. The informants argued that great free-

dom in the work situation enhanced their opportu-

nities of having good work, as well as of doing good

work. Moral aspects dominated among all infor-

mants and across the categories describing positive

aspects of the work. One of the dentists expressed

that ‘being good to others’ also gave an internal feeling

of being at peace with oneself. Others stated that

professionalism was more important than money

when advising patients which treatments to choose.

Moral aspects were also central when achieving a

balance between the private and the work life. It was

argued that only by having a clear conscience was it

possible to leave the job behind and to relax, and

even to get a good night’s sleep. Moral aspects did

not only include the relationship with patients, but

also responsibility for colleagues, staff, i.e. the whole

clinic.

The position of moral values for the informants

confirms the theory of human service organizations

by Hasenfeld (22, 35). This is an essential difference

between psychosocial working environment in

industrial contexts and in human service settings

(36). This particular difference was also expressed

in the use of metaphors in describing perceptions

of work. Metaphors coming from the creative,

artistic world were often used to describe the

positive aspects of the work. On the other hand,

most of the dentists did not avoid bringing up their

perception of what contradicts Good Work. When

describing their personal bogey of ‘bad work’

metaphors taken from industrial settings were

common. Two of the informants verbalised it like

this: ‘You must avoid the work becoming a tooth-

factory’ and ‘Dentists may never be regarded as

repairmen. It is so insulting for the profession in all

respects’.

When working with other human beings it

becomes crucial to take conscience into consider-

ation. The moral dimension also confirms the

previous findings by Hjalmers concerning female

165

Good Work for dentists

unpromoted Swedish dentists (23). Having corre-

spondence between internal moral values and the

values applied in daily work seems important, not

only in avoiding stress, but also in the urge for a

Good Work over time.

The metaphors used underline the connection

between the self-perception of doing artistic work

and the organizational setting. In an industrial

setting, the work piece is an object, in human

service work it is a subject, another human being

(22). When the dentists want their work to be

respected as artistic instead of being some kind of

assembly work, in our interpretation it expresses

the wish of keeping the relationship to the patient

as two individuals meeting each other, urging to

achieve a common goal. It is not enough to deliver

a nice piece of odontological handicraft, it should

also be maintained over time to be meaningful,

thus underlining the mutual relation and the time

perspective in the work.

Another association about the metaphorical use

of industry is relating directly to work conditions

in the form of management style and organization.

The results underline the importance of having

influence, independence and freedom in work. It is

well-known from Karasek’s Demand-Control-

Model as ‘control’ in the form of skill discretion

and decision latitude (37). As health professionals,

dentists in the present study described the impor-

tance of having influence, freedom and indepen-

dence to perceive having Good Work. Clinical

freedom is needed to keep up ethical standards

and by that keeping a clear conscience in corre-

spondence with important personal values. Den-

tists are socialized into their ethical standards

through their education and vocational training.

The most important part of the socialisation may

even happen through contact with colleagues. This

is corroborated in the results by the desire of being

together with colleagues; to cooperate with col-

leagues; to pass over wisdom to younger dentists;

and by having mutual benefits from mentorships.

Dentists pass over values and standards, and there

are strict ethical standards advocated by the dental

associations as well as by peer control. Thereby,

personal values and professional values become

internalized and fuse together. This is more than

just personal freedom, but it also concerns esteem

coming from their reputation among their col-

leagues, from patients and from the perception of

the profession in the population.

The balance described by the dentists between a

desire for challenging, creative work and a need for

recovery time as well may also be understood in

the light of traditional work-environmental mod-

els. The Demand Control Model implicates that

when the demands are high and the control is low,

a strain diagonal can be described (37). Most

empirical research has mainly concentrated on this

strain hypothesis (38). The results from the present

study point to the other diagonal, – an activity, or

learning, diagonal, describing a situation with high

demands and high control (39).

In Siegrist’s Effort-Reward Model, the basic idea is

the balance between intrinsic as well as extrinsic

demands on the one side and rewards on the other

side (10). This model has not been developed for

human service work, but can be extended especially

on the reward side (11). The present study shows

that when dealing with human services the rewards

are described as coming from oneself by the positive

emotion on knowing you have done good work, as

well as from the extrinsic rewards. One should thus

include the internal rewards when studying work

environment in human service organizations.

Indeed, the intrinsic rewards in human service work

may be so powerful that they imply a risk of

accepting poor work conditions in other respects.

The results from a group of female unpromoted

dentists in Sweden can be interpreted as pointing to

this dilemma; about 40% of the dentists stated that

they would choose the same work again even

though a large majority also expressed having far

from satisfying work conditions (23, 40).

Time pressure and dealing with troublesome

patients have often been described as some of the

most common stressors in dentistry. Another way

to understand such stressors is to see them as

symptoms of a deeper problem complex. The

present study provides us with an insight into

how these same issues also can address the positive

aspects in the work. By organizing the work in a

way that gives sufficient time for the work it is

possible to achieve positive patient relationships

and positive feelings. Thus, the phenomenon of

Good Work is not the other end of a scale of

problematic work. The time perspective and

mutual influence in trusted relationships with

patients, colleagues, staff and manager set a frame

for Good Work also to be sustainable.

The overall results concerning quality in the

handicraft as well as in the relations to patients and

colleagues support the findings of relevant job

resource factors in dentistry (21, 41). Intrinsic

rewards in dentistry have previously also been

found important for job satisfaction in dentistry

166

Berthelsen et al.

(42). Dentists in the present study did not empha-

size income as a central contributor to Good Work,

although it has previously been shown to be

important for job satisfaction as well as job

engagement (12, 13, 21, 42). This difference points

to Good Work as concerning work fulfillment and a

pleasure in the work per se, while income repre-

sents the work conditions or the framework of the

job, corresponding with the theoretical distinction

between motivators and hygiene factors (18).

Another point is the emphasis placed on trusting

and democratic relationships as well as on the

time perspectives of the work. Good Work

becomes also the perception of having sustainable

work, including more than simple satisfaction or

engagement at the time.

When studying Good Work by interviewing

informants, we analysed reflexions coming from

the informants’ personal understanding and inter-

pretation of the phenomenon, rather than their

actual behaviour. The dentists decided consciously

or unconsciously what they wanted to share with

us. Some arguments and intentions are more

morally acceptable than others and thus more

likely to be presented. Thereby, the results most

probably reflect an ideal that helps us to under-

stand the life world of dentists as they see and

formulate it from their own norms.

From the results, it is obvious that the core of

dentists’ perception of Good Work has its starting

point in doing the best for the individual patient:

by carrying out the best handicraft and having a

positive relation with the patient. This is naturally

positive for patients already enrolled in the system

and able to respond positively to the treatment. On

the other hand, there are the demands of the

population as a whole, and especially disadvan-

taged groups, who for different reasons may have

difficulties in access and adherence to dentistry.

The Ottawa Charter advocates for a need to

re-orientate health services towards the needs of

the population (43). Even though much emphasis

has been on New Public Management reforms

implying changes in health care culture (44), the

results illustrate that professional culture is still

predominant. Changing the culture within a

professional context is known to be difficult

(45, 46), which is corroborated by findings such

as those coming from the present study. This

implicates a special awareness of the political

responsibility for adaption of the overall organiza-

tion of health care to the needs of the population.

Inequality in oral health is still an issue in the

Scandinavian context (47). The insight coming from

qualitative studies such as the present one may be

of importance for planning and evaluating differ-

ent ways of organizing dentistry, such as task

division (48). Organization of dentistry including

incentive systems and task division should be

addressed especially to avoid built-in contributors

to inequality in health. It is important to take into

consideration that incentives are needed for

recruitment and the maintaining of dentists in the

work force, especially for dentists working with

vulnerable groups. Work conditions facilitating

opportunities for achievement of personal satisfac-

tion in the work also with other groups than that of

the ‘ideal patient’ is needed to avoid further

inequality in oral health.

The interviews were performed by the first two

authors, both dentists. Thereby, the situation

became natural and enhanced the understanding

of the context and the vocabulary used. It may

have helped to obtain a trusting relationship in the

short time of the interview, due to a basic under-

standing of the work conditions. On the other

hand, there is a risk of influencing the informants,

guiding them to verify the perceptions of the

researchers themselves. An interview technique

with open questions following the trail of the

interviewee was used to avoid this (29, 31). Also

the flexible sampling method, allowing threads to

be followed from interview to interview, helped to

ensure a theoretical representation of the breadth

and depth of the phenomenon. After five inter-

views only limited new information appeared, and

the following interviews showed that saturation of

the categories was achieved after six interviews,

even if it was decided to increase the number of

informants ensuring this saturation.

During the interviews many informants also

talked about problems with their work environ-

ment. The dentists varied in their attitudes to their

work as dentists do in general, while the follow-up

questions emphasized the perceived aspects of

Good Work. Therefore, participating dentists were

by no means wholly satisfied with their work life

as well as their private life, even if that impression

may emerge when reading the interviews as

quoted here.

In the initial steps, the analysis was partly

parallel to other analytic approaches such as

conventional content analysis and grounded the-

ory. The method used goes beyond a conventional

content analysis in the last part of the analysis

where a complete understanding of the context

167

Good Work for dentists

forms the basis for development of a nuanced

understanding of the lived work experiences

(49).There was no intention of gathering knowl-

edge about how social structures and processes

influence the perception of work, for which pur-

pose Grounded Theory probably would have been

preferable (33). However, during the analysis, it

became apparent that the circumstances under

which the work took place, could not in all aspects

be separated from the perception of Good Work.

One example is when delegating responsibility to

employees was seen as recognition. The collabora-

tion with the dental nurse described as a dance-

play is another example. This illustrates the way

positive work relations contribute directly to per-

ceptions of having Good Work. All in all, the

method applied was considered the best one for

answering the research question. With the back-

ground of the resulting comprehensive and

nuanced descriptions obtained, we find the phe-

nomenological approach in data collection and

analysis has proved to be relevant for illustrating

perceptions of Good Work.

Triangulation was used in the analyses, as

researchers with different educational and profes-

sional backgrounds took part in the process.

Returning to the interviews for justification of the

formulation of essential meanings and the general

structure also contributed to validate the interpre-

tation (29, 32).

The study is strengthened by including partici-

pants with various backgrounds, also regarding

nationality. The internal validity is believed to be

good and the main results are found to correspond

with previous studies concerning dentists and sup-

port the theory of Human Service Organizations, of

which dentistry is a core example. The core of dental

general practitioners’ patient-related work is prob-

ably fairly similar across borders in Europe even

though organizational forms may vary. Therefore,

the results concerning the perceived intrinsic

rewards can be considered as transferable to dental

general practitioners on the whole. The findings

regarding relationships at the clinic may be

perceived as more related to the contextual frame-

work of the work situation, which is culturally

dependent. The transferability of the results

concerning the perception of work organization

may consequently differ according to the cultural

context. If we had chosen to include other national-

ities it might have influenced this part of the results.

In addition, including dentists from other countries

as well would have complicated the interviews,

transcription and analysis considerably due to lan-

guage problems and would thus have compromised

the internal validity of the results. It may be so that

others could find additional aspects of Good Work

for dentists, but we regard the present study as

giving a substantial contribution to deeper under-

standing of the concept. For readers who know

dentistry from inside the findings should be intui-

tively correct if the analysis is valid and transferable

to a broad range of dental general practitioners. For

readers coming from outside human service orga-

nizations the analysis may provide an insight into

the mentality of a profession which they cannot

achieve from their own personal work experience.

We intend to use the insights for constructing a

measure of Good Work perceived as rewarding

aspects of work in a human service organization.

AcknowledgementsThe authors wish to acknowledge the Swedish Councilfor Working Life and Social Research for financialsupport of the study. We would also like to thank theparticipating dentists for spending time and effort intosharing their thoughts about working in dentistry withus. Finally we are grateful to have good and supportivecolleagues at the department and for the help withgraphical layout of the illustration of Good Workprovided by Elsa Mathiasen.

References1. Bejerot E, Soderfeldt B, Aronsson G, Harenstam A,

Soderfeldt M. Perceived control systems, work con-ditions, and efficiency among Swedish dentists:interaction between two sides of human resourcemanagement. Acta Odontol Scand 1999;57:46–54.

2. Bejerot E. Dentistry in Sweden - Healthy work orruthless efficiency? Lund, Sweden: National Institutefor Working Life, Lund University. Arbete och halsa.Vetenskaplig skriftserie, 1998:14 (Dissertation).

3. Hjalmers K, Soderfeldt B, Axtelius B. Psychosomaticsymptoms among female unpromoted general prac-tice dentists. Swed Dent J 2003;27:35–41.

4. Berthelsen H. Stress, health and social support at theworkplace in view of changes in the demands madeon dentists – A cross-sectional survey of Danishgeneral dental practitioners. Copenhagen: Copenha-gen University. Master of Public Health, 2003:96(Dissertation). In Danish with English abstract.

5. Te Brake JHM, Bouman AM, Gorter RC, HoogstratenJ, Eijkman MAJ. Using the Maslach Burnout Inven-tory among dentists: burnout measurement andtrends. Community Dent Oral Epidemiol 2008;36:69–75.

6. Gorter RC, Storm MK, Te Brake JH, Kersten HW,Eijkman MAJ. Outcome of career expectancies and

168

Berthelsen et al.

early professional burnout among newly qualifieddentists. Int Dent J 2007;57:279–85.

7. Te Brake H, Bouman AM, Gorter R, Hoogstraten J,Eijkman M. Professional burnout and work engage-ment among dentists. Eur J Oral Sci 2007;115:180–5.

8. Myers HL, Myers LB. ‘It’s difficult being a dentist’:stress and health in the general dental practitioner.Br Dent J 2004;197:89–93.

9. Puriene A, Janulyte V, Musteikyte M, BendinskaiteR. General health of dentists. Literature review.Stomatologija 2007;9:10–20.

10. Siegrist J. Adverse health effects of high-effort ⁄ low-reward conditions. J Occup Health Psychol 1996;1:27–41.

11. Van Vegchel N. Two models at work: a study ofinteractions and specificity in relation to the De-mand-Control Model and the Effort-Reward Imbal-ance Model. Utrecht, The Netherlands: UtrechtUniversity, 2005 (Dissertation).

12. Shugars DA, Dimatteo MR, Hays RD, Cretin S,Johnson JD. Professional satisfaction among Califor-nia general dentists. J Dent Educ 1990;54:661–9.

13. Logan HL, Muller PJ, Berst MR, Yeaney DW. Con-tributors to dentists’ job satisfaction and quality oflife. J Am Coll Dent 1997;64:39–43.

14. Humphris GM, Peacock L. Occupational stress andjob satisfaction in the community dental service ofnorth Wales: a pilot study. Community Dent Health1993;10:73–82.

15. Gilmour J, Stewardson DA, Shugars DA, Burke FJ.An assessment of career satisfaction among a groupof general dental practitioners in Staffordshire. BrDent J 2005;198:701–4.

16. Harris RV, Ashcroft A, Burnside G, Dancer JM, SmithD, Grieveson B. Facets of job satisfaction of dentalpractitioners working in different organisationalsettings in England. Br Dent J 2008;204:E1–7.

17. Dollard MF, Dormann C, Boyd CM, Winefield HR,Winefield AH. Unique aspects of stress in humanservice work. Aust Psychol 2003;38:84–91.

18. Herzberg F, Mausner B, Snyderman BB. The moti-vation to work. New York: John Wiley; 1959.

19. Hackman JR, Oldham GR. Motivation throughdesign of work: test of a theory. Organ Behav HumPerform 1976;16:250–79.

20. Hakanen JJ, Bakker AB, Demerouti E. How dentistscope with their job demands and stay engaged: themoderating role of job resources. Eur J Oral Sci2005;113:479–87.

21. Gorter RC, Te Brake HJ, Hoogstraten J, Eijkman MA.Positive engagement and job resources in dentalpractice. Community Dent Oral Epidemiol2008;36:47–54.

22. Hasenfeld Y. Human service organizations. AnnArbor, MI: University of Michigan Press; 1974.

23. Hjalmers K, Soderfeldt B, Axtelius B. Moral valuesand career: factors shaping the image of healthywork for female dentists. Acta Odontol Scand2006;64:255–61.

24. Johansson J, Abrahamsson L. The good work – aSwedish trade union vision in the shadow of leanproduction. Appl Ergon 2009;40:775–80.

25. Gardner H, Csikszentmihalyi M, Damon W. GoodWork. When excellence and ethics meet. New York:Basic Books; 2001.

26. Ezzy D. Subjectivity and the labour process:conceptualising ‘Good Work’. Sociology 1997;31:427–44.

27. Bower E, Scambler S. The contributions of qualita-tive research towards dental public healthpractice. Community Dent Oral Epidemiol 2007;35:161–9.

28. Roelofs C. Using qualitative methods to evaluate andmake change in the work environment. New Solut2005;15:337–41.

29. Malterud K. Qualitative research: standards, chal-lenges, and guidelines. Lancet 2001;358:483–8.

30. Kravitz AS, Treasure ET. EU Manual of DentalPractice: version 4 (2008). Brussels: The Council ofEuropean Dentists; 2008.

31. Kvale S. InterViews: an introduction to qualitativeresearch interviewing. London: Sage Publications;1996.

32. Kleiman S. Phenomenology: to wonder and searchfor meanings. Nurse Res 2004;11:7–19.

33. Starks H, Trinidad SB. Choose your method: acomparison of phenomenology, discourse analysis,and grounded theory. Qual Health Res 2007;17:1372–80.

34. Giorgi A. Sketch of a psychological phenomenolog-ical method. In: Aanstoos C, Fischer W, Giorgi A,Wertz F editors. Phenomenology and psychologicalresearch. Pittsburgh: Duquesne University Press;1985; 8–22.

35. Hasenfeld Y. Organizational forms as moral prac-tices: the case of welfare departments. Soc Serv Rev2000;74:329–51.

36. Soderfeldt B, Soderfeldt M, Muntaner C, O’campo P,Warg LE, Ohlson CG. Psychosocial work environ-ment in human service organizations: a conceptualanalysis and development of the demand-controlmodel. Soc Sci Med 1996;42:1217–26.

37. Karasek R. Job demands, job decision latitude, andmental strain: implications for job redesign. AdminSci Q 1979;24:285–308.

38. De Lange AH, Taris TW, Kompier MA, HoutmanIL, Bongers PM. ‘The very best of the millennium’:longitudinal research and the demand-control-(sup-port) model. J Occup Health Psychol 2003;8:282–305.

39. Schaufeli WB, Bakker AB. Job demands, jobresources, and their relationship with burnout andengagement: a multi-sample study. J OrganizatBehav 2004;25:293–315.

40. Hjalmers K. Good work for dentists – ideal andreality for female unpromoted general practice den-tists in a region of Sweden. Swed Dent J Suppl2006;182:10–136.

41. Gorter RC, Te Brake JHM, Eijkman MAJ, Hoogstraa-ten J. Job resources in Dutch dental practice. Int DentJ 2006;56:22–8.

42. Wells A, Winter PA. Influence of practice andpersonal characteristics on dental job satisfaction. JDent Educ 1999;63:805–12.

43. World Health Organization. The Ottawa Charter forhealth promotion. Ottawa, Canada: WHO; 1986.

44. Green-Pedersen C. New Public Management reformsof the Danish and Swedish Welfare States: the role ofdifferent social democratic responses. Governance2002;15:271–94.

169

Good Work for dentists

45. Scott T, Mannion R, Davies HT, Marshall MN.Implementing culture change in health care: the-ory and practice. Int J Qual Health Care 2003;15:111–8.

46. Davies HT, Nutley SM, Mannion R. Organisationalculture and quality of health care. Qual Health Care2000;9:111–9.

47. Petersen PE, Kjøller M, Christensen LB, Krustrup U.Changing dentate status of adults, use of dental

health services, and achievement of National DentalHealth Goals in Denmark by the Year 2000. J PublicHealth Dent 2004;64:127–35.

48. Abelsen B, Olsen JA. Task division between dentistsand dental hygienists in Norway. Community DentOral Epidemiol 2008;36:558–66.

49. Hsieh HF, Shannon SE. Three approaches toqualitative content analysis. Qual Health Res 2005;15:1277–88.

170

Berthelsen et al.